Unit 5: Telemedicine Services
2.5 Introduction to Telemedicine
2.5 Prescribing Protocol for Telemedicine Services
2.5 Telemedicine Service Benefit and Approved Vendors
2.5 Virtual PCP Visits and Virtual Retail Clinic Visits
2.5 Updating the Provider Directory for Virtual Services
2.5 Delaware Telemedicine Mandate – House Bill 69
2.5 West Virginia Mandate – House Bill 2024
Many factors can make it difficult for patients to get appropriate medical care when they need it — geography, weather, availability of specialists, transportation, and others. With advancements in technology that allow for visual communications and information exchange at a distance, the telemedicine field is evolving rapidly to meet the needs of the patient community.
Telemedicine includes a growing variety of applications and services using two-way forms of telecommunications technology. The use of this technology is now becoming integrated into the ongoing operations of hospitals, specialty departments, and physician offices. For both providers and patients, telemedicine can play a significant role in facing the challenges of maintaining or improving health care outcomes while reducing costs.
Some of the most important benefits of telemedicine include accessibility and flexibility for the patient community. With the mounting shortage of physicians, especially for primary care, telemedicine offers patients the convenience of connecting with medical professionals more easily when traveling, pressed for time, unable to take time off from work or school, or not able to drive long distances to see their health care provider.
What is Telemedicine?
Telemedicine is defined as the exchange of medical information between sites via electronic communication for transmitting clinical information for diagnostic, monitoring, and therapeutic purposes. The term “telehealth” is often used in conjunction with telemedicine and is intended to include a broader range of services using telecommunication technologies, including videoconferencing. These terms are often used interchangeably.
Highmark is committed to expanding access to quality care for our members and providing new options for more timely and convenient access to meet their needs. In our efforts to expand services and coverage to more members, we are providing telemedicine coverage options through:
- A telemedicine service benefit that provides coverage for services provided by our approved telemedicine vendors via real-time interactive audio and video telecommunications technology. These vendors provide 24/7 access to a national network of board-certified physicians.
- Benefit enhancements that provide coverage for “virtual visits” with our members’ trusted primary care providers and specialists using telecommunications technology.
Telemedicine Legislation
A wide variety of organizations support the use of telemedicine and legislation to require reimbursement by insurance companies and the Medicare and Medicaid programs.
- The State of Delaware enacted telemedicine legislation in 2015 that affects commercial individual and group insurance coverage. For additional information, please see the section of this unit on the Delaware Telemedicine Mandate – House Bill 69. Delaware has also enacted House Bill 160 which expands the definition of telehealth and gives providers easier access to performing telehealth services across state boarders.
- West Virginia House Bill 4363, effective June 11, 2016, created new sections to West Virginia Code (§30-3-13(a) and §30-14-12(d)) and implemented a variety of telemedicine practice standards and prescribing rules; however, West Virginia still lacks a payment parity law for telehealth care that applies to commercial health plans. West Virginia House Bill 4003, effective on July 1 2020, created new sections to West Virginia Code (in relevant part §33-53- 1) requiring coverage of telehealth services. West Virginia House Bill 2024, amended and reenacted West Virginia Code (§33-57-1), all relating to telehealth, defining telehealth services to include audio only telephone calls, requiring coverage of health care services provided through telehealth services if those same services are covered through face-to-face consultation, and requiring payment parity in accordance with the mandate. For additional information, please see the section of this unit on the West Virginia Telemedicine Mandate – House Bill 2024.
- Proposed legislation for telehealth practice standards and coverage by commercial insurance plans is under consideration in Pennsylvania.
Reimbursement Policy Bulletin RP-046
For information on billing and reimbursement for commercial and Medicare Advantage products, please see:
Highmark Reimbursement Policy Bulletin RP-046: Telemedicine and Telehealth Services.
This policy includes complete guidelines for both professional and facility billing requirements for reimbursement, including the use of Place of Service code 02 or code 10 on all professional telehealth claims and the modifiers needed for both professional and facility claims.
Reimbursement policies are available on the Provider Resource Center under Claims & Authorization, then Reimbursement Programs, and choose Reimbursement Policies.
The standard of care applicable to an in-person patient encounter also applies to a virtual patient encounter. Telemedicine consultations and treatment, including the authorization and dispensing of prescription medication(s), must be held to the same professional standards of appropriate medical practice as traditional in- person patient encounters.
Prior to issuing prescriptions via telemedicine, providers must ensure that a provider-patient relationship is established and documented in the member's file. A proper “provider-patient relationship” may be established when the provider (physician/practitioner) obtains all relevant medical history and conducts an appropriate evaluation to establish a diagnosis(es) and identify underlying conditions or contraindications to recommended treatment.
A valid provider-patient relationship may be established using telemedicine technologies provided the appropriate standard of care is met and all applicable state and federal statutes and regulations are followed. The services to establish the provider-patient relationship during the initial encounter, as described above, must take place via an interactive audio and video telecommunications system (unless exceptions are allowed for certain medical services as appropriate under applicable state laws).
Providers should give careful consideration in determining whether an in-person office visit for the initial visit would be beneficial in establishing a provider-patient relationship based on the particular member’s presenting condition(s). While some situations are appropriate for using telemedicine technologies for member care in lieu of the traditional in-person office visit, others are not.
Important
Telemedicine can be delivered via a real time 2-way audio-only conversation in Delaware (DE), New York (NY), and West Virginia (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.
Methods That Are Not Acceptable
A provider-patient relationship may not be established through, but not limited to, the following:
- Internet questionnaires;
- Social media;
- Email messages;
- Patient-generated medical history;
- Pennsylvania Only: Audio only communication including, but not limited to, interactive audio
- Text messages;
- Facsimile (fax) machine; or
- Any combination of the above.
These do not constitute acceptable standard of care and prescriptions cannot be issued to Highmark members when a provider seeks to establish a provider-patient relationship with the member based solely on these methods.
The following guidelines apply when using telemedicine technology to issue prescriptions to Highmark members:
- Prior to issuing a prescription, all relevant information that shows that a provider-patient relationship has been established (e.g., patient demographic information, chief complaint, history of present illness, allergies, medications, past medical/surgical/family history, social history, etc.) must be documented and maintained in the member’s medical record as required with in-person diagnosis and treatment services.
- If state law requires an in-person examination prior to the delivery of telemedicine services, the in-person services must be concluded and documented in the member’s medical record prior to the initiation of any related telehealth visits and issuance of prescriptions.
- For situations in which the standard of care requires an in-person examination in order to establish a diagnosis and determine recommended treatment, the in-person examination must be performed and documented in the member’s medical record prior to issuing a prescription via telemedicine.
- If allowable per state regulations, a provider without an established provider-patient relationship may issue a prescription via telemedicine if the prescribing provider is:
- Consulting at the request of another practitioner who maintains an ongoing relationship with the member;
- The other practitioner has performed an in-person physical examination of the member; and
- The other practitioner agrees to supervise the member’s ongoing care and use of the prescribed medications.
All federal and state prescribing statutes and regulations, including any limitations on prescribing and dispensing controlled substances, must be adhered to in prescribing through telemedicine technology.
American Well™ (Amwell) is the Highmark-approved vendor for Well360 Virtual Health, Highmark’s virtual care solution.
