Pennsylvania providers face a continuous stream of payer policy changes: coverage edits, prior authorization expansions, billing code revisions, and Medicaid reimbursement updates that affect day-to-day practice operations. This page surfaces every tracked policy change that explicitly names Pennsylvania, so your billing and compliance teams can act before the effective date, not after a claim denial.
Capital Blue Cross is implementing significant updates to Medicare Advantage plans effective January 1, 2027, including plan county changes, revised medical and pharmacy benefits, elimination of OTC hearing aid coverage, and new clinical guidelines. Additionally, new prior authorization requirements for specific oncology drugs (Bortezomib and Pemetrexed codes) take effect December 1, 2026.
Effective December 1, 2026, Highmark is implementing a new 15-month (455 calendar day) deadline for submitting claim adjustment requests, measured from the claim finalization date rather than receipt date. Claim adjustment requests submitted after this deadline will be automatically denied for untimely filing. This change applies to Commercial, Medicare Advantage, and Federal Employee Program (FEP) plans but excludes BlueCard Home.
Highmark ValueBlue introduces a partial capitation reimbursement model for primary care providers (PCPs) effective January 1, 2027. PCPs must enroll by December 1, 2026, to participate; those who do not enroll will face a 20% reduction in capitated codes on the community fee schedule effective April 1, 2027.
Highmark is launching the ValueBlue partial capitation program for professional providers effective January 1, 2027, replacing traditional fee-for-service reimbursement with PMPM (per-member-per-month) base rates adjusted by member health factors and provider performance metrics. Billing teams must review 2027 base capitation rates by region and line of business, access the 2027 PAF Report, and understand that payments are retrospective and subject to quality/efficiency adjustments of up to ±40% and ±20% respectively.
Highmark is implementing new EMR system capabilities effective January 1, 2027, to streamline prior authorization workflows through CMS-mandated interoperability APIs. Providers will be able to check authorization needs, retrieve documentation requirements, and submit/track prior authorizations directly within compatible EMR systems. Additionally, providers gain secure access to patient Highmark health records including claims, encounter data, and clinical information through a new Provider Access API.
Effective January 1, 2027, Pennsylvania Medical Assistance (MA) retroactive eligibility periods are reducing for new applicants: Adult Expansion Group (ages 19-64) drops from 3 months to 1 month; all other federally-funded MA categories drop from 3 months to 2 months; state-funded MA remains at 3 months. Additionally, the COMPASS 'Date of First Admission or Treatment' field will no longer determine MA application dates—instead, the actual date the application is received at the County Assistance Office (CAO) will control coverage periods. This directly impacts claims adjudication for services rendered before application dates.
Effective January 1, 2027, UnitedHealthcare is adding prior authorization requirements for 11 HCPCS oncology medication codes when administered in outpatient settings for cancer treatment. These codes include busulfan, leucovorin calcium, luspatercept, dexrazoxane, dinutuximab, octreotide, triptorelin, omidubicel, zoledronic acid, and cyclosporine. This change applies across commercial, Medicare Advantage, Medicaid, and Individual Exchange plans.
Highmark is launching the ValueBlue partial capitation program effective January 1, 2027, establishing new base capitation rates by line of business (Commercial 18+: $4.81, Commercial under 18: $21.69, Medicare Advantage: $20.51) and introducing performance adjustment factors (PAF) for primary care providers based on quality metrics and ED utilization. Billing teams must review 2027 PAF reports, understand the new Member Adjustment Factor (MAF) structure, and prepare systems for retrospective capitation payments.
Effective January 1, 2027, Highmark is adding 13 new drugs to its Medical Injectable Drug Program and adjusting reimbursement rates to align with average selling price (ASP) or average wholesale price (AWP) for drugs lacking an ASP. These drugs receive HCPCS codes and remain in the program once coded. Billing teams must update their systems to recognize these new HCPCS codes and apply the correct reimbursement methodology.
