HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 
Medical Policy:
U-9-001
Topic:
Maternity Ultrasound
Section:
Maternity
Effective Date:
March 3, 2025
Issued Date:
March 3, 2025
Last Revision Date:
February 2025
Annual Review:
February 2025
 
 

A maternity ultrasound, also known as a prenatal ultrasound, is a non-invasive imaging test that uses high-frequency sound waves to create images of the developing fetus inside the mother's womb (uterus).

An ultrasound can be performed abdominally or trans vaginally

Ultrasound exams allow the provider to evaluate the fetus’s health and development, monitor the pregnancy, and detect congenital anomalies.

Ultrasound also is used during chorionic villus sampling and amniocentesis to help guide these procedures.

The American College of Obstetricians and Gynecologists (ACOG) 2018 Practice Bulletin, Ultrasonography in Pregnancy, defines exams performed during the second and third trimesters as follows:

  • Standard: includes fetal presentation, amniotic fluid volume, cardiac activity,
    placental position, fetal biometry, fetal number, and an anatomic survey.
  • Limited: not a comprehensive exam but a focused study performed at some time after a complete ultrasound study to obtain information on a specific issue. 
  • Specialized: a detailed study indicated to address suspected or confirmed anomaly based on previous ultrasound exam, laboratory test, history, or clinical findings; a specialized ultrasound may include fetal Doppler ultrasonography, biophysical profile, amniotic fluid assessment, fetal echocardiography, or additional biometric measurements.
Policy Position

One standard first trimester ultrasound (less than 14 weeks 0/7 days) is considered medically necessary.  

A first trimester ultrasound (less than 14 weeks 0/7 days) may be considered medically necessary for one or more of the following conditions:

  • Screen for fetal aneuploidy (nuchal translucency NT measurement specific guidelines); or
  • Estimation of gestational age; or
  • Confirmation of cardiac activity; or
  • Abnormal fetal heart rate or rhythm; or
  • Diagnosis or evaluation of multiple gestations; or
  • Evaluation of suspected ectopic pregnancy: or
  • Evaluate maternal pelvic or adnexal masses or uterine abnormalities; or
  • Evaluation of pelvic pain; or
  • Assessment of cervical length; or
  • Evaluation of suspected hydatidiform mole; or
  • Evaluation of vaginal bleeding; or
  • Confirmation of the presence of an intrauterine pregnancy.; or
  • Confirmation of gestational age prior to a voluntary termination of pregnancy.

A first trimester ultrasound not meeting the criteria as indicated in this policy is considered not medically necessary.

0690T

76801

76802

76813

76814

76815

 


One standard second or third trimester ultrasound (>14 weeks 0/7 day or greate) is considered medically necessary.  

A second or third trimester ultrasound may also be considered medically necessary for one or more of the following conditions:

  • Screening for fetal anomalies; or
  • As an adjunct to amniocentesis or other procedure; or
  • As an adjunct to cervical cerclage placement; or
  • As an adjunct to external cephalic version; or
  • Determination of fetal presentation; or
  • Estimation of gestational age; or
  • Evaluation for abnormal biochemical markers; or
  • Evaluation for fetal well-being; or
  • Evaluation for premature rupture of membranes of premature labor; or
  • Evaluation in those with a history of previous congenital anomaly; or
  • Evaluation of abdominal and pelvic pain; or
  • Evaluation of cervical insufficiency; or
  • Evaluation of fetal condition in late registrants for prenatal care; or
  • Evaluation of fetal growth; or
  • Evaluation of pelvic mass; or
  • Evaluation of suspected amniotic fluid abnormalities (e.g., oligohydramnios, polyhydramnios); or
  • Evaluation of suspected ectopic pregnancy; or
  • Evaluation of suspected fetal death; or
  • Evaluation of suspected multiple gestation; or
  • Evaluation of suspected placental abruption; or
  • Evaluation of suspected uterine abnormality (e.g., bicornuate uterus); or
  • Evaluation of vaginal bleeding; or
  • Examination of suspected hydatidiform mole; or
  • Follow-up evaluation of a fetal anomaly; or
  • Follow-up evaluation of placental location for suspected placenta previa; or
  • Significant discrepancy between uterine size and clinical dates; or
  • Maternal history of previous fetal anomaly; or
  • Abnormal maternal serum marker screening for fetal aneuploidy; or
  • Prior ultrasound is suspicious for or demonstrating anatomic abnormality; or
  • Amniotic band syndrome; or
  • Single umbilical artery (SUA); or
  • Possible fetal aneuploidy suspected with a prior ultrasound finding of one or more of the following:
    • Absent or hypoplastic nasal bone; or
    • Choroid plexus cyst; or
    • Echogenic bowel; or
    • Echogenic intracardiac focus; or
    • Fetal pyelectasis; or
    • Increased nuchal translucency (fetal nuchal translucency measurement of
    • 3.0 mm or greater in the first trimester); or
    • Shortened long bones (femur or humerus); or
  • Pregnancy in bicornuate uterus or uterus didelphys; or
  • Pregnancy resulting from advanced reproductive technology (ART), e.g., in-vitro fertilization, embryo transfer, other infertility treatments; or
  • Maternal history of miscarriages or stillbirth; or
  • Maternal hypertension; or
  • Maternal untreated or inadequately treated syphilis (best at or after 20 weeks); or
  • Maternal diabetes, defined as pre-existing or gestational diabetes; or
  • Obesity complicating pregnancy (pre-pregnancy BMI greater than 30 kg/m2); or
  • Fetal exposure to teratogen, e.g., Zika virus; or
  • Fetal exposure to maternal substances and medications; or
  • Genetic risk, e.g., advanced parental age, family history of genetic disorder.

A second or third trimester ultrasound not meeting the criteria as indicated in this policy is/are considered not medically necessary.

0690T

76805

76810

76811

76812

76815

76816

76817

 

 

 

 

 

 


In the postpartum period, a maternity ultrasound may be considered medically necessary for one or more of the following:

  • Abnormal or heavy postpartum vaginal bleeding (ie, suspected trophoblastic disease, retained products of conception, arteriovenous malformations); or
  • Abnormal placentation, suspected (eg, placenta accreta).
Professional Statements and Societal Positions Guidelines

American College of Obstetricians and Gynecologists (ACOG)/American Institute of Ultrasound in Medicine (AIUM): A 2016 clinical management guideline on the use of ultrasound in pregnancy issued by ACOG and AIUM stated that the best gestational age for an obstetric ultrasound will depend on the clinical indication for the examination. First trimester ultrasonography is most accurate for patients with uncertain or unreliable menstrual dating or with an indication to confirm viability. When used as part of combined first-trimester screening or integrated screening for aneuploidy, an ultrasound examination with nuchal translucency measurement before 14 0/7 weeks of gestation provides accurate dating of pregnancy and an effective screening test for trisomy 13, trisomy 18, and trisomy 21 when combined with maternal age and serum markers. ACOG stated that in the absence of other specific indications, the optimal time for a single ultrasound examination is at 18–22 weeks of gestation. This timing allows for a survey of fetal anatomy in most women and an accurate estimation of gestational age (ACOG, 2022). According to the joint guidelines, the technical advantages of 3D ultrasonography include its ability to acquire and manipulate an infinite number of planes and to display ultrasound planes traditionally inaccessible by 2D ultrasonography. Despite these technical advantages, proof of a clinical advantage of 3D ultrasonography in prenatal diagnosis in general is still lacking. Until clinical evidence shows a clear advantage to conventional 2D ultrasonography, 3D ultrasonography is not considered a required modality at this time (ACOG, 2022).

 

National Institute for Health and Care Excellence (NICE): The 2021 NICE guideline for antenatal care recommended that women should be offered an ultrasound between 11+2 weeks and 14+1 weeks for determining gestational age, multiple pregnancy and possible fetal anomaly screening. An additional ultrasound should be offered to screen for fetal anomalies and to determine placental location between 18+0 weeks and 20+6 weeks. Additionally, if there are concerns regarding fundal height, unexplained vaginal bleeding, or a breech presentation an ultrasound may be considered. The guideline further stated that routine use of ultrasound scanning for uncomplicated singleton pregnancies after 28 weeks of gestation is not supported by the evidence and therefore should not be offered (NICE, 2021).