Effective January 1, 2022, we are introducing a long-term virtual health platform, Well360 Virtual Health. To support our Well360 Virtual Health platform, we have chosen Amwell as our exclusive vendor solution, with Highmark and Amwell both sharing a goal of offering the ultimate member experience for virtual urgent and behavioral health care, virtual primary care, dermatology, and women’s health.
Well360 Virtual Health will be easy to access and navigate when members need convenient, real-time virtual urgent care visits and virtual access to behavioral health.
Important: Teladoc will still continue to be available to some ASO clients.
Services Provided by Well360 Virtual Health
Well360 Virtual Health provides national coverage by certified providers via real-time interactive video and audio telecommunications technology. If members use Well360 Virtual Health for any of the following treatments, member cost sharing applies and can vary in the form of a copay or subject to network deductible and/or coinsurance as per their benefits:
- 24/7/365 Urgent Care: Primary Care Physician (PCP)-type care, such as, but not limited to the following: cough, sinus infection, sore throat, vomiting, diarrhea, fever, pinkeye, flu/cold, headache. These practitioners belong to nationwide networks of licensed, board-certified physicians, including family practitioners, internists, and pediatricians for acute care for minor illness.
- See member's Telemedicine Service benefit.
- Virtual behavioral health provided by Well360 Virtual Health. Scheduled video appointments, contingent upon provider availability, for conditions such as, but not limited to the following: Depression, anxiety, stress management, relationship challenges, and child behavior difficulties.
- See member’s Outpatient Mental Health benefit.
- Virtual Primary Care: The Virtual Primary Care solution connects members to virtual primary care doctors, providing easy and fast access to care. Primary care visits are scheduled visits with the member’s virtual PCP. Pediatricians are available servicing children 12 and older. Primary Care appointments can typically be scheduled within seven days or less. Services include both medically necessary office visits and routine physical exams.
- See member’s PCP/Physician Office Visit benefit.
- Dermatology: The dermatology solution virtually connects a member to a dermatologist. This is done by secure asynchronous* capabilities which allow for more convenient skin examinations and faster turnaround times compared to in-person dermatology visits.
- See member’s Specialist Office Visit benefit.
- Women’s Health: Women’s Health provides services for women by providers who specialize in women’s care. Women’s Health service consists of three different services offered on the platform – Women’s Health Medical Care, Women’s Health Therapy and Women’s Health Lactation Consulting.
- See member’s Telemedicine Service, Outpatient Mental Health and Preventive Adult Care benefit.
All vendors operate in accordance with state laws and regulations, and their providers are licensed to practice in the state in which the member is located. Members must have the benefit associated with the service line to obtain these services from Well360 Virtual Health.
Important! Well360 Virtual Health consists of providers within the Amwell Medical Group (AMG).
Important! Each Well360 Virtual Health service line is housed within a member’s benefits. Urgent care within Telemedicine Service Benefit, Behavioral Health within Outpatient Mental Health, Primary Care under PCP/Physician Office Visit, Dermatology under Specialist Office visit, and Women’s Health (Medical Care under Telemedicine Service, Therapy under Outpatient Mental Health, and Lactation under Preventive Adult Care).
Member Eligibility
The Telemedicine Service benefit provides coverage for Well360 Virtual Health services to most Highmark members with individual health plans and employer group coverage, both fully insured and self-insured.
Telemedicine coverage for services provided by Well360 Virtual Health is not available for members with Medicare supplemental plans, Medicare Carve Out, and Medicare Prime. Enhanced Services (Primary Care, Dermatology & Women’s Health) are not available for Traditional, Comprehensive, or Indemnity plans.
Please Note: Certain self-insured employer groups will continue to retain Teledoc as their telemedicine vendor.
Using Availity® to Determine a Member’s Coverage for Telemedicine Services
You can easily identify Highmark members with coverage for telemedicine services by our approved vendors by requesting the consultation benefit through Eligibility and Benefits Inquiry or by using Additional Benefit Notes in Eligibility and Benefits Response. If a member has coverage for telemedicine services, the Telemedicine benefit will indicate “Yes.”
For More Information
To learn more about Amwell, visit amwell.com.
Important! Amwell is not available for providers in the New York service areas.
Additional Services Offered by Amwell
In addition to online consultations with Well360 Virtual Health powered by Amwell’s nationwide network of providers, which are available to Highmark members through their Telemedicine Service benefit, as well as other benefits (see above), American Well offers an array of safe and secure HIPAA-compliant technology solutions for individual providers, group practices, and health care systems. These solutions allow providers to offer the convenience of a live, online virtual visit option for their own patients using the Amwell platform.
To learn more about the options American Well offers providers for use of their HIPAA-compliant technology platform, you can visit the Amwell website at business.americanwell.com.
Attention: Providers Using the Amwell Technology Platform for Their Private Practices
If you contract with American Well to provide an online virtual visit option for your patients using the Amwell technology platform, the agreement includes 24/7 support provided by Amwell’s nationwide provider network, the “Online Care Group,” whenever you/your staff are not available. Please keep in mind that Highmark member benefits may vary depending on who is actually performing the services:
- If you provide Virtual PCP Visits or Virtual Retail Clinic Visits to Highmark members, the services are eligible under the Highmark member’s PCP/Physician Office or Retail Clinic benefits, as applicable.
- If primary care services are provided to a Highmark member by an Amwell Online Care Group provider, they are eligible under a Highmark member’s Telemedicine Service benefit, if applicable.
As a result, the Highmark member’s cost-sharing may vary depending on which provider performs the service — you or the Online Care Group. In addition, if the member does not have the Telemedicine Service benefit, as well as other benefits (see above), the services would not be covered when provided by an Online Care Group provider.
In your discussions with American Well, confirm that it will be clear to your patients who is providing care when they sign on for an online visit — you or the Online Care Group. In addition, educate your patients about your online access and availability, and ensure that your Highmark patients understand that their benefits/cost-sharing could differ if care is provided by the Online Care Group when you are not available.
Attention: Behavioral Health Providers
Virtual Behavioral Health visits, whether provided by you or by an Online Care Group provider, are subject to cost-sharing under the member’s Outpatient Mental Health benefit; therefore, the member’s cost-sharing is the same for services provided by you or by the Online Care Group. However, please remember that a Highmark member must have both the Telemedicine Service benefit and coverage for Outpatient Mental Health services for behavioral health visits provided by Amwell’s Online Care Group.
Reminder: Most Highmark members have coverage for telemedicine services; however, benefits can vary by product and group. Always verify a member’s benefits prior to providing service.
For More Information
Please see the applicable sections of this unit for more information on Highmark’s benefit enhancements that provide coverage for Virtual PCP Visits and Virtual Retail Clinic Visits, Virtual Behavioral Health, Specialist Virtual Visits, and Teledermatology.
Virtual PCP Visits and Virtual Retail Clinic Visits provide our network participating primary care providers with the option of delivering primary care services to our members via real-time interactive audio and video telecommunications, or “telemedicine,” when appropriate. Telemedicine enables primary care providers to extend their reach and improve their efficiency and effectiveness while still maintaining high quality care and attention to patient safety.