Beginning January 1, 2027, Evolent will manage prior authorization reviews for medical and radiation oncology services for Highmark Commercial members in New York and ASO members in Delaware, New York, Pennsylvania, and West Virginia. Prior auth for oncology services WITH a cancer diagnosis will be managed by Evolent, while services WITHOUT a cancer diagnosis will remain with Highmark's UM team. Initial auth requests still submit through Availity, but supporting clinical documentation for Evolent reviews must be uploaded to Evolent's CarePro portal.
Highmark is replacing its current PCP fee-for-service and True Performance programs with two new value-based models effective January 1, 2027: ValueBlue (partial capitation with monthly payments for attributed members plus fee-for-service for preventive/wellness services) and ValueBlue Connect (incentive program rewarding quality outcomes and care coordination). This fundamentally changes how primary care providers are reimbursed, shifting from visit-based billing to population health management with stable monthly payments.
Evolent Specialty Services will require prior authorization for 23 cardiology codes covering angioplasty, stent placement and atherectomy in the iliac, femoral and popliteal, tibial and peroneal, and inframalleolar arteries, plus code 92930 for placement of intracoronary stents. The requirement begins January 1, 2027 for members of the Ambetter Health Marketplace and Wellcare Medicare health plans.
Beginning January 2027, Highmark will implement a new claims edit that validates patient date of birth (DOB) against their records during EDI submission. Claims with DOB mismatches will be rejected and must be corrected and resubmitted. This affects all professional and facility providers submitting claims to Highmark.
Effective January 1, 2027, Highmark will implement industry-wide maternity billing changes replacing the current global maternity code with service-level coding across four phases of care (antepartum, labor management, delivery, postpartum). Antepartum and postpartum care will now use standard E/M codes instead of global codes, while new codes will be introduced for labor management, delivery, and specific obstetric procedures. Billing teams must prepare systems and workflows for this transition before the effective date.
Effective February 1, 2027, Highmark is consolidating non-claims, manual, and value-based reimbursement payments through ECHO Health, which already processes standard claims. All these payments will route to a single electronic account, requiring providers to confirm or update bank account information by January 4, 2027, to avoid payment disruption or conversion to paper checks.
UnitedHealthcare Community Plan of Pennsylvania added a Medicaid medical benefit policy for Genglycos (pariglasgene brecaparvovec-opnr) for glycogen storage disease type Ia, effective 2026-12-01. Coverage is limited to patients 8 years or older with a confirmed diagnosis, documented by bi-allelic G6PC variants or absent G6Pase activity on liver biopsy, who are on cornstarch therapy, have no detectable AAV8 antibodies, have never received gene therapy for GSDIa, are managed by or with a metabolic specialist, and are dosed per FDA labeling. Authorization covers one lifetime treatment and no more than 45 days from approval.
UnitedHealthcare Community Plan of Pennsylvania revised its Cardiovascular Disease Risk Tests medical policy for Pennsylvania Medicaid members, effective 2026-12-01. Subfractions or particle size advanced lipoprotein analysis is now listed as unproven and not medically necessary for cardiovascular risk, the list adds noninvasive point-of-care cardiac diagnostic platforms (such as CorVista) for predicting coronary artery disease, pulmonary hypertension, or pulmonary capillary wedge pressure, and CPT 83695 has been removed from the applicable codes.
UnitedHealthcare Community Plan of Pennsylvania revised its Medicaid medical policy for breast imaging for screening and diagnosing cancer, effective 2026-12-01. Magnetic resonance elastography and molecular breast imaging are now listed as unproven and not medically necessary, with the molecular imaging entry narrowed to routine screening in normal or high-risk individuals and positron emission mammography. The coverage rationale also adds a specific MRI-of-the-breast entry for elastography, and the criteria for proven high-risk breast MRI are unchanged in the text provided.
UnitedHealthcare Community Plan of Pennsylvania revised its coverage policy for Transarterial Radioembolization (TARE)/Selective Internal Radiation Therapy (SIRT) effective December 1, 2026. The policy now specifies six covered indications for yttrium-90 microsphere treatment in liver cancer patients with ECOG Performance Status 0-2, replacing the previous indication list and updating clinical evidence references. Key change: "metastasis from uveal/ocular melanoma" language was revised to "metastasis from uveal melanoma."
