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Highmark Now Offers Virtual PCP Visits—What Does This Mean for Physicians?

Highmark now offers its members Virtual PCP Visits and Virtual Retail Clinic Visits, effective for dates of service on or after Jan. 1, 2016.

Network participating primary care providers who have the required telecommunications technology have the option of delivering primary care services to Highmark members via real-time interactive audio and video telecommunications. Providing telemedicine services is optional and is not a requirement for network providers.

Virtual PCP Visits and Virtual Retail Clinic Visits can be conducted for initial, follow-up, or maintenance care. However, Highmark recommends that providers should carefully consider whether an in-person office visit for the initial visit would be beneficial in establishing a doctor-patient relationship. Primary care providers can make the determination as to whether virtual visits are the right course of treatment.

Which Highmark members are eligible?

Virtual PCP and 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. Virtual visits are also available to 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, the copay would be applied to Virtual PCP Visits.

Virtual PCP Visits and Virtual Retail Clinic Visits are not available for members with Medicare Advantage and Medicare supplemental plans.  

Patient eligibility can be reviewed via Highmark’s NaviNet Eligibility and Benefits Inquiry or by submitting a HIPAA 270 transaction.

What are the technology requirements for physicians and practices?

The Virtual PCP Visits and Virtual Retail Clinic Visits must take place using hardware and software that are HIPAA (Health Insurance Portability and Accountability Act) and HITECH (Health Information Technology for Economic and Clinical Health Act) compliant.

Interactive telecommunications technology must be multi-media communication that, at a minimum, includes audio and video equipment permitting real-time consultation between the patient location and provider location.  

How should physicians and practices handle billing and reimbursement for virtual visits?

According to Highmark, when billing professional services (1500/837P), Virtual PCP Visits and Virtual Retail Clinic Visits should be billed with outpatient Evaluation & Management (E&M) CPT codes (99201-99215) applicable to the services provided and with a GT modifier indicating the use of interactive audio and video telecommunications technology. Outpatient facility claims (UB-04/837I) should be billed using the appropriate procedure code (99201-99215) with the GT modifier and the appropriate revenue code.  

For more information regarding virtual visits, including detailed guidelines for providing telemedicine services, access chapter two of the Highmark Blue Shield Office Manual.

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