Virtual PCP Visits and Virtual Retail Clinic Visits are the remote delivery of outpatient primary care services through the use of secure real-time interactive audio and video telecommunications technology. A patient can participate in a virtual visit with a primary care provider from the privacy of their own home, office, or other private setting.
Important!
Telemedicine can be delivered via a real time 2-way audio-only conversation in Delaware (DE), New York (NY), and West Virginia (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.
Why Virtual PCP Visits and Virtual Retail Clinic Visits?
Virtual PCP Visits and Virtual Retail Clinic visits are about more than convenience — it is about getting members the care they need when they need it.
Virtual PCP Visits and Virtual Retail Clinic Visits can provide expanded access to services, more efficient delivery of services, and also potential cost savings.
- Access to primary care can be increased for all members — especially for individuals with multiple chronic health conditions, those with severe illness and disability, and underserved populations in rural and remote areas.
- Virtual visits are a cost-effective way to engage with patients and deliver care anywhere, anytime, while reducing administrative costs for the provider and travel costs for the patient.
- Virtual PCP Visits and Virtual Retail Clinic Visits can be used to triage cases and help reduce emergency room visits and hospitalizations by diverting members to less costly forms of care.
Eligible Providers
Highmark participating primary care providers who have the required telecommunications technology to support Virtual PCP Visits and Virtual Retail Clinic Visits may participate. The services performed must fall under the scope of the provider’s license, and the sessions must be conducted following Highmark’s service and security guidelines.
Providing Virtual PCP Visits and Virtual Retail Clinic Visits for Highmark members is optional and not a requirement of network providers.
Member Eligibility
Virtual PCP Visits and Virtual Retail Clinic Visits are available to most Highmark members with individual health plans and employer group coverage, both fully and self-insured, that include benefits for PCP/Physician Office Visits and/or Retail Clinic Visits. This is also available for Federal Employee Program (FEP) members.
Any member cost-sharing or visit limits under the PCP/Physician Office/Outpatient Visit benefits or the Retail Clinic benefit would apply. For example, if a member’s benefit has a copay for a PCP visit, then the copay would be applied to Virtual PCP Visits.
Please consult coverage materials to determine eligibility for Medicare Advantage and Medicare Supplemental plans.
Reminder: Always Verify Benefits
Providers are reminded to always verify a member’s eligibility and benefits prior to rendering services. It is the provider’s responsibility to confirm that the member’s benefit plan provides the appropriate benefits for the anticipated date of service. You can verify benefits electronically quickly and easily via Availity’s Eligibility and Benefits Inquiry or by submitting a HIPAA 270 transaction.
In Availity, use Additional Benefit Notes in Eligibility and Benefits Response.
If the member has coverage for Virtual PCP Visits and/or Virtual Retail Clinic Visits, the benefit category will indicate “Virtual Visits – Yes.”
Important: Telemedicine Service Benefit Category is for Well360 Virtual Health and Teledoc Services Only
Virtual PCP Visits and Virtual Retail Clinic Visits are a service delivery option provided to our members under the PCP/Physician and Retail Clinic benefits. They are separate from the services provided by our approved telemedicine services vendors — Amwell and Teladoc, which are independent companies that provide online medical consultation services for patients through their network of practitioners.
In Availity's Eligibility and Benefits Inquiry, the “Telemedicine Service” benefit category under Professional Services is an indicator for Well360 Virtual Health and Teladoc services only. It does not indicate a member’s eligibility for Virtual PCP Visits and Virtual Retail Clinic Visits. For more information on the services these vendors provide for Highmark members, please see the section in this unit titled Telemedicine Service Benefit and Approved Vendors.
Note: Highmark partners with Amwell to deliver Well360 Virtual Health, Highmark’s virtual care solution.
Technology Requirements
The Virtual PCP Visits and Virtual Retail Clinic Visits must take place via real-time audio and video telecommunications. Interactive telecommunications technology must be multi-media communication that, at a minimum, includes audio and video equipment permitting real-time consultation among the patient location and provider location.
The provider must ensure that the aesthetic quality of the consultation is comparable to that of an in-person consultation (i.e., proper lighting, camera positioning, network connection, etc.). The provider’s monitor resolution (matrix) must be a minimum of 512x512 at 8-bit pixel depth.
The technology needed by the member will be driven by the technology platform that the provider uses to conduct this service. Members can be at any location that they choose that is conducive for Virtual PCP Visits and Virtual Retail Clinic Visits, provided the member has access to both audio and video streaming technology. The member should be in a location that is private and away from distractions.
Important!
Telemedicine can be delivered via a real time 2-way audio-only conversation in Delaware (DE), New York (NY), and West Virginia (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.
Security Guidelines
Virtual PCP Visits and Virtual Retail Clinic Visits must be conducted through real-time interactive audio and video telecommunications hardware and software that are HIPAA (Health Insurance Portability and Accountability Act) and HITECH (Health Information Technology for Economic and Clinical Health Act) compliant.
Highmark supports the highest standards to protect the confidentiality of our members’ information, but there may be risks in passing personal health information (PHI) virtually. Highmark is not responsible for the security of virtual visits and does not validate the safeguards of any equipment and software used on either side of the virtual transmission.
Guidelines for Providing Services
Virtual visits are not intended to replace in-person visits and support; it is another care delivery option that can be used by primary care providers if they choose. The primary care provider can make the determination whether Virtual PCP Visits and Virtual Retail Clinic Visits are the right course of treatment for their patients. If you offer Virtual PCP Visits or Virtual Retail Clinic Visits but feel that it will not be the most effective approach for a patient, then you may refuse to see the patient virtually.
Virtual PCP Visits and Virtual Retail Clinic Visits can be conducted for initial, follow-up, or maintenance care; however, providers should give careful consideration in determining whether an in-person office visit for the initial visit would be beneficial in establishing a doctor-patient relationship.
The following guidelines must be followed 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 and West Virginia: telemedicine can be delivered via a real time 2-way audio-only conversation in West Virginia (WV) and Delaware (DE) but in DE, 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.
- Services performed must fall under the scope of the provider’s licensure.
- Providers shall comply with local, state, and federal laws and other regulatory agency requirements.
- Mechanisms to ensure continuity of care, follow-up, and referrals for emergency services must be in place and transparent to patients. Telemedicine treatment and consultations, including the authorization and dispensing of prescription medication(s), shall be held to the same professional standards of appropriate medical practice as those in a traditional in-office face-to-face encounter.
- The provider must take the appropriate steps to establish a doctor-patient relationship and conduct all appropriate evaluations and history consistent with traditional standards.
- The provider must obtain all relevant medical information (e.g., patient demographic information, chief complaint, history of present illness, allergies, medications, past medical/surgical/family history, and social history) prior to delivery of a medical diagnosis and treatment.
- Documentation of any visits using secure interactive audio and video telecommunications technology must be maintained in the patient’s medical record as required with in-person diagnosis and treatment services.
Billing and Reimbursement
Claims for Virtual PCP Visits and Virtual Retail Clinic Visits are submitted based on how you are contracted with Highmark.
Reimbursement will be based on the plan allowance in place at the time services were rendered.
Member cost sharing (copay, deductible, and/or coinsurance) and visit limits apply if applicable.
