Telemedicine and Virtual Visits

• 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 are 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 24/7 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.

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.

Provider Manual Chapter 2, Unit 5

*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.

The Centers for Medicaid and Medicare Services (CMS) guidelines

Yes, new patients are eligible.

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.

Communication technologies continue to evolve. Choosing the appropriate communication technology for telehealth appointments is a matter best decided by providers and their patients.

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.

Providing the Annual Wellness Visit Through Virtual Visits During COVID-19

Highmark will continue to reimburse providers for virtual visits at parity with face-to-face services if the services:

1. Are eligible for separate reimbursement
2. Are part of the member's benefit
3. Can be fully (meets the definition of the code), safely and effectively delivered through a virtual option
4. 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.

CMS Guidelines

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

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 the 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 an 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.

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 authorization for certain procedures has been extended during this time to avoid the need for a second authorization.

No. All benefit maximums still apply (e.g., X number of visits in a calendar year or plan benefit period).

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.

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.