Independence Blue Cross expanded coverage for Teplizumab-mzwv (Tzield) to include pediatric patients aged 1 to <8 years with stage 2 type 1 diabetes, while maintaining non-coverage for patients aged 8-17 with stage 3 T1D (classified as experimental/investigational). Six ICD-10 diagnosis codes were removed from the policy. Billing teams must update systems to reflect the new pediatric age coverage expansion effective December 7, 2026.
Published June 22, 2026: Ambetter Health announced that 46 listed HCPCS H codes will no longer be covered beginning January 1, 2027, while HCPCS H0006 will become covered on that same date. Billing teams should identify claims and scheduled services using the listed H codes for January 2027 dates of service and prepare charge entry and provider notification accordingly.
Geisinger Health Plan (GHP) announced it will implement CMS-0057-F interoperability requirements, including a Provider Access API for in-network providers and a Prior Authorization API for electronic prior authorization exchange, with compliance beginning January 1, 2027 for Geisinger Gold (Medicare Advantage and Medicaid managed care), GHP Family, GHP Kids, Geisinger Marketplace, and FEHB products. Providers and their technology partners will need to register through the GHP Developer Portal and confirm a treatment relationship before member data can be requested; the publication says prior authorization requirements and decision criteria are unchanged.
UnitedHealthcare Community Plan of Pennsylvania revised its Saphnelo (anifrolumab-fnia) IV medical benefit drug policy, effective 2027-01-01. Starting then, coverage for moderate to severe SLE requires a prescriber attestation, with explanation, that the patient or caregiver cannot be trained or is physically unable to self-administer Saphnelo or Benlysta, along with a history of failure, contraindication, or intolerance to Benlysta IV or SQ, and the policy continues to exclude severe active CNS lupus, severe active lupus nephritis, and combination use with other biologics.
Medicaid members in Pennsylvania under the UnitedHealthcare Community Plan will see revised FcRn blocker coverage criteria effective 2027-01-01. Imaavy (nipocalimab-aahu) is now described as proven and medically necessary for warm autoimmune hemolytic anemia (wAIHA) in patients 12 years and older who are currently or were previously treated with corticosteroids, subject to documented diagnosis, prior therapy and prescriber requirements. ICD-10 code D59.11 was added to the applicable codes.
Highmark is updating its Medicare Part D formularies effective January 1, 2027, with medication removals and new restrictions. The Fundamental Formulary is being replaced with the Performance Formulary for all affected plans. Providers and members will receive notification letters starting mid-November 2026, and coverage determination requests can be submitted beginning November 16, 2026.
Highmark is expanding its CopayGo health plan in 2027 to include new product options: ASO clients will gain access to EPO and QHDHP designs (in addition to the existing PPO), and fully insured EPO and PPO products will become available in Delaware, New York, and Pennsylvania. Providers should verify member plan types and tiered copay designations (enhanced vs. standard) through Availity, as these affect member cost-sharing but not provider reimbursement.
Highmark is launching the Copay Armor Medical program on January 1, 2027, which provides copay assistance for eligible members receiving high-cost, provider-administered specialty drugs. Billing teams must be prepared to submit secondary claims to manufacturers after receiving Highmark's primary payment, with no upfront action required unless contacted by HelpScript. A complete medication list will be shared in upcoming communications.
Effective January 1, 2027, Highmark is simplifying its Risk Adjustment Program by removing four high-prevalence Part D conditions (Thyroid Disorders, Anxiety/Psychiatric Disorders, Hypertension, Coronary Artery Disease) from targeting and restructuring bonus tiers for gap assessments across Medicare Advantage, D-SNP, ACA, and Medicaid plans. These changes reduce targeted conditions by approximately 50% and introduce new tiered payment thresholds to reward higher performance levels.
