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.
ACCESS
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™. 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.
*NOTE: Highmark Medicare Advantage plans continue to follow The Centers for Medicaid and Medicare Services (CMS) 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.
Can I continue to use alternate communication channels, such as Skype or FaceTime, for telehealth treatment or diagnosis purposes now that the Public Health Emergency (PHE) has officially ended?
Access to care is important to our members. Delivering virtual care through the appropriate technology makes health care accessible and convenient to members, especially those who live in rural or remote areas and those who don’t have access to reliable transportation.
Communications technologies continue to evolve. Choosing the appropriate communications technology for telehealth appointments is a matter best decided by providers and their patients.
What telehealth (video) services will Highmark Commercial continue to cover now that the PHE has ended?
The following guidelines must be adhered to when conducting Virtual PCP Visits and Virtual Retail Clinic Visits:
- Pennsylvania Only: Any telecommunications technology used must provide both audio and video streams that meet Highmark’s technology and security guidelines.
- Delaware (DE), New York (NY), and West Virginia (WV): Telemedicine services can be delivered via a real time 2-way, audio-only conversation in, DE, NY, and WV, but in DE and NY, the patient must be unable to access the appropriate broadband service or other technology necessary to establish an audio and visual connection.
- All services provided must be medically necessary.
For additional information, please read the Telehealth FAQs article in the May 2023 issue of Provider News.
Is a visual component required in the telehealth service?
The answer depends on the state where you practice.
- Pennsylvania – Visual Needed: Yes, there must be a visual component. Any telecommunications technology used must provide both audio AND video streams that meet Highmark’s technology and security guidelines.
- West Virginia – Audio-Only: Telemedicine can be delivered via a real time 2-way, audio-only conversation in West Virginia.
- Delaware and New York – Audio-Only with a Caveat: Audio-only is acceptable only if a visual and audio connection can’t be established via the appropriate broadband service or other technology.
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.
CODING/BILLING/REIMBURSEMENT
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 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.
Are providers still able to do Annual Wellness Visits (AWVs) via telehealth after the end of the PHE?
Yes. Use the following codes, with the appropriate modifiers:
| G0438 |
Annual Wellness Visit; Includes a personalized prevention plan of service (PPS), initial visit. |
| G0439 |
Annual Wellness Visit; Includes a personalized prevention plan of service (PPS), subsequent visit. |
| G0468 |
Federally qualified health center (FQHC) visit, IPPE or AWV; a FQHC visit that includes an initial preventive physical examination (IPPE) or annual wellness visit (AWV) and includes a typical bundle of Medicare-covered services that would be furnished per diem to a patient receiving an IPPE or AWV. |
| 99497 |
Advance care planning including the explanation and discussion of advance directives, such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate. |
| 99498 |
Advance care planning including the explanation and discussion of advance directives, such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; each additional 30 minutes (List separately in addition to code for primary procedure). |
| 99391 |
Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender-appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; infant (age younger than 1 year). |
| 99392 |
Periodic comprehensive preventive medicine reevaluation and management of an individual, including an age and gender-appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; early childhood (age 1 through 4 years). |
| 99393 |
Periodic comprehensive preventive medicine reevaluation and management of an individual, including an age and gender-appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; late childhood (age 5 through 11 years). |
| 99394 |
Periodic comprehensive preventive medicine reevaluation and management of an individual, including an age and gender-appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; adolescent (age 12 through 17 years). |
| 99395 |
Periodic comprehensive preventive medicine reevaluation and management of an individual, including an age and gender-appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunization(s), laboratory/diagnostic procedures, established patient; 18-39 years. |
| 99396 |
Periodic comprehensive preventive medicine reevaluation and management of an individual, including an age and gender-appropriate history, examination, counseling//anticipatory guidance/risk factor reduction interventions, and ordering of appropriate immunizations(s), laboratory/diagnostic procedures, established patient; 40-64 years. |
| 99397 |
Periodic comprehensive preventive medicine reevaluation and management of an individual, including age and gender-appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering or appropriate immunization(s), laboratory/diagnostic procedures, established patient; 65 years and over. |
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.
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).
MEMBER COVERAGE
What is the cost to the member?
The waiver of Highmark member cost-sharing for in-network telehealth visits was in effect for dates of service from March 13 through June 30, 2021. As of July 1, 2021, regular member cost-sharing for telehealth visits was reinstated.
If members have a virtual visit but need a screening test, will they need a second doctor visit with additional cost share?
Possibly. 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.