CommercialCoverageMedium impact
Expanding Care for Members with Substance Use Disorder
Highmark·PA, NY, DE, WV, NJ · Psychiatry, Internal Medicine, Family Medicine·Provider Bulletin
Effective date
Jan 1, 2026
We identified it
Jul 28, 2026
Summary
Highmark launched a new Specialty Care – Substance Use Disorder (SUD) Expansion program effective January 1, 2026, offering virtual services including medication-assisted treatment, peer recovery coaching, and care navigation for eligible members aged 18+ with alcohol, opioid, cannabis, stimulant, or benzodiazepine dependence. Billing teams must implement referral processes through Availity Essentials and ensure proper documentation of member eligibility and clinical assessments to support claims.
Action Required
By January 1, 2026: Billing and clinical teams must familiarize staff with the new Specialty Care – SUD program eligibility criteria and referral process. Providers should review the provider handout and overview video on the PRC's Behavioral Health Telemedicine and Virtual Visits page. Begin using Availity Essentials portal to submit referrals for eligible members (age 18+, Commercial/MA/ACA/ASO opt-in plans, with documented substance use symptoms and expressed interest in change). Ensure clinical staff conduct appropriate screening and assessment documentation to support referral eligibility. Update internal protocols to route SUD cases to the Mental Well-Being powered by Spring Health solution. No specific billing code updates are required, but claims must include documentation of member eligibility and clinical assessment supporting the referral. Failure to properly document eligibility may result in claim denials.