Highmark is discontinuing four condition management programs effective January 1, 2027: Onduo/Verily Diabetes Management, Vida CHF/COPD Management, Well360 Behavioral Health Services, and related programs. Type 2 diabetes patients may transition to Noom Weight Management; behavioral health patients may access Spring Health. Billing teams must remove these programs as referral options from Availity Essentials by the effective date.
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.
Highmark is implementing a High-Performance Network eligibility evaluation based on Practice Performance Insights metrics (quality, care appropriateness, documentation quality, and cost efficiency). Practices that do not meet performance thresholds relative to peers may lose eligibility to participate in these networks. Network participation changes for 2027 will be communicated next month, and practices should review their scorecards now to identify improvement opportunities.
Highmark is discontinuing the Choice Blue product in nine counties in Central Pennsylvania (CPA) effective January 1, 2027. Existing members will transition at their 2027 benefit renewal and do not need to take action now. Billing teams should prepare for member migrations to alternative Highmark plans, particularly Performance Flex Blue.
Highmark will transition prior authorization determination letters from mailed format to digital delivery through the Availity Essentials Digital Correspondence Hub beginning in late January 2027. All providers are automatically enrolled; providers can opt out via Availity account settings. The authorization submission process and auth status checking remain unchanged.
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.
UnitedHealthcare Community Plan of Pennsylvania (Medicaid) added a medical policy for Pasatru (garetosmab-grts) for fibrodysplasia ossificans progressive (FOP), effective 2026-12-01. Initial therapy requires patients over 18, a FOP diagnosis, chart notes documenting clinical signs and symptoms, genetic testing confirming an ACVR1 mutation, prescribing by or in consultation with an FOP expert, dosing per FDA labeling, no combined use with Sohonos (palovarotene), and authorization for no more than 12 months; continuation requires documented positive clinical response with similar limits.
Highmark will publish an updated Interoperability and Data Exchange (IDE) Requirements Manual by January 1, 2027, on the Provider Resource Center. This manual explains which electronic medical record (EMR) solutions meet Highmark's data exchange requirements. Providers should monitor Provider News for notification when the manual is posted and review it to ensure EMR compliance.
UnitedHealthcare Community Plan of Pennsylvania revised its Oncology Medication Clinical Coverage policy, adding Vykoura (leucovorin) to the non-preferred oncology products list and introducing HCPCS code J0644 for billing. This policy governs coverage of injectable oncology medications based on NCCN Compendium evidence categories and requires prior authorization for non-preferred products when patients have documented intolerance to preferred alternatives.
UnitedHealthcare Community Plan of Pennsylvania has updated coverage for two thyroid eye disease treatments (Lumvoa and Tepezza) effective November 1, 2026. The policy now covers both drugs under the same clinical criteria, adds new HCPCS billing codes (J3490, J3590), and establishes lifetime dose limits (5 doses for Lumvoa, 8 doses for Tepezza). Billing teams must implement prior authorization requirements and update systems to enforce these new limits.
UnitedHealthcare Community Plan of Pennsylvania updated its Obstructive and Central Sleep Apnea treatment policy effective November 1, 2026. The revision adds radiofrequency ablation of the soft palate and/or tongue base to the list of unproven and not medically necessary procedures, updates clinical evidence references, and clarifies coverage criteria for surgical and non-surgical treatments. Billing teams must immediately identify and deny claims for this newly excluded procedure.
UnitedHealthcare Community Plan of Pennsylvania updated its Spinal Fusion and Decompression medical policy for Medicaid effective November 1, 2026. The policy revised clinical coverage criteria by adding a reference to InterQual® Client Defined lumbar decompression/fusion criteria and removing an older reference. Additionally, the policy explicitly states that several procedures are unproven and not medically necessary: Dynamic Stabilization systems, Facet Joint Replacement, Isolated Facet Joint Fusion, and Vertebral joint implants. Staging multiple spinal procedures in separate sessions when one session can address all sites is also deemed not medically necessary.
