To ensure our members are quickly able to access the right care in the right setting during the COVID-19 pandemic, Highmark is committed to assisting you in this important effort to ensure that our members have continued access to quality health care despite such challenging circumstances.
PUBLIC HEALTH EMERGENCY SET TO END
On January 30, 2023, the Biden Administration announced that it intends to end the COVID-19 public health emergency on May 11, 2023.
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COVID-19 VACCINES
The Food and Drug Administration (FDA) has granted full approval or emergency authorized use (EAU) to several COVID-19 vaccines. The rollout and distribution of the vaccines is determined by each state and the Centers for Disease Control and Prevention (CDC) helped to set those guidelines.
IN-NETWORK PROVIDERS
Highmark provides coverage for both the vaccine(s) and the administration(s) of the vaccine(s) in accordance with the member's benefit coverage. Highmark does not reimburse for vaccine(s) obtained at no cost to the provider. Modifier SL is used to identify vaccine(s) that were obtained at no cost.
See Reimbursement Policy RP-064 Government Supplied Vaccinations and Antibody Treatments for more detailed information and coding guidance.
OUT-OF-NETWORK PROVIDERS
Highmark will cover the cost of the vaccine and vaccine administration fees for out-of-network (OON) providers during the public health emergency. Current state and/or federal regulations prohibit any provider from balance billing patients for the COVID-19 vaccine.
INPATIENT HOSPITAL CARE
MEMBER COVERAGE
Medicare Advantage members will see no copays for COVID-related hospital admissions through the duration of the PHE.
Additional Information:
- Waiver applies to inpatient claims with a confirmed diagnosis (after positive COVID-19 test).
- Benefit limits/maximums (e.g., SNF days) still apply.
- Standard prior authorizations still apply.
- Waiver applies to covered services from in-network providers.
- Upon discharge, routine medical benefit coverage will apply.
| Visit Type |
Membership |
Dates of Service |
Must Be Related to COVID-19 |
|
In-Network Inpatient Hospital Care
|
Medicare Advantage
|
Feb. 1, 2020 – Duration of the PHE
|
Yes*
|
|
Office, Urgent Care, Emergency Department (ED)
|
All
|
Feb. 4, 2020 – Duration of the PHE
|
Yes**
|
*For COVID-19 treatment
**For COVID-19 testing and associated visit
OFFICE VISITS
In alignment with the Families First Coronavirus Response Act, Highmark will waive the member cost share for office visits (including telehealth), urgent care visits and Emergency Department visits when the visit results in a COVID-19 test being ordered or administered.
This means copayments, deductibles, and coinsurance do not apply for COVID-19 testing. This applies to all Medicare Advantage, ACA, and select employer plans. (Members should contact Member Services to see if this applies to their plan using the number on the back of their card.)
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 and standard cost sharing will apply.
TELEMEDICINE AND VIRTUAL VISITS
Please see Highmark’s Provider Manual, Chapter 2, Unit 5 for more information regarding the services that may be provided through this modality and other guidelines.
*Medicare Advantage NOTE: Highmark Medicare Advantage plans continue to follow The Centers for Medicaid and Medicare Services (CMS)’s guidelines for telemedicine visit coverage and reimbursement. Only the codes identified by CMS as appropriate for telemedicine services will be reimbursed by Highmark for Medicare Advantage members.
For additional guidance on Telemedicine and Virtual Visits, visit our Telemedicine and Virtual Visits page.
ASSOCIATED SERVICES
Additionally, Highmark will waive member cost share for any items or services provided during the visit in which the COVID-19 test is ordered or administered. Items or services unrelated to the evaluation of whether a patient should be tested for COVID-19 will be paid based on the member’s benefit plan.
A service will be considered related to COVID-19 diagnosis or treatment if:
- The COVID-19 test is attached to the claim OR the COVID-19 diagnosis code is on the claim when the provider is not also performing the test (e.g., when the Health department performs the test for the patient)
- The service falls into one of the following categories:
- Evaluation and Management (Office Visit, Urgent Care, Emergency Department)
- Consultation
- Chest X-ray
- Chest CT
- Respiratory Panel
- Influenza Test
- Breathing Treatment, including drugs administered in the office as part of the treatment
- Nebulizer Treatment, including drugs administered in the office as part of the treatment
The following service categories are examples of those considered non-related to COVID-19 diagnosis or treatment in the outpatient setting*, where applicable member cost share liability remains in effect. This list may be revised as new information becomes available.
- Allergy Testing
- Ambulance
- Anesthesia
- Behavioral Health
- Chemotherapy
- DME
- Self-Administered Prescription and Non-Prescription Drugs
- Occupational Therapy
- Physical Therapy
- Surgery
*Cost sharing for inpatient services will be waived based on Highmark’s decision to pay in-network, inpatient claims for COVID-19 treatment, except for self-funded groups that elected out of the program.
ALTERNATE HEDIS CHART SUBMISSION GUIDELINES
To further support containment of COVID-19, Highmark is encouraging all providers to fax any HEDIS® chart requests back to the designated return fax number identified on the original chart request. This change was communicated in eBulletin HEDIS CHART REVIEW AND ALTERNATE SUBMISSION GUIDELINES REGARDING THE CORONAVIRUS 2019 (COVID-19).
Last updated on 1/31/2023 11:56:05 AM