California

Last updated 06/29/2023

Consent Requirements

Health care providers must inform the patient prior to the initial delivery of telehealth services about the use of telehealth and obtain verbal or written consent from the patient for the use of telehealth as an acceptable mode of delivering health care services.

If a health care provider, whether at the originating site or distant site, maintains a general consent agreement that specifically mentions use of telehealth as an acceptable modality for delivery of services and includes the required information, as explained below, then this is sufficient for documentation of patient consent and should be kept in the patient’s medical file. Providers also need to document when a patient consents to receive services via audio-only prior to initial delivery of services.

The consent shall be documented in the patient’s medical file and be available to DHCS upon request. Providers are required to share additional information with beneficiaries regarding:

• Right to in-person services
• Voluntary nature of consent
• Availability of transportation to access in-person services when other available resources have been reasonably exhausted
• Limitations/risks of receiving services via telehealth, if applicable
• Availability of translation services

Consent requirements may be found in Business and Professions Code, Section 2290.5 [b] and Welfare and Institutions Code, Section 14132.725 [d]. Model patient consent language may be found on the DHCS website.

FQHCs and RHCs are directed to refer to the above on consent requirements.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth. (Jan. 2023), Pg. 5., CA Department of Health Care Services (DHCS). Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHC) Outpatient Services Manual. Jan. 2023. Pg. 13. (Accessed Jun. 2023). 

Applies to Healthcare Providers including FQHCs/RHCs

In addition to any existing law requiring beneficiary consent to telehealth, including, but not limited to, subdivision (b) of Section 2290.5 of the Business and Professions Code, all of the following shall be communicated by a health care provider, FQHC, and RHC to a Medi-Cal beneficiary, in writing or verbally, on at least one occasion prior to, or concurrent with, initiating the delivery of one or more health care services via telehealth to a Medi-Cal beneficiary:

• An explanation that beneficiaries have the right to access covered services that may be delivered via telehealth through an in-person, face-to-face visit;
• An explanation that use of telehealth is voluntary and that consent for the use of telehealth can be withdrawn at any time by the Medi-Cal beneficiary without affecting their ability to access covered Medi-Cal services in the future;
• An explanation of the availability of Medi-Cal coverage for transportation services to in-person visits when other available resources have been reasonably exhausted; and
• The potential limitations or risks related to receiving services through telehealth as compared to an in-person visit, to the extent any limitations or risks are identified by the provider, FQHC, or RHC.

The provider, FQHC, or RHC shall document in the patient record the provision of this information and the patient’s verbal or written acknowledgment that the information was received.

The department shall develop, in consultation with affected stakeholders, model language for purposes of the communication described in this subdivision.

This subdivision does not apply to Medi-Cal covered services delivered by providers via any telehealth modality to eligible inmates in state prisons, county jails, or youth correctional facilities.

SOURCE: Welfare and Institutions Code 14132.725 & Welfare and Institutions Code