For more information on billing and reimbursement, please see Highmark Reimbursement Policy RP-046: Telemedicine and Telehealth Services. Reimbursement policies are available on the Provider Resource Center under Claims & Authorization, and then Reimbursement Policies, and then choose Reimbursement Policies.
PCPs: Updating Your Information for the Online Provider Directory
If you are able to offer Virtual PCP Visits, you can have that noted in your practice information in the online Highmark Provider Directory. The Provider Directory is a valuable tool for our members to find providers who provide the services they need in locations convenient for them.
For instructions on reporting your ability to provide Virtual PCP Visits, please see the section in this unit on Updating the Provider Directory for Virtual Services.
Delaware House Bill 69
In 2015, the State of Delaware enacted telemedicine legislation that provides coverage for the telemedicine services of most physicians and many other providers. For additional information, please see the section of this unit on the Delaware Telemedicine Mandate – House Bill 69.
West Virginia House Bill 2024
In 2021, the State of West Virginia enacted telemedicine legislation that amended and reenacted West Virginia Code (§33-57-1), defining telehealth services to include audio only telephone calls, requiring coverage of health care services provided through telehealth services if those same services are covered through face-to-face consultation, and requiring payment parity in accordance with the mandate. For additional information, please see West Virginia Telemedicine Mandate – House Bill 2024.
The demand for behavioral health care services continues to steadily increase, while access to qualified behavioral health specialists remains limited. The growing demand often results in longer wait times for patients to receive treatment. However, telemedicine is now allowing behavioral health specialists to provide their expertise remotely, offering more flexibility and reducing the time it takes for patients to receive proper treatment. Effective for dates of service on and after January 1, 2015, Highmark will reimburse mental health providers for outpatient care delivery via Virtual Behavioral Health.
What is Virtual Behavioral Health?
Virtual behavioral health is the remote delivery of outpatient mental health services through the use of secure real-time interactive audio and video telecommunications technology. A patient can participate in a virtual visit with a behavioral health specialist from the privacy of their own home, office, or other private setting.
Important!
Telemedicine can be delivered via a real time 2-way audio-only conversation in Delaware (DE), New York (NY), and West Virginia (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.
Why Virtual Behavioral Health?
Virtual behavioral health is about more than just convenience — it is about getting members the care that they need when they need it, or the care they are afraid to seek in person due to social stigma. It helps address barriers to access, stigma, and time constraints typically associated with mental health services. Virtual behavioral health can provide expanded access to services, more efficient delivery of services, and also potential cost savings.
- Access to mental health care can be increased for all patients but especially for individuals with multiple chronic health conditions, those with severe illness and disability, and underserved populations in rural and remote areas.
- Virtual visits can provide added comfort to patients who otherwise might be fearful and resistant to meet face-to-face in a clinic.
- Counseling and intervention services can be delivered more quickly via teleconferencing sessions versus on-site appointments that may take longer to arrange.
- Virtual visits are a cost-effective way to engage with patients and deliver care anywhere, anytime while reducing administrative costs for the provider and travel costs for the patient.
- Virtual behavioral health visits can be used to conduct psychiatric consultations to triage cases and help reduce emergency room visits and hospitalizations by diverting clients to less costly forms of care.
Eligible Providers
Any Highmark participating mental health provider who has the necessary telecommunications technology to support a virtual outpatient mental health visit may participate. The services performed must fall under the scope of the provider’s license, and the sessions must be conducted following Highmark’s recommended service and security guidelines. Providing virtual behavioral health visits for Highmark members is optional and not a requirement.
Member Eligibility
Virtual behavioral health is available to most Highmark members with individual health plans and employer group coverage, both fully and self-insured, that include an Outpatient Mental Health benefit. Please Note: If a member’s group plan does not include or carves out mental health benefits to a vendor, then Highmark’s virtual behavioral health coverage would not apply to the member.
Any member cost-sharing under the Outpatient Mental Health benefit would apply. For example, if a member’s benefit plan has a copay for an outpatient mental health visit, the copayment will apply to virtual behavioral health services.
Virtual behavioral health services are not available for members with Medicare supplemental plans.
Note: This is also available for Federal Employee Program (FEP) members.
Important: Telemedicine Service Benefit Category is for Well360 Virtual Health and Teledoc Services Only
Virtual behavioral health is a service delivery option provided to our members under the Outpatient Mental Health benefit. It is separate from the services provided by our approved vendors — Amwell and Teladoc — under the Telemedicine Service benefit. Amwell and Teladoc are independent companies that provide online medical consultation services for patients through their network of practitioners.
In Availity's Eligibility and Benefits Inquiry, the "Telemedicine Service" benefit category under Professional Services is an indicator for Well360 Virtual Health and Teladoc services only. It does not indicate a member’s eligibility for virtual behavioral health services. For more information on the services these vendors provide for Highmark members, please see the section in this unit titled Telemedicine Service Benefit and Approved Vendors.
Note: Highmark partners with Amwell to deliver Well360 Virtual Health, Highmark’s virtual care solution.
Important!
Amwell and Teladoc are not available for behavioral health providers in the New York service areas.
Reminder: Always Verify Benefits
Providers are reminded to always verify a member’s eligibility and benefits prior to rendering services. It is the provider’s responsibility to confirm that the member’s benefit plan provides the appropriate benefits for the anticipated date of service. You can verify benefits electronically quickly and easily via Availity’s Eligibility and Benefits Inquiry or by submitting a HIPAA 270 transaction.
Technology Requirements
The virtual behavioral health visit must take place via real-time interactive video and audio telecommunications. Interactive telecommunications technology must be multi-media communication that, at a minimum, includes audio and video equipment permitting real-time consultation among the patient location and provider location.
The provider must ensure that the aesthetic quality of the consultation is comparable to that of an in-person consultation (i.e., proper lighting, camera positioning, network connection, etc.). The provider’s monitor resolution (matrix) must be a minimum of 512x512 at 8-bit pixel depth.
The technology needed by the member will be driven by the technology platform that the provider uses to conduct this service. Members can be at any location that they choose that is conducive for virtual behavioral health visits, provided the member has access to both audio and video streaming technology. The member should be in a location that is private and away from distractions.
Important!
Telemedicine can be delivered via a real time 2-way audio-only conversation in Delaware (DE), New York (NY) and West Virginia (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.
Security Guidelines
Virtual behavioral health visits must be conducted through real-time interactive audio and video telecommunications hardware and software that are HIPAA (Health Insurance Portability and Accountability Act) and HITECH (Health Information Technology for Economic and Clinical Health Act) compliant.
Highmark supports the highest standards to protect the confidentiality of our members’ information, but there may be risks in passing personal health information (PHI) virtually. Highmark is not responsible for the security of virtual visits and does not validate the safeguards of any of the equipment and software used on either side of the virtual transmittal.
Guidelines for Providing Services
Virtual visits are not intended to replace in-person visits and support; it is another care delivery option that can be used by mental health providers if they choose. The provider can make the determination whether a virtual behavioral health visit is the right course of treatment for their patients. The mental health provider must determine what channel of care is the best for their patient. If you offer virtual behavioral health services but feel that it will not be the most effective approach for a patient, then you may refuse to see the patient virtually.
Virtual behavioral health visits can be conducted for initial, follow-up, or maintenance care; however, providers should give careful consideration in determining whether an in-person office visit for the initial visit would be beneficial in establishing a doctor patient relationship.