Effective Nov. 1, 2026, Highmark will require all providers in the Southeastern Pennsylvania (SEPA) service area to use self-service tools (Availity Essentials, Provider Chat, IVR) for claim status inquiries and claim investigations. The Highmark Provider Service Center will no longer handle these requests and will direct providers to self-service options instead.
Starting November 1, 2026, Highmark will implement Hospital OPPS claim reviews using cost-to-charge ratios adjusted by CMS OPPS methodology, with specific exclusions for drugs/biologicals, implants, and non-separately reimbursable items governed by specific reimbursement policies (RP-019A, RP-040, RP-061, RP-080). Highmark retains authority to conduct detailed line-item reviews and chargemaster audits. The Hospital OPPS Based Payment Method Provider Training Manual will be updated to reflect these changes.
Independence Blue Cross Medicare Advantage added face-to-face encounter and written order prior authorization requirements for home oxygen equipment codes K0738 (effective 10/28/2026) and E0424, E0431, E0433, E0434, E0439, E1390, E1391, E1392 (effective 04/13/2026, which has already passed). The practice must now obtain prior authorization before delivering these oxygen devices to Medicare Advantage members.
Independence Blue Cross added face-to-face encounter and written order prior authorization requirements to eight wheelchair HCPCS codes (E1161, K0002, K0003, K0004, K0005, K0006, K0007, K0831) effective 10/28/2026, aligning with Medicare Final Rule. The practice must obtain prior authorization before these wheelchairs are delivered or prior to authorization issuance.
Effective October 26, 2026, Highmark will no longer separately reimburse CPT code 97124 (massage therapy) when billed by providers in Chiropractic, Physical Therapy, Occupational Therapy, and Physiatry specialties. Claims with this code from these specialties will be denied as non-separately reimbursed. This change applies to Commercial and Medicare Advantage plans; massage therapists billing as rendering providers are not affected.
Effective October 16, 2026, Highmark is reducing reimbursement rates for CPT code 97153 (Adaptive Behavior Treatment by Protocol) across Commercial PPO products in Delaware, Pennsylvania, and West Virginia. Rates are being decreased to align technician-delivered ABA services with market benchmarks and maintain appropriate differentiation from clinician-delivered services. No changes to member eligibility, medical necessity criteria, authorization requirements, or coverage policies.
This is a comprehensive Medicare Advantage coverage policy for molecular biomarker tests used in prostate cancer risk stratification (effective 10/1/2026). The policy establishes coverage criteria for tests like ArteraAI, EpiSwitch, IsoPSA, MyProstateScore 2.0, ProMark, and ProsTAV, with coverage determinations based on MAC-specific LCDs/LCAs that vary by geographic jurisdiction. Billing teams must identify the correct MAC jurisdiction and apply the corresponding LCD requirements for each test ordered.
Independence Blue Cross updated policy 00.03.07au effective 10/01/2026 to add 39 new laboratory CPT codes (0660U-0698U) to the capitated laboratory program for HMO/HMO-POS members, terminate CPT code 0585U, and revise narratives for codes 0247U, 0575U, and 0591U. These codes must now be billed to the member's PCP-designated capitated laboratory site, not to non-capitated facilities, or claims will be denied.
Independence Blue Cross updated ICD-10 diagnosis codes for AECG/MCOT monitoring policy effective 10/01/2026. Nine codes were terminated and replaced with more specific codes that better capture dilated cardiomyopathy subtypes, arrhythmogenic cardiomyopathy, and specific arrhythmia diagnoses including CPVT, Brugada syndrome, and ventricular bigeminy. Billing teams must update claim submission systems to use only the new codes to avoid claim denials.
Pennsylvania Medical Assistance (Medicaid) has updated hospital presumptive eligibility (PE) determination criteria effective October 1, 2026, to restrict federal Medicaid coverage for certain noncitizen groups. Refugees, asylees, humanitarian parolees, and other lawfully present individuals (except those under 21 or pregnant) are now ineligible for PE determinations. Acute care and psychiatric hospitals must immediately update their PE screening procedures to apply the new citizenship/immigration status criteria.
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