Covered Dx codes when submitted with procedure codes

 

A59.9

B58.1

B58.2

B58.3

B58.9

B58.00

B58.01

B58.09

B58.81

B58.82

B58.83

B58.89

C91.Z0

D25.9

D56.0

D56.1

D56.2

D56.3

D56.5

D56.8

D56.9

D57.1

D57.3

D57.00

D57.01

D57.02

D57.03

D57.09

D57.20

D57.40

D57.42

D57.44

D57.80

D57.211

D57.212

D57.213

D57.218

D57.219

D57.411

D57.412

D57.413

D57.418

D57.419

D57.431

D57.432

D57.433

D57.438

D57.439

D57.451

D57.452

D57.453

D57.458

D57.459

D57.811

D57.812

D57.813

D57.818

D57.819

D58.2

D68.52

D68.59

D68.61

D68.69

D89.9

E01.0

E03.8

E03.9

E04.9

E05.90

E11.9

I10

I15.1

I15.2

I15.8

I15.9

I16.0

I16.1

I16.9

K50.119

M32.0

M32.8

M32.9

M32.10

M32.11

M32.12

M32.13

M32.14

M32.15

M32.19

N18.1

N18.2

N18.3

N18.4

N18.5

N18.6

N18.9

N18.30

N18.31

N18.32

N88.3

N93.8

N93.9

N94.4

N94.5

N96

N97.0

N97.1

N97.2

N97.8

N97.9

O9A.211

O00.8

O00.9

O00.01

O00.80

O00.81

O00.90

O00.91

O00.101

O00.102

O00.109

O00.111

O00.112

O00.119

O00.201

O00.202

O00.209

O00.211

O00.212

O00.219

O01.0

O01.1

O01.9

O02.1

O02.9

O02.81

O03.1

O03.4

O03.9

O03.30

O03.39

O03.80

O03.89

O04.80

O04.89

O07.4

O09.00

O09.01

O09.02

O09.03

O09.11

O09.12

O09.13

O09.31

O09.32

O09.33

O09.41

O09.42

O09.43

O09.71

O09.72

O09.73

O09.91

O09.92

O09.93

O09.211

O09.212

O09.213

O09.219

O09.291

O09.292

O09.293

O09.511

O09.512

O09.513

O09.521

O09.522

O09.523

O09.611

O09.612

O09.613

O09.621

O09.622

O09.623

O09.811

O09.812

O09.813

O09.821

O09.822

O09.823

O09.891

O09.892

O09.893

O09.A1

O09.A2

O09.A3

O10.011

O10.012

O10.911

O10.912

O10.919

O13.1

O13.2

O13.3

O13.4

O13.5

O13.9

O14.03

O14.10

O14.12

O14.13

O14.22

O14.23

O16.1

O16.2

O16.3

O16.9

O20.0

O20.8

O20.9

O21.0

O21.1

O21.8

O21.9

O22.8X9

O23.02

O23.11

O23.41

O23.592

O24.019

O24.111

O24.112

O24.319

O24.410

O24.414

O24.415

O24.419

O26.10

O26.11

O26.12

O26.13

O26.20

O26.21

O26.22

O26.31

O26.612

O26.649

O26.841

O26.842

O26.843

O26.849

O26.851

O26.852

O26.853

O26.859

O26.872

O26.873

O26.879

O28.0

O28.3

O28.5

O28.8

O28.9

O29.119

O30.91

O30.92

O30.93

O30.001

O30.002

O30.003

O30.009

O30.011

O30.012

O30.013

O30.019

O30.021

O30.022

O30.023

O30.029

O30.031

O30.032

O30.033

O30.039

O30.041

O30.042

O30.043

O30.091

O30.092

O30.093

O30.101

O30.102

O30.103

O30.111

O30.112

O30.113

O30.121

O30.122

O30.123

O30.131

O30.132

O30.133

O30.191

O30.192

O30.193

O30.201

O30.202

O30.203

O30.211

O30.212

O30.213

O30.221

O30.222

O30.223

O30.231

O30.232

O30.233

O30.291

O30.292

O30.293

O30.801

O30.802

O30.803

O30.811

O30.812

O30.813

O30.821

O30.822

O30.823

O30.831

O30.832

O30.833

O30.891

