Payment Policies



All Highmark Wholecare Products Payment Policies:
Hot and Cold Packs- Payment Policy
Screening, Brief Intervention, and Referral to Treatment (SBIRT) Reimbursement
Sepsis-3


Medicare Payment Policies:
Diabetic Retinal Eye Exam
Maximum Units of Service - Claims Payment Policy - Outpatient
Maximum Units of Service - Claims Payment Policy - Professional
Opioid Treatment Providers (OTP)


PA Medicaid Payment Policies:
Heparin Flush Policy
ICD-10-CM Excludes Notes Policy
Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)
Maximum Units of Service - Claims Payment Policy - Outpatient
Maximum Units of Service - Claims Payment Policy - Professional
NDC Codes
Preventative Visits and Sick Visits on the Same Day
Telemedicine Services
Use of CMS NCDs and LCDs


This information is issued on behalf of Highmark Wholecare, coverage by Gateway Health Plan, which is an independent licensee of the Blue Cross Blue Shield Association. Highmark Wholecare serves a Medicaid plan to Blue Shield members in 13 counties in central Pennsylvania, as well as, to Blue Cross Blue Shield members in 27 counties in western Pennsylvania. Highmark Wholecare serves Medicare Dual Special Needs plans (D-SNP) to Blue Shield members in 14 counties in northeastern Pennsylvania, 12 counties in central Pennsylvania, 5 counties in southeastern Pennsylvania, and to Blue Cross Blue Shield members in 27 counties in western Pennsylvania.

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