Please see Highmark’s Provider Manual, Chapter 2, Unit 5 for more information regarding the services that may be provided through this modality and other guidelines. For guidance specific to Home Health, please see the Home Health Frequently Asked Questions, otherwise please follow the guidelines below.
What telehealth options does Highmark offer?
Virtual Visits: Services 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.
Telemedicine: Services provided by Highmark-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 telehealth. These approved vendors provide access to a national network of board-certified physicians with twenty-four hour, seven days a week availability.
*Note: In-network providers do not need to utilize these vendor services to provide virtual services to Highmark members. These vendors are a separate option and benefit to certain members.
What services can be offered via virtual visits?
Please see Highmark’s Provider Manual, Chapter 2, Unit 5 for more information regarding the services that may be provided through this modality and other guidelines.
*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, new patients are eligible.
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 they will exercise enforcement discretion and waive potential HIPAA penalties for consumer communication applications if used for telehealth through December 31, 2023.
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 telehealth 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, a provider may use video OR audio to provide virtual visits if the service can be reasonably delivered in that way. This allowance is currently set to expire after December 31, 2023. Visit documentation for audio-only services should follow the same level of documentation as similar E&M visit complexity.
Per state statutes in Delaware and West Virginia, providers may continue use audio only to provide virtual visits after December 31, 2023.
*Medicare Advantage NOTE: Highmark Medicare Advantage plans continue 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?
For Medicare Advantage, annual wellness visits may be delivered through a virtual visit and may be used to identify care gaps that lead to gap closures or other STAR benefits and submit diagnoses to close risk adjustment gaps. The ability to impact STAR or risk adjustments measures through virtual visits is dependent on the type of gap and data able to be collected through this modality. See “Providing the Annual Wellness Visit Through Virtual Visits During Covid-19” for more information.
What telehealth codes are reimbursable by Highmark?
Highmark will continue to reimburse providers for virtual visits at parity with face-to-face services if the services:
- Are eligible for separate reimbursement
- Are part of the member's benefit
- Can be fully (meets the definition of the code), safely and effectively delivered through a virtual option
- Are not specifically disallowed by a Highmark medical or reimbursement policy
The use of place of service 02 (Telehealth Provided Other Than in Patient's Home) or 10 (Telehealth Provided in Patient's Home) for 1500 claims when billing for virtual health services is still required along with the appropriate use of modifier 95 on the applicable claim lines.
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.
For more information on billing and reimbursement for commercial and Medicare Advantage products, please see Highmark Reimbursement Policy Bulletin RP-046: Telemedicine and Telehealth Services.
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?
The waiver of Highmark member cost-sharing for in-network telehealth visits is effective for dates of service from March 13 through June 30, 2021. Beginning July 1, 2021, regular member cost-sharing for telehealth visits will begin again.
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.