O30.892

O30.893

O31.10X0

O31.11X0

O31.30X0

O31.32X2

O32.0XX0

O32.0XX1

O32.0XX2

O32.0XX3

O32.0XX4

O32.0XX5

O32.0XX9

O32.1XX0

O32.1XX1

O32.1XX2

O32.1XX3

O32.1XX4

O32.1XX5

O32.1XX9

O32.2XX0

O32.2XX1

O32.2XX2

O32.2XX3

O32.2XX4

O32.2XX5

O32.2XX9

O32.3XX0

O32.3XX1

O32.3XX2

O32.3XX3

O32.3XX4

O32.3XX5

O32.3XX9

O32.4XX0

O32.4XX1

O32.4XX2

O32.4XX3

O32.4XX4

O32.4XX5

O32.4XX9

O32.6XX0

O32.6XX1

O32.6XX2

O32.6XX3

O32.6XX4

O32.6XX5

O32.6XX9

O32.8XX0

O32.8XX1

O32.8XX2

O32.8XX3

O32.8XX4

O32.8XX5

O32.8XX9

O32.9XX0

O32.9XX1

O32.9XX2

O32.9XX3

O32.9XX4

O32.9XX5

O32.9XX9

O34.211

O34.219

O34.531

O34.592

O35.2XX0

O35.5XX0

O35.6XX0

O35.8XX0

O35.9XX0

O35.9XX1

O35.9XX2

O35.9XX3

O35.9XX4

O35.9XX5

O35.9XX9

O35.02X0

O35.03X0

O35.09X0

O35.10X0

O35.BXX0

O35.EXX0

O36.4XX0

O36.4XX1

O36.4XX2

O36.4XX3

O36.4XX4

O36.4XX5

O36.4XX9

O36.60X0

O36.60X1

O36.60X2

O36.60X3

O36.60X4

O36.60X5

O36.60X9

O36.61X0

O36.61X1

O36.61X2

O36.61X3

O36.61X4

O36.61X5

O36.61X9

O36.62X0

O36.62X1

O36.62X2

O36.62X3

O36.62X4

O36.62X5

O36.62X9

O36.63X0

O36.63X1

O36.63X2

O36.63X3

O36.63X4

O36.63X5

O36.63X9

O36.80X0

O36.80X1

O36.80X2

O36.80X3

O36.80X4

O36.80X5

O36.80X9

O36.91X0

O36.92X0

O36.0910

O36.0911

O36.0912

O36.0913

O36.0914

O36.0915

O36.0919

O36.0920

O36.0921

O36.0922

O36.0923

O36.0924

O36.0925

O36.0929

O36.0930

O36.0931

O36.0932

O36.0933

O36.0934

O36.0935

O36.0939

O36.0990

O36.0991

O36.0992

O36.0993

O36.0994

O36.0995

O36.0999

O36.1910

O36.1911

O36.1912

O36.1913

O36.1914

O36.1915

O36.1919

O36.1920

O36.1921

O36.1922

O36.1923

O36.1924

O36.1925

O36.1929

O36.1930

O36.1931

O36.1932

O36.1933

O36.1934

O36.1935

O36.1939

O36.1990

O36.1991

O36.1992

O36.1993

O36.1994

O36.1995

O36.1999

O36.5111

O36.5112

O36.5113

O36.5114

O36.5115

O36.5119

O36.5121

O36.5122

O36.5123

O36.5124

O36.5125

O36.5129

O36.5131

O36.5132

O36.5133

O36.5134

O36.5135

O36.5139

O36.5910

O36.5911

O36.5912

O36.5913

O36.5914

O36.5915

O36.5919

O36.5920

O36.5921

O36.5922

O36.5923

O36.5924

O36.5925

O36.5929

O36.5930

O36.5931

O36.5932

O36.5933

O36.5934

O36.5935

O36.5939

O36.5990

O36.5991

O36.5992

O36.5993

O36.5994

O36.5995

O36.5999

O36.8120

O36.8121

O36.8122

O36.8123

O36.8124

O36.8125

O36.8129

O36.8130

O36.8131

O36.8132

O36.8133

O36.8134

O36.8135

O36.8139

O36.8190

O36.8191

O36.8192

O36.8193

O36.8194

O36.8195

O36.8199

O36.8310

O36.8311

O36.8312

O36.8313

O36.8314

O36.8315

O36.8319

O36.8320

O36.8321

O36.8322

O36.8323

O36.8324

O36.8325

O36.8329

O36.8330

O36.8331

O36.8332

O36.8333

O36.8334

O36.8335

O36.8339

O36.8390

O36.8391

O36.8392

O36.8393

O36.8394

O36.8395

O36.8399

O36.8910

O36.8911