The following guidelines must be followed when conducting virtual behavioral health visits:
Any telecommunications technology used must provide both audio and video streams that meet Highmark’s technology and security requirements.
- All services provided must be medically appropriate and necessary.
- Services performed must fall under the scope of the provider’s licensure.
- Providers shall comply with local, state, and federal laws and other regulatory agency requirements.
- Telemedicine treatment and consultations, including the authorization and dispensing of prescription medication(s), shall be held to the same professional standards of appropriate medical practice as those in a traditional in-office face-to-face encounter.
- The provider must take the appropriate steps to establish a doctor-patient relationship and conduct all appropriate evaluations and history consistent with traditional standards.
- The provider must have all of the relevant medical information (e.g., patient demographic information, chief complaint, history of present illness, allergies, medications, past medical/surgical/family history, and social history) to deliver a competent medical diagnosis, treatment, and counseling plan.
- Documentation of the real-time interactive audio and video telecommunication relevant to the ongoing medical care of the patient should be maintained as part of the patient’s medical record.
Important!
Telemedicine can be delivered via a real time 2-way audio-only conversation in Delaware (DE), New York (NY) and West Virginia (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.
Billing and Reimbursement
Reimbursement for virtual behavioral health service is based on the fee schedule in place on the date of service and is subject to any applicable member cost-sharing (copay, deductible, and/or coinsurance).
For more information on billing and reimbursement, please see Highmark Reimbursement Policy Bulletin RP-046: Telemedicine and Telehealth Services. Reimbursement policies are available on the Provider Resource Center under Claims & Authorization, and then Reimbursement Programs, and then choose Reimbursement Policies.
Updating Your Information for the Online Provider Directory
If you offer virtual behavioral health services, you can have that noted in your practice information in the online Highmark Provider Directory. The Provider Directory is a valuable tool for our members to find providers who provide the services they need in locations convenient for them. For instructions on reporting your ability to provide virtual behavioral health services, please see the section in this unit on Updating the Provider Directory for Virtual Services.
Telemedicine is defined as the exchange of medical information between sites via electronic communication for transmitting clinical information for diagnostic, monitoring, and therapeutic purposes. The term “telehealth” is often used in conjunction with telemedicine and is intended to include a broader range of services using telecommunication technologies, including videoconferencing.
An enhancement to the specialist visit benefit provides Highmark members with coverage for outpatient “virtual” visits with specialists using telecommunications technology. This “specialist virtual visit” benefit enhancement provides coverage for specialist services for members who do not have readily available access to such specialty services.
What is a Specialist Virtual Visit?
The specialist virtual visit is an outpatient telehealth service that is a real-time interactive audio and video transmission of a physician-patient encounter from one site to another using telecommunications technology.
The patient is located at an “originating site.” An originating site can be a medical site (e.g., PCP’s office, outpatient facility) or a non-medical site (e.g., member’s home or office) and is connected to a specialist at a “distant site.” The benefit provides coverage for the services of the specialist at the distant site and also for an access fee billed by the medical originating site where the patient is located, when applicable.
Applicable Products
The specialist virtual visit benefit enhancement is applicable to all Highmark group products and to most individual products.
This benefit enhancement does not apply to the following:
- Medicare supplemental products in all service areas
- Individual HMO product available in Pennsylvania’s Western Region
- Complete Care in Pennsylvania
Verifying Member Eligibility
Participating providers should use Eligibility and Benefits Inquiry in Availity to verify a member’s coverage for specialist virtual visits. If Availity is not available, please call the Provider Service Center.
Important: Telemedicine Service Benefit Category is for Well360 Virtual Health and Teledoc Services Only
Specialist virtual visits are a benefit enhancement and separate from the services provided by our approved vendors — Amwell and Teladoc — under the Telemedicine Service benefit. Amwell and Teladoc are independent companies that provide online medical consultation services for patients through their network of practitioners.
In Availity's Eligibility and Benefits Inquiry, the "Telemedicine Service" benefit category under Professional Services is an indicator for Well360 Virtual Health and Teladoc services only. It does not indicate a member’s eligibility for specialist virtual visits. For more information on the services these vendors provide for Highmark members, please see the section in this unit titled Telemedicine Service Benefit and Approved Vendors.
Note: Highmark partners with Amwell to deliver Well360 Virtual Health, Highmark’s virtual care solution.
Important! (NY Only)
Amwell is not available for providers in the New York service areas.
Requirements
The specialist virtual visit benefit enhancement provides coverage for outpatient specialist services for members who do not have readily available access to such specialty services. When a covered benefit, evaluation and management and consultation services that occur with the specialty physician using telecommunications technology may be covered under the following conditions:
- Any telecommunications technology must provide both audio and video streams that meet Highmark’s technology and security requirements;
- When applicable, at a medical originating site, the medical examination of the patient at the originating site must be under the control of the specialty practitioner at the distant site;
- All services provided must be medically appropriate and necessary;
- Services performed must be under the scope of the provider’s licensure;
- Providers shall comply with local, state, and federal laws and other regulatory agency requirements;
- Mechanisms to ensure continuity of care, follow-up, and referrals for emergency services must be in place and transparent to patients;
- The specialist consultation must take place via real-time interactive audio and video telecommunications technology. Interactive telecommunications systems must be multi-media communication that, at a minimum, include audio and video equipment permitting real-time consultation; Documentation of the real-time interactive audio and video telecommunication relevant to the ongoing medical care of the patient should be maintained as part of the patient’s medical record;
- A designated room with appropriate equipment, including camera, lighting, transmission, and other needed electronics and the appropriate medical office amenities is established in both the medical originating site, when applicable, and the distant site.
- Telemedicine treatment and consultations, including the authorization and dispensing of prescription medication(s), shall be held to the same professional standards of appropriate medical practice as those in a traditional in-office face-to-face encounter.
- The provider must take the appropriate steps to establish a doctor-patient relationship and conduct all appropriate evaluations and history consistent with traditional standards; • The provider must have all of the relevant medical information (e.g., patient demographic information, chief complaint, history of present illness, allergies, medications, past medical/surgical/family history, and social history) to deliver a competent medical diagnosis, treatment, and counseling plan.
Important!
Telemedicine can be delivered via a real time 2-way audio-only conversation in Delaware (DE), New York (NY) and West Virginia (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.
Reminder: Directing Care to Network Providers
Providers are reminded that members will receive the highest level of benefits if the specialist involved in the specialist virtual visit is a participating Highmark network provider and, when applicable, is in the highest benefit tier. Depending on their benefit plan, some members may not receive coverage for services provided by an out-of-network specialist or may be responsible for higher cost- sharing amounts for services provided by an out-of-network specialist.
As a participating provider, you should direct members to other providers who participate in the network associated with the member’s benefit plan. If a recommended specialist is not participating in the network associated with the member’s benefit plan, the member must be notified in advance that a non- participating provider is not obligated to follow Highmark contractual guidelines and services could result in higher out-of-pocket expenses for the member.
