Highmark Sets New Commercial 97153 Rates in PA, DE and WV on Friday

The notice lists new PPO rates by state and place of service, and says technician pay had run high against clinician codes.

Highmark's new commercial rates for CPT 97153 take effect Friday, October 16, 2026, in Pennsylvania, Delaware and West Virginia. The notice went up on August 17 and gives the new PPO rate by state and place of service. It doesn't give the old ones.

Why Highmark says it's doing this

Highmark says its review found that 97153 reimbursement "in several markets exceeded prevailing reimbursement relationships commonly observed between technician-delivered services and clinician-delivered services." In other words, it's pricing the technician code against the analyst codes, and in some markets it decided the gap was too small. Highmark doesn't call this a cut, and without the prior rates you can't tell from the notice how big the change is in any one market. Your contract and Availity fee schedule can.

Highmark also says it ran the review "consistent with the applicable Non-Quantitative Treatment Limitation (NQTL) analysis" and documented its rationale. That matters for employer-plan clients. In September the Labor Department narrowed its parity enforcement to three areas, and provider reimbursement methodology is one of them.

The new rates

  • Pennsylvania, PPO: $16.59 office, $15.73 non-office.
  • West Virginia, PPO: $14.53 office, $13.78 non-office.
  • Delaware, PPO: $15.73 office and non-office.

The notice applies to "applicable Commercial products" and lists PPO rates only. Highmark says the update doesn't change eligibility, benefits, medical necessity criteria, authorization requirements, coverage policies or documentation expectations. Only 97153 is affected.

The limits

"Applicable Commercial products" isn't defined, so it's not clear from the notice whether HMO, EPO or self-funded products follow the PPO table. The notice says nothing about Medicaid or Medicare Advantage. In Pennsylvania and West Virginia the non-office rate is lower, so a practice that delivers most 97153 hours in homes or the community will feel the non-office figure, not the office one.

What you must know or do

  • Billing lead, before Friday: pull your current Highmark 97153 rate from the contract or Availity fee schedule for each state you bill. Put it next to the new figure for your place of service.
  • Owners: multiply the difference by last quarter's Highmark 97153 units, split by office and non-office. That's your exposure, and it's the number to bring to a rate conversation.
  • Ask your Highmark provider representative in writing which commercial products beyond PPO the new rates apply to.
  • From late October, check the first Highmark remittances with dates of service on or after October 16 against the new table.
  • Highmark's Pennsylvania clinical policy also changed this year. Our piece on V-37-045 covers its eight discontinuation criteria.