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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.

All benefit maximums still apply e. The waiver of Highmark member cost-sharing for in-network telehealth visits is effective for dates of service from March 13 through June 30, Beginning July 1, , regular member cost-sharing for telehealth visits will begin again. If a member has a virtual visit but needs a screening test, will they need a second doctor visit with additional cost share?

Some testing sites may require additional evaluation in order for a person to be deemed eligible to be tested for COVID If the member is referred for testing, Highmark will waive the member cost share for the COVID test and in-person visit if the visit results in the COVID diagnostic test being ordered or administered. Contact Us. Provider Directory. Highmark Blue Cross Blue Shield serves the 29 counties of western Pennsylvania and 13 counties of northeastern Pennsylvania.

Highmark Blue Shield serves the 21 counties of central Pennsylvania and also provides services in conjunction with a separate health plan in southeastern Pennsylvania. Quick Links: Manuals. Highmark Provider Manual. Medical Policy Medical Policy. Medical Policies. Medicare Advantage Medical Policies. Requiring Authorization.

Pharmacy Policy Search. Message Center. Manuals Highmark Provider Manual. The authorization is typically obtained by the ordering provider. Some authorization requirements vary by member contract. This information should not be relied on as authorization for health care services and is not a guarantee of payment.

Benefit plans vary widely and are subject to change based on the contract effective dates. The provider is responsible for verification of member eligibility and covered benefits. Effective dates are subject to change. Highmark will provide written notice when codes are added to the list; deletions are announced via online publication.

Examples of services that may require authorization include the following. This is not an all-inclusive list. Benefits can vary; always confirm member coverage. The online portal is designed to facilitate the processing of authorization requests in a timely, efficient manner.

If you are a Highmark network provider and have not signed up for NaviNet, learn how to do so here. Highmark recently launched a utilization management tool, Predictal, that allows offices to submit, update, and inquire on medical inpatient authorization requests. Fax: If you are unable to use NaviNet, you may also fax your authorization requests to one of the following departments. The associated preauthorization forms can be found here.

Telephone: For inquiries that cannot be handled via NaviNet, call the appropriate Clinical Services number , which can be found here.

Highmark contracts with WholeHealth Networks, Inc. Additional information about the programs and links to prior authorization codes are available under Care Management Programs in the left website menu. Authorization number not appearing, unable to locate member, questions about clinical criteria screen. Contact Us. Provider Directory.

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Virtual Visits : S ervices 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. Highmark has also partnered with Bright Heart Health to provide our members with comprehensive addiction treatment services for opioid use disorder via telehealth. These approved vendors provide access to a national network of board-certified physicians with twenty-four hour, seven days a week availability.

These vendors are a separate option and benefit to certain members. 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? The U. For further guidance and information, visit the OCR website. May I provide virtual visits by phone or audio only?

This allowance is currently set to expire after December 31, Per state statutes in Delaware and West Virginia, providers may continue use audio only to provide virtual visits after December 31, F or 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.

Highmark will continue to reimburse providers for virtual visits at parity with face-to-face services if the services:. The use of place of service 02 Telehealth Provided Other Than in Patient's Home or 10 Telehealth Provided in Patient's Home for claims when billing for virtual health services is still required along with the appropriate use of modifier 95 on the applicable claim lines.

Do I need to submit prior authorizations for applicable services during this time? 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.

All benefit maximums still apply e. The waiver of Highmark member cost-sharing for in-network telehealth visits is effective for dates of service from March 13 through June 30, Beginning July 1, , regular member cost-sharing for telehealth visits will begin again.

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