Security Guidelines
Specialist virtual visits must be conducted through interactive audio and video telecommunications hardware and software that are HIPAA (Health Insurance Portability and Accountability Act) and HITECH (Health Information Technology for Economic and Clinical Health Act) compliant, which must be certified by your technology platform vendor. The provider is responsible for ensuring that the aesthetic quality of the consultation is comparable to that of an in-person consultation (e.g., proper lighting, camera positioning, network connections, etc.).
Highmark supports the highest standards to protect the confidentiality of our members’ information, but there may be risks in passing personal health information (PHI) virtually. Highmark is not responsible for the security of virtual visits and does not validate the safeguards of any of the equipment and software used on either side of the virtual transmittal.
Important!
Telemedicine can be delivered via a real time 2-way audio-only conversation in Delaware (DE), New York (NY) and West Virginia (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.
Originating Site Billing and Reimbursement
The originating site is the location of an eligible member at the time the evaluation or consultation service is being provided via a specialist virtual visit. The originating site can be either a medical site or a non-medical site.
Only a medical originating site (e.g., PCP’s office, outpatient facility) is eligible for an access fee. Claims for the medical originating site’s access fee will be accepted as either professional (1500/837P) or outpatient facility (UB-04/837). No other fees may be billed to either Highmark or to the member by the medical originating site and all contractual member hold harmless requirements shall apply.
Reimbursement will be based on the fee schedule in place at the time the services were rendered. The member will be responsible for applicable cost-sharing (deductible and/or coinsurance) according to their benefit plan.
Distant Site Billing and Reimbursement
The distant site is the location where the specialist rendering the professional service is located. Highmark will accept only a professional claim (1500 Claim Form/837P) for the specialist’s evaluation/assessment services provided at the distant site.
Reimbursement will be based on the fee schedule in place at the time the services were rendered. Highmark will not accept or reimburse claims submitted for an access fee by the distant site. Member cost-sharing (copay, deductible, and/or coinsurance) will apply if applicable.
For More Information
For more information on billing and reimbursement for the originating and distant sites, please see Highmark Reimbursement Policy Bulletin RP-046: Telemedicine and Telehealth Services. Reimbursement policies are available on the Provider Resource Center under Claims & Authorization, and then Reimbursement Programs, and then choose Reimbursement Policies.
Updating Your Information for the Online Provider Directory
If you offer Specialist Virtual Visits, you can have that noted in your practice information in the online Highmark Provider Directory. The Provider Directory is a valuable tool for our members to find providers who provide the services they need in locations convenient for them.
For instructions on reporting your ability to provide Specialist Virtual Visits, please see the section in this unit on Updating the Provider Directory for Virtual Services.
The demand for access to dermatologists continues to steadily increase. However, patients in need of skin care often wait a long time for a face-to-face office appointment with a board-certified dermatologist. In some instances, the wait could result in delays in treatment of serious conditions such as skin cancer.
Highmark is committed to expanding access to quality care for our members. In order to provide faster and more convenient access to dermatologists for our members, teledermatology services are eligible for reimbursement for most Highmark members.
What is Teledermatology?
Teledermatology is the use of secure telecommunications technology to deliver dermatologic services and clinical information remotely. It uses technology that allows the patient to send digital images and personal information to the consulting dermatologist.
The dermatologist views the images and reviews the information provided by the patient to determine if the patient can be treated virtually. Patients for whom the diagnosis remains unclear or who have potentially serious conditions can be scheduled for an in-person office visit.
Teledermatology is not intended to replace an in-person doctor’s visit and support. Rather, Highmark wants members to have access to the care they need, when then need it -- before their situation could turn into something more serious and costly. There may, however, be situations in which teledermatology is not right for the member’s condition and this would need to be determined by the physician.
Benefits of Teledermatology for Physicians and Members
With secure technology, physicians are able to provide their expertise online and offer more flexibility to our members and reduce the time it takes to receive treatment. Many minor skin conditions can be safely diagnosed and treated virtually while serious cases requiring immediate in-person care can be identified more quickly.
For our members, the availability of virtual visits can eliminate the extended wait time for in-office visits and can significantly enhance access to dermatologic care. Members can get care when it is more convenient without having to miss work, school, or other activities. They can conduct a visit from the comfort of their home while allowing the dermatologist to use office visits for more critical cases.
Member Eligibility
Teledermatology is available to most Highmark members with individual health plans and both fully insured and self-insured employer group coverage. A Specialist Office Visit, which is eligible under most benefit plans, must be a covered service for a member to have coverage for teledermatology services.
Any member cost-sharing under the Specialist Office Visit benefit would apply. For example, if a member’s benefit plan has a copay for a Specialist Office Visit, the copayment will be applied to teledermatology services.
Teledermatology is not available for members with Medicare supplemental plans.
Note: This is also available for Federal Employee Program (FEP) members.
Important: Telemedicine Service Benefit Category is for Well360 Virtual Health and Teledoc Services Only
Teledermatology is a service delivery option provided to our members under the Specialist Office Visit benefit. It is separate from the services provided by our approved vendors — Amwell and Teladoc — under the Telemedicine Service benefit. Amwell and Teladoc are independent companies that provide online medical consultation services for patients through their network of practitioners.
In Availity's Eligibility and Benefits Inquiry, the "Telemedicine Service" benefit category under Professional Services is an indicator for Well360 Virtual Health and Teladoc services only. It does not indicate a member’s eligibility for teledermatology services. For more information on the services these vendors provide for Highmark members, please see the section in this unit titled Telemedicine Service Benefit and Approved Vendors.
Note: Highmark partners with Amwell to deliver Well360 Virtual Health, Highmark’s virtual care solution.
Technology Requirements
Teledermatology services must be provided using store and forward technology. Store and forward is secure technology (HIPAA & HITECH compliant) that allows a member to log in to an online site, enter medical history, explain the medical issue, upload images, submit the request to a doctor, and receive an electronic response from the doctor.
Requirements for store and forward technology to be used for providing teledermatology services are outlined in Highmark Medical Policy Z-70. Highmark’s medical policies are accessible on the Provider Resource Center in the main menu at the top of the page under Policies & Programs, and then Medical Policies.
Security Requirements
Teledermatology visits must be conducted through store-and-forward (asynchronous conferencing) hardware and software that are HIPAA (Health Insurance Portability and Accountability Act) and HITECH (Health Information Technology for Economic and Clinical Health Act) compliant.
Highmark supports the highest standards to protect the confidentiality of our members’ information, but there may be risks in passing personal health information (PHI) virtually. Highmark is not responsible for the security of virtual visits and does not validate the safeguards of any of the equipment and software used on either side of the virtual transmittal.
Guidelines for Providing Services
Providing teledermatology services for Highmark members is optional and not a requirement. Any Highmark dermatologist who has the necessary technology to support secure online service delivery may participate as long as they follow Highmark’s recommended guidelines for service and security.
Teledermatology services must be provided by dermatologists and services performed must fall under the scope of the provider’s licensure. In addition, the following guidelines must be followed:
- The provider must take the appropriate steps to establish a doctor-patient relationship and conduct all appropriate evaluations and history consistent with traditional standards.
- All services provided must be medically necessary and appropriate.
- Providers shall comply with local, state, and federal laws and other regulatory agency requirements. Telemedicine treatment and consultations, including the authorization and dispensing of prescription medication(s), shall be held to the same professional standards of appropriate medical practice as those in a traditional in-office face-to-face encounter.
