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HighmarkAll Plans · Prior Auth · Prior Authorization · PA, NY, WV, DE · Oncology, Hematology, RheumatologyMedium impact

Technical Coding Alignment for Prior Auth Processing of Select MIDs

Act
by Aug 31, 2026
Effective date
Sep 1, 2026
Identified
Jul 28, 2026

Summary

Effective September 1, 2026, Highmark is aligning technical coding configurations for prior authorization processing of 20 select medical injectable drugs (MIDs), including new denosumab biosimilars and oncology/specialty drugs. This ensures consistency with previously published prior authorization requirements. While widespread impact is not anticipated, variations may occur based on individual benefit plans and eligibility.

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What to do

by Aug 31, 2026 · 6 steps
01Billing team must verify that all 17 affected HCPCS codes (Q5157, Q5158, Q5159, J9248, J9021, J9347, J9272, J9011, J9282, J9061, J9326, Q5122, J9227, J1448, J0224, Q5118, J9038) are configured in the billing system to require prior authorization through Availity Essentials for Highmark plans.
02Confirm that system rules align with the technical coding configuration by September 1, 2026.
03Verify member eligibility and benefits through Availity's Patient Registration feature before claim submission.
04Reference the most up-to-date Highmark Medical Policies via the Provider Resource Center (PRC) to confirm coverage criteria for each injectable.
05Communicate any changes to clinical staff.
06Claims submitted without proper prior authorization may be denied.

Codes mentioned

Q5157Q5158Q5159J9248J9021J9347J9272J9011J9282J9061J9326Q5122J9227J1448J0224Q5118J9038

Original notice

Technical Coding Alignment for Prior Auth Processing of Select MIDs
providers.highmark.com · Always check the source before changing claims.
View original ↗

Related changes

See all Highmark changes →
Medical Injectable Drug Program Changes in the New YearHighEffective Jan 1, 2027 · PharmacyMedical Injectable Drug Program Changes in the New YearHighEffective Jan 1, 2027 · PharmacyBrowse every Highmark change in the policy list

Related policy hubs

Highmark policiesPA policy changesNY policy changesWV policy changesDE policy changesOncologyHematologyRheumatologyCode Q5157Code Q5158Code Q5159Code J9248Code J9021Code J9347Code J9272Code J9011Code J9282Code J9061Code J9326Code Q5122Code J9227Code J1448Code J0224Code Q5118Code J9038

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