View the Webinar: Telemedicine During COVID-19
Highmark is committed to assisting you in this important effort to ensure that our members have continued access to quality health care despite such challenging circumstances. To help avoid further spread the virus, Highmark is actively encouraging our members to utilize telemedicine services and virtual visits.
We are also expanding our telemedicine medical and reimbursement policies for a limited time to permit and pay for more telehealth providers, services and modalities. For guidance specific to Home Health, please see the Home Health Frequently Asked Questions, otherwise please follow the guidelines below.
Please be advised that any temporary modifications or provisions in our telemedicine policies and procedures are for dates of service from March 13, 2020 through June 30, 2021 unless otherwise noted. Should this change at any time, we will update this information accordingly.
What telemedicine options does Highmark offer?
Virtual Visits: Virtual Retail Clinic Visits, Virtual PCP Visits, Specialist Virtual Visits, Virtual Behavioral Health and TeleDermatology through in-network providers.
Telemedicine Highmark contracts with three Blue Cross Blue Shield Association (BCBSA) approved Telemedicine vendors – American Well (Amwell)™, Doctor On Demand™, and Teladoc™. Highmark has also partnered with Bright Heart Health to provide our members with comprehensive addiction treatment services for opioid use disorder via Telemedicine. These approved vendors provide access to a national network of board-certified physicians with twenty-four hour, seven days a week availability.
Which providers can offer telemedicine?
Virtual Visits for covered services are eligible when provided by Highmark in-network providers within the scope of their license, deemed appropriate using their medical judgment, and delivered within the definition of the code billed.
Please note: Telemedicine services are services provided by Highmark approved telemedicine vendors – (Amwell)™, Doctor On Demand™, Teladoc™, and Bright Heart Health.
What services can be offered via Virtual Visits?
See answer above. Highmark’s reimbursable telemedicine code list can be found here.*
*Medicare Advantage NOTE: Highmark Medicare Advantage plans continue to follow The Centers for Medicaid and Medicare Services (CMS)’s guidelines for telemedicine visit coverage and reimbursement. Only the codes identified by CMS as appropriate for telemedicine services will be reimbursed by Highmark for Medicare Advantage members.
Are new patients eligible to utilize virtual visits?
Yes. In accordance with the telehealth waiver issued by CMS related to COVID-19, new patients will be permitted to receive telehealth until the Public Health Emergency (PHE) declared by the Department of Health and Human Services (HHS) expires.
Am I allowed to use alternate communication channels, such as Skype or FaceTime, for telehealth treatment or diagnosis purposes during the COVID-19 spread?
Yes. The U.S. Department of Health and Human Services’ Office of Civil Rights (OCR) announced that, effective immediately, they will exercise enforcement discretion and waive potential HIPAA penalties for consumer communication applications if used for telehealth during the COVID-19 nationwide public health emergency.
The OCR’s discretion applies to widely available communications apps, such as FaceTime or Skype, when used in good faith for any telehealth treatment or diagnostic purpose, regardless of whether the telehealth service is directly related to COVID-19.
In line with the OCR’s decision, Highmark will temporarily relax its current telemedicine policy requirements as they relate to the specific communication applications used. For further guidance and information, visit the OCR website.
May I provide virtual visits by phone or audio only?
Yes.* Per the OCR’s guidelines, during the Public Health Emergency (PHE), a provider may use video OR audio to provide virtual visits to patients using any non-public facing remote communication product that is available. Claims billed for these services will be processed the same as a virtual visit that utilizes both audio and video as normally recommended.
*Medicare Advantage NOTE: Highmark Medicare Advantage plans continues to follow CMS’s guidelines for telemedicine visit coverage and reimbursement.
Can Annual Wellness Visits delivered through a virtual visit be used to address Stars and Risk Adjustment measures?
Yes. Read "Providing the Annual Wellness Visit During COVID-19" for more information.
What telemedicine codes are reimbursable by Highmark?
Highmark has temporarily expanded its list of reimbursable telemedicine codes to include procedures that were not previously eligible to be performed via virtual visits and telemedicine. This includes some physical/occupational/speech therapy services (not requiring physical touch by definition) and additional behaviorial health services.
Click here for the expanded code set.*
Please be advised that we trust providers to use their professional judgment when providing a service, and they remain responsible for correct coding and documentation procedures.
*Medicare Advantage NOTE: Highmark Medicare Advantage plans continue to follow CMS’s guidelines for telemedicine visit coverage and reimbursement. Only the codes identified by CMS as appropriate for telemedicine services will be reimbursed by Highmark for Medicare Advantage members.
What does Highmark reimburse for virtual visits?
Highmark will reimburse each code at the contracted rate or Highmark established Fee Schedule for these services. Highmark’s Telehealth Reimbursement Policy is currently being updated and will address the temporary provisions outlined above.
Do I need to submit prior authorizations for applicable services during this time?
Yes. With a few exceptions, our current Utilization Management standards still apply. Procedures that currently require a prior authorization will still apply to both in-person and virtual visits.
Prior authorizations for certain procedures have been extended during this time to avoid the need for a second authorization. Please see our Clinical/Operational Update page for more information.
Are any visit limits expanded during this time?
No. All benefit maximums still apply (e.g., X number of visits in a calendar year or plan benefit period).
What is the cost to the member?
- ACA and Commercial Members: Highmark member cost-sharing (deductibles, coinsurance and copayments) for outpatient, in-network Virtual Visits and covered Telemedicine Services provided by our approved national vendors (American Well, Doctor On Demand, and Teladoc) will be waived for dates of service from March 13 through June 30, 2021 regardless of medical diagnosis.
- Medicare Advantage Members: Highmark member cost-sharing (deductibles, coinsurance and copayments) for outpatient, in-network or out-of-network Virtual Visits and covered Telemedicine Services provided by our approved national vendors (American Well, Doctor On Demand, and Teladoc) will be waived for dates of service from March 13 through June 30, 2021 regardless of medical diagnosis.
- FEP and Self-Insured Employer Group Members: The telehealth cost share waiver does not apply to FEP or any self-insured employer group that has opted out of the cost share waiver. Members should contact Member Services (using the number on the back of their card) to see if this applies to their plan.
- CHIP Members: Highmark member cost sharing (copays) for outpatient, in-network Virtual Visits and covered Telemedicine Services provided by our approved national vendors (American Well, Doctor On Demand, and Teladoc) does not apply. There is no cost for these services.
If a member has a virtual visit but needs a screening test, will they need a second doctor visit with additional cost share?
Possibly. Some testing sites may require additional evaluation in order for a person to be deemed eligible to be tested for COVID-19.
If the member is referred for testing, Highmark will waive the member cost share for the COVID-19 test and in-person visit (if the visit results in the COVID-19 diagnostic test being ordered or administered).
Any items or services provided during the visit in which the test is ordered or administered, but unrelated to the evaluation of whether a patient should be tested, will be paid based on the member’s benefit plan.
If the visit does not result in the COVID-19 diagnostic test being ordered or administered, the visit will be paid based on the member’s benefit plan.