- Mechanisms to ensure continuity of care, follow-up, and referrals for emergency services must be in place and transparent to patients.
- The provider must have all of the relevant medical information (e.g., patient demographic information, chief complaint, history of present illness, allergies, medications, past medical/surgical/family history, and social history combined with the appropriate review of high-quality digital images (serving as the physical examination) to deliver a competent medical diagnosis, treatment, and counseling plan.
- Documentation of online secure store and forward communications (asynchronous conferencing) relevant to the ongoing medical care of the patient and the downloaded image of the patient’s medical issue should be maintained as part of the patient’s medical record.
- Digital image(s) used should be a minimum of 800 X 600 pixel (480,000) resolution.
- Online platforms should maintain accurate and transparent information about their website, the owner(s)/operator(s), location, and contact information.
Billing and Reimbursement
Reimbursement will be based on the fee schedule in place at the time services were rendered. Member cost-sharing (copay, deductible, and/or coinsurance) would apply if applicable.
For more information on billing and reimbursement, please see Highmark Reimbursement Policy Bulletin RP-046: Telemedicine and Telehealth Services. Reimbursement policies are available on the Provider Resource Center under Claims & Authorization, and then Reimbursement Programs, and then choose Reimbursement Policies.
Updating Your Information for the Online Provider Directory
If you offer teledermatology services, you can have that noted in your practice information in the online Highmark Provider Directory. The Provider Directory is a valuable tool for our members to find providers who provide the services they need in locations convenient for them.
For instructions on reporting your ability to provide teledermatology services, please see the section in this unit on Updating the Provider Directory for Virtual Services.
The Highmark Provider Directory located on each of our public websites is a fast, easy way for our members to find providers near their homes or their workplace. And it is a valuable tool that offers your current and potential patients important details about your practice, including office location, hours of operation, parking availability, and nearby public transit information.
The online Provider Directory can also indicate if you are able to offer the “virtual” telemedicine services as described in this unit (Virtual PCP Visits; Virtual Behavioral Health; Specialist Virtual Visit; Teledermatology; and for providers located in Delaware, telemedicine services as applicable under Delaware House Bill 69 and Delaware House Bill 160). This is self-reporting and up to you to supply us with this information.
Updating Your Practice Information via Availity
If you are able to provide virtual visits/telemedicine services, you can notify Highmark by updating your practice information via Availity. Select Provider Data Maintenance or Provider File Management (Delaware, Pennsylvania, and West Virginia only) in Availity's Payer Spaces.
Once your files are updated, your listing in the online Provider Directory will be updated to indicate that you can provide telemedicine services. Here is an example of how this would display in Practice Information in your file of the Provider Directory:
In addition to the telemedicine programs discussed in the previous sections of this unit, effective January 1, 2016, Highmark Blue Cross Blue Shield (DE) will also provide coverage for the services of most physicians and many other providers performed via telemedicine. House Bill 69, now Delaware law, requires that insured members are covered for telemedicine services on the same basis as an in-person visit to their provider.
This new law affects all fully insured commercial group and individual health care plans. Self- insured employer groups may or may not elect to provider coverage.
Note: Medicare supplemental plans are exempt from this law.
Key Definitions Under Delaware House Bill 69
Telemedicine is a form of telehealth, which is the delivery of clinical health care services by means of real time two-way audio, visual, or other telecommunications or electronic communications, including the application of secure video conferencing or store and forward transfer technology to provide or support health care delivery which facilitate the assessment, diagnosis, consultation, treatment, education, care management and self-management of a patient’s health care by a health care provider practicing within his or her scope of practice as would be practiced in-person with a patient, and legally allowed to practice in the state, while such patient is at an originating site and the health care provider is at a distant site.
- Distant site – a site at which a health care provider legally allowed to practice in the state is located while providing health care services by means of telemedicine or telehealth.
- Originating site – a site in Delaware at which a patient is located at the time health care services are provided to him or her by means of telemedicine or telehealth, unless the term is otherwise defined with respect to the provision in which it is used; provided, however, notwithstanding any other provision of law, insurers and providers may agree to alternative siting arrangements deemed appropriate by the parties.
- Store and forward transfer – the transmission of a patient’s medical information either to or from an originating site or to or from the provider at the distant site, but does not require the patient being present nor must it be in real time.
Applicable Products
Delaware House Bill 69 is applicable to all fully insured Highmark commercial group and individual products. Self-insured clients may or may not elect to provide coverage.
This benefit enhancement does not apply to Medicare supplemental products in Delaware.
REMINDER: Always verify benefits
Providers are reminded to always verify a member’s eligibility and benefits prior to rendering services. It is the provider’s responsibility to confirm that the member’s benefit plan provides the appropriate benefits for the anticipated date of service.
You can verify benefits electronically quickly and easily via Availity’s Eligibility and Benefits Inquiry or by submitting a HIPAA 270 transaction. If Availity is not available, please call the Highmark Blue Cross Blue Shield (DE) Provider Service Center.
Highmark Blue Cross Blue Shield (DE) members can be directed to call the Member Services telephone number on their ID cards to inquire about coverage under their benefit plan.
Non-Covered Services
Services that are not covered include, but are not limited to, the following:
- Unsecured and unstructured services such as, but not limited to, Skype, instant messaging, and email
- Provider-to-provider consultations, provider-to-provider telephone conversations, facsimile, or email communications
Security Guidelines
Services conducted through real-time interactive audio and video telecommunications (or via a real time 2-way audio-only conversation if the patient is not able to access the appropriate broadband service or other technology necessary to establish an audio and visual connection) or Store and Forward technology must use hardware and software that are HIPAA (Health Insurance Portability and Accountability Act) and HITECH (Health Information Technology for Economic and Clinical Health Act) compliant.
Highmark Blue Cross Blue Shield (DE) supports the highest standards to protect the confidentiality of our members’ information, but there may be risks in passing personal health information (PHI) virtually. Highmark Blue Cross Blue Shield (DE) is not responsible for the security of telemedicine communication and does not validate the safeguards of any of the equipment and software used on either side of the virtual transmission.
Guidelines for Providers
Services eligible under Delaware House Bill 69 are not intended to replace in-person visits. Providers should give careful consideration in determining whether an in-person office visit for the initial visit would be appropriate and beneficial.
The provision of telemedicine services is optional and not a requirement of network providers. Eligible Highmark Blue Cross Blue Shield (DE) providers with the appropriate technology must follow the additional guidelines below:
- Provider must take the appropriate steps to establish a doctor-patient relationship and conduct all appropriate evaluations and history consistent with traditional standards.
- All services provided must be medically necessary and appropriate.
- Services performed must fall under the scope of the provider’s licensure.
- Providers shall comply with local, state, and federal laws and other regulatory agency requirements.
- Telemedicine treatment and consultations, including the authorization and dispensing of prescription medication(s), shall be held to the same professional standards of appropriate medical practice as those in a traditional in-office face-to-face encounter.
- Mechanisms to ensure continuity of care, follow-up, and referrals for emergency services must be in place and transparent to patients.
- Provider must obtain all relevant medical information (e.g., patient demographic information, chief complaint, history of present illness, allergies, medications, past medical/surgical/family history, and social history) combined with the appropriate review of high-quality digital images (if applicable) prior to delivery of medical diagnosis and treatment.