O36.8919

O36.8920

O36.8921

O36.8990

O36.8999

O40.1XX0

O40.1XX1

O40.1XX2

O40.1XX3

O40.1XX4

O40.1XX5

O40.1XX9

O40.2XX0

O40.2XX1

O40.2XX2

O40.2XX3

O40.2XX4

O40.2XX5

O40.2XX9

O40.3XX0

O40.3XX1

O40.3XX2

O40.3XX3

O40.3XX4

O40.3XX5

O40.3XX9

O40.9XX0

O40.9XX1

O40.9XX2

O40.9XX3

O40.9XX4

O40.9XX5

O40.9XX9

O41.8X10

O41.8X11

O41.8X30

O41.8X90

O41.8X99

O41.00X0

O41.00X1

O41.00X2

O41.00X3

O41.00X4

O41.00X5

O41.00X9

O41.01X0

O41.01X1

O41.01X2

O41.01X3

O41.01X4

O41.01X5

O41.01X9

O41.02X0

O41.02X1

O41.02X2

O41.02X3

O41.02X4

O41.02X5

O41.02X9

O41.03X0

O41.03X1

O41.03X2

O41.03X3

O41.03X4

O41.03X5

O41.03X9

O41.1011

O41.1012

O41.1013

O41.1014

O41.1015

O41.1019

O41.1021

O41.1022

O41.1023

O41.1024

O41.1025

O41.1029

O41.1031

O41.1032

O41.1033

O41.1034

O41.1035

O41.1039

O41.1091

O41.1092

O41.1093

O41.1094

O41.1095

O41.1211

O41.1212

O41.1213

O41.1214

O41.1215

O41.1219

O41.1221

O41.1222

O41.1223

O41.1224

O41.1225

O41.1229

O41.1231

O41.1232

O41.1233

O41.1234

O41.1235

O41.1239

O41.1291

O41.1292

O41.1293

O41.1294

O41.1295

O41.1299

O41.1411

O41.1412

O41.1413

O41.1414

O41.1415

O41.1419

O41.1421

O41.1422

O41.1423

O41.1424

O41.1425

O41.1429

O41.1431

O41.1432

O41.1433

O41.1434

O41.1435

O41.1439

O42.00

O42.02

O42.10

O42.12

O42.90

O42.92

O42.011

O42.012

O42.013

O42.019

O42.111

O42.112

O42.113

O42.119

O42.911

O42.912

O42.913

O42.919

O43.91

O43.92

O43.93

O43.011

O43.012

O43.013

O43.021

O43.022

O43.023

O43.101

O43.102

O43.103

O43.111

O43.112

O43.113

O43.121

O43.122

O43.123

O43.191

O43.192

O43.193

O43.211

O43.212

O43.213

O43.219

O43.221

O43.222

O43.223

O43.231

O43.232

O43.233

O43.239

O43.811

O43.812

O43.813

O43.891

O43.892

O43.893

O44.00

O44.01

O44.02

O44.03

O44.11

O44.12

O44.13

O44.21

O44.22

O44.23

O44.31

O44.32

O44.33

O44.41

O44.42

O44.43

O44.51

O44.52

O44.53

O45.8X1

O45.8X2

O45.8X3

O45.91

O45.92

O45.93

O45.001

O45.002

O45.003

O45.011

O45.012

O45.013

O45.021

O45.022

O45.023

O45.091

O45.092

O45.093

O46.8X1

O46.8X2

O46.90

O46.91

O46.92

O46.93

O47.00

O47.02

O47.03

O60.00

O60.02

O60.03

O62.8

O69.4XX0

O69.4XX1

O69.4XX2

O69.4XX3

O69.4XX4

O69.4XX5

O69.4XX9

O71.9

O71.89

O72.1

O72.2

O72.3

O73.1

O76

O90.89

O98.011

O98.012

O98.013

O98.019

O98.111

O98.112

O98.113

O98.119

O98.211

O98.212

O98.213

O98.219

O98.311

O98.312

O98.313

O98.319

O98.411

O98.412

O98.413

O98.419

O98.511

O98.512

O98.513

O98.519

O98.611

O98.612

O98.613

O98.619

O98.711

O98.712

O98.713

O98.719

O98.811

O98.812

O98.813

O98.819

O98.911

O98.912

O98.913

O98.919

O99.011

O99.012

O99.112

O99.211

O99.212

O99.213

O99.280

O99.281

O99.282

