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HighmarkAll Plans · Administrative · Medical Policy · PA, NY, DE, WV · Audiology, Endocrinology, Dermatology +4 moreMedium impact

Changes to 24/7 Coverage Requirements for Providers

Effective date
Jan 1, 2027
Identified
Sep 22, 2026

Summary

Effective January 1, 2027, Highmark is removing 24/7 coverage verification from the credentialing process but maintaining the 24/7 after-hours coverage requirement for most providers. A new random monthly verification process will replace the old credentialing-based verification, with 100 practices sampled each month. Specific specialties (audiologists, dieticians, physical therapists, psychologists performing only testing/evals, etc.) are now exempt from this requirement.

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What to do

Action · 7 steps
01Before January 1, 2027.
02Billing and credentialing teams must review the list of 14 exempt specialties and flag practices in those specialties so they are not expected to maintain 24/7 coverage—no action needed for exempt specialties.
03For all other providers, audit current after-hours coverage methods and ensure they align with one of the seven acceptable methods listed (after-hours text/email response within 60 minutes, answering service, answering machine with callback, ER/operator referral, office triage, provider cell phone, or for behavioral health: crisis center or individualized crisis plans).
04Document the selected 24/7 coverage method in the provider file or credentialing system for reference during random verification outreach.
05Train front-desk and clinical staff on the new verification process—starting January 2027, random practices will be contacted monthly to confirm coverage.
06Establish an internal appeal process protocol for any termination notices received; providers will have the right to appeal if coverage verification fails.
07Update provider manual sections 3.1, 3.2, 4.1, and 4.2 per Highmark's notification prior to the effective date.

Original notice

Changes to 24/7 Coverage Requirements for Providers
providers.highmark.com · Always check the source before changing claims.
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Related policy hubs

Highmark policiesPA policy changesNY policy changesDE policy changesWV policy changesAudiologyEndocrinologyDermatologyOccupational TherapyPhysical TherapySpeech TherapyPsychiatry

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