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HighmarkCommercial · Administrative · Provider Bulletin · DE, NY, PA, WVMedium impact

Avalon to Manage Post-Service Reviews for Non-Molecular Lab Claims

Act
by Feb 1, 2027
Effective date
Feb 1, 2027
Identified
Oct 20, 2026

Summary

Effective February 1, 2027, Highmark will transition post-service review management for non-molecular laboratory claims from eviCore to Avalon Healthcare Solutions across Delaware, New York, Pennsylvania, and West Virginia. This change affects Commercial, Medicare Advantage, and ACA plans for routine outpatient lab testing. Billing teams must ensure accurate diagnosis and procedure coding and review Avalon's laboratory operational policies before the transition date.

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What to do

by Feb 1, 2027 · 5 steps
01Billing team should prepare for transition from eviCore to Avalon Healthcare Solutions for post-service reviews of non-molecular laboratory claims.
02Before the effective date, review Avalon's laboratory operational policies available on their dedicated Highmark provider landing page to understand new review standards.
03Ensure all laboratory claims submitted on or after February 1, 2027 use accurate diagnosis and procedure coding to align with Avalon's Laboratory Benefit Management (LBM) program requirements and reduce claims adjustments and provider refunds.
04Monitor the Provider Resource Center (PRC) and join Highmark's mailing list for policy updates.
05Note: eviCore's prepayment reviews for non-molecular lab claims in Delaware, Pennsylvania, and West Virginia were already discontinued on September 30, 2026; verify whether your practice has transitioned processes accordingly and confirm current applicability of any existing eviCore-based workflows.

Original notice

Avalon to Manage Post-Service Reviews for Non-Molecular Lab Claims
providers.highmark.com · Always check the source before changing claims.
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