- Documentation of the telemedicine service must be maintained in the patient’s medical record, as with in-person diagnosis and treatment services.
Telemedicine services are not covered when the above criteria are not met. A participating, preferred, or network provider can bill the member for the non- covered service.
Billing and Reimbursement
Reimbursement for all services will be based on the fee schedule in place at the time services were rendered. Member cost-sharing (copay, deductible, and/or coinsurance) and service limits will apply if applicable.
For more information on billing and reimbursement, please see Highmark Reimbursement Policy Bulletin RP-046: Telemedicine and Telehealth Services. Reimbursement policies are available on the Provider Resource Center in the main menu at the top of the page under Claims & Authorization, and then Reimbursement Programs, and then choose Reimbursement Policies.
Updating Your Information for the Online Provider Directory
If you offer telemedicine services, you can have that noted in your practice information in the online Highmark Delaware Provider Directory. The Provider Directory is a valuable tool for our members to find providers who provide the services they need in locations convenient for them.
For instructions on reporting your ability to provide telemedicine services, please see the section in this unit on Updating the Provider Directory For Virtual Services.
Providers who are licensed, in good standing in all states in which he or she is licensed, and not currently under investigation or subject to an administrative complaint; and registered as an interstate telehealth practitioner with the appropriate board in West Virginia are able to provide telehealth services when the health care practitioner-patient relationship is established.
The standard of care for the provision of telehealth services requires the patient visits an in-person health care practitioner within 12 months of using the initial telemedicine service or the telemedicine service will no longer be available to the patient until an in-person visit is obtained. Providers can use their discretion to suspend this requirement on a case-by-case basis.
This does not apply to the following services:
- Acute inpatient care,
- Post-operative follow-up checks,
- Behavioral medicine,
- Addiction medicine, or
- Palliative care.
Telemedicine Medical Records
The patient record established during the use of telemedicine technologies must be accessible and documented for both the provider and the member, consistent with the laws and legislative rules governing patient health care records. All laws governing the confidentiality of health care information and governing patient access to medical records apply to records of practice of medicine or podiatry provided through telemedicine technologies. A provider solely providing services using telemedicine technologies must make documentation of the encounter easily available to the patient, and subject to the patient’s consent, to any identified care provider of the patient.
Establishing a Patient-Physician Relationship
If an existing provider-member relationship does not exist prior to the utilization of telemedicine or if services are rendered solely through telemedicine, the relationship may only be established:
- Through the use of telemedicine technologies which incorporate interactive audio using store and forward technology, real-time videoconferencing, or similar secure video services during the initial physician-patient or podiatrist-patient encounter;
- For the practice of pathology and radiology, a physician-patient relationship may be established through store and forward telemedicine or other similar technologies; or
- Through the use of audio-only calls or conversations that occur in real time. Patient communication though audio-visual communication is preferable, if available or possible.
Telemedicine Medical Records
The patient record established during the use of telemedicine technologies must be accessible and documented for both the provider and the member, consistent with the laws and legislative rules governing patient health care records. All laws governing the confidentiality of health care information and governing patient access to medical records apply to records of practice of medicine or podiatry provided through telemedicine technologies. A provider solely providing services using telemedicine technologies must make documentation of the encounter easily available to the patient, and subject to the patient’s consent, to any identified care provider of the patient.
Prescribing Medication via Telehealth
Providers may not prescribe controlled substances listed in Schedule II of the Uniform Controlled Substances Act to members who they see solely through telemedicine. This includes:
- Pain-relieving controlled substance listed in Schedule II of the Uniform Controlled Substance Act as part of a course of treatment for chronic nonmalignant pain solely based upon a telemedicine
- Drugs with the intent of causing an abortion
The prescribing limitations do not apply when:
- A physician is providing treatment to patients who are minors, or if 18 years of age or older, who are enrolled in a primary or secondary education program and are diagnosed with intellectual or developmental disabilities, neurological disease, Attention Deficit Disorder, Autism, or a traumatic brain injury in accordance with guidelines as set forth by organizations such as the American Psychiatric Association, the American Academy of Child and Adolescent Psychiatry, or the American Academy of Pediatrics. In these cases, providers must maintain records supporting the diagnosis and the continued need of treatment.
- Submits an order to dispense a controlled substance listed in Schedule II of the Uniform Controlled Substances Act to a hospital patient for immediate administration in a hospital.
What is Telestroke?
A telestroke service is a consultative modality that facilitates care for patients with acute stroke in a hospital emergency department by a vascular neurologist at stroke centers. These services are provided through telemedicine in the form of real-time video-conferencing for timely consultations with a vascular neurologist.
Telestroke services operate on a "hub and spoke" model allowing community hospitals that lack comparable staffing as larger urban hospitals and academic medical centers to access the expertise of the stroke centers and provide enhanced stroke care.
Applicable Products
The telestroke benefit enhancement applies to all eligible Highmark members with Commercial coverage.
Hub and Spoke
The "hub" is considered the specialist, the vascular neurologist at the stroke center. They are able to visualize real-time video feeds and conduct examinations of patients experiencing stroke-like symptoms from various emergency departments that represent the "spoke" via a video-conference link.
Originating Site Billing and Reimbursement
When a "spoke" facility is providing a telestroke service via a telecommunications system, they are to use HCPCs code Q3014 (telehealth originating site facility code) to bill for the technical services, along with Revenue Code 0780 with a stroke diagnosis.
Always check Medical Policy!
Medical Policy includes medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. For guidelines for telestroke services, please see Highmark Medical Policy Z-65: Telestroke.
Highmark's medical policies are accessible on the Provider Resource Center in the main menu at the top of the page under Policies & Programs, and then Medical Policies.
Verify Eligibility
Providers are reminded to always verify a member's eligibility and benefits prior to rendering services. It is the provider's responsibility to confirm that the member's benefit plan provides the appropriate benefits for the anticipated date of service.
You can verify benefits electronically quickly and easily via Availity's Eligibility and Benefits Inquiry or by submitting a HIPAA 270/271 transaction.
The following entities, which serve the noted regions, are independent licensees of the Blue Cross Blue Shield Association: Western and Northeastern PA: Highmark Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Choice Company, Highmark Health Insurance Company, Highmark Coverage Advantage Inc., Highmark Benefits Group Inc., First Priority Health, First Priority Life or Highmark Senior Health Company. Central and Southeastern PA: Highmark Inc. d/b/a Highmark Blue Shield, Highmark Benefits Group Inc., Highmark Health Insurance Company, Highmark Choice Company or Highmark Senior Health Company. Delaware: Highmark BCBSD Inc. d/b/a Highmark Blue Cross Blue Shield. West Virginia: Highmark West Virginia Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Health Insurance Company or Highmark Senior Solutions Company. Western NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Cross Blue Shield. Northeastern NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Shield.
All references to “Highmark” in this document are references to the Highmark company that is providing the member’s health benefits or health benefit administration and/or to one or more of its affiliated Blue companies.
All revisions to this Highmark Provider Manual (the “manual” or “Highmark Provider Manual”) are controlled electronically. All paper copies and screen prints are considered uncontrolled and should not be relied upon for any purpose.