O99.283

O99.284

O99.310

O99.311

O99.312

O99.313

O99.320

O99.321

O99.322

O99.323

O99.330

O99.331

O99.332

O99.333

O99.340

O99.341

O99.342

O99.411

O99.419

O99.511

O99.512

O99.519

O99.611

O99.810

Q51.0

Q51.2

Q51.3

Q51.4

Q51.7

Q51.9

Q51.10

Q51.11

Q51.20

Q51.21

Q51.22

Q51.28

Q51.810

Q51.811

Q51.818

Q79.62

R10.0

R10.2

R10.9

R10.10

R10.11

R10.30

R10.31

R10.32

R10.84

R19.00

R93.89

S39.91XA

T86.49

Z3A.00

Z03.71

Z03.72

Z03.73

Z03.74

Z03.75

Z03.79

Z03.89

Z09

Z12.4

Z31.83

Z32.01

Z33.2

Z34.01

Z34.02

Z34.81

Z34.82

Z34.91

Z34.92

Z36.0

Z36.1

Z36.2

Z36.3

Z36.4

Z36.5

Z36.8A

Z36.9

Z36.81

Z36.82

Z36.83

Z36.84

Z36.85

Z36.86

Z36.87

Z36.88

Z36.89

Z57.9

Z82.79

Z84.89

Z87.51

Z87.59

Z87.74

Z90.710

Z94.0

Z94.1

Z94.2

Z94.3

Z94.4

Z94.9

Z94.82

Z94.83

Z94.89

Z98.890

 

 

 


Place of Service: Inpatient/Outpatient

Maternity ultrasound is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.


The policy position applies to all commercial lines of insured business and, if elected, ASO.



Links





This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
    • Qualified sign language interpreters
    • Written information in other formats (large print, audio, accessible electronic formats, other formats)
  • Provides free language services to people whose primary language is not English, such as:
    • Qualified interpreters
    • Information written in other languages

If you need these services, contact the Civil Rights Coordinator.

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

This information is issued by Highmark Blue Shield on behalf of its affiliated Blue companies, which are independent licensees of the Blue Cross Blue Shield Association.  Highmark Inc. d/b/a Highmark Blue Shield and certain of its affiliated Blue companies serve Blue Shield members in the 21 counties of central Pennsylvania. As a partner in joint operating agreements, Highmark Blue Shield also provides services in conjunction with a separate health plan in southeastern Pennsylvania.  Highmark Inc. or certain of its affiliated Blue companies also serve Blue Cross Blue Shield members in 29 counties in western Pennsylvania, 13 counties in northeastern Pennsylvania, the state of West Virginia plus Washington County, Ohio, the state of Delaware[ and [8] counties in western New York and Blue Shield members in [13] counties in northeastern New York].  All references to Highmark in this document are references to Highmark Inc. d/b/a Highmark Blue Shield and/or to one or more of its affiliated Blue companies.




Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
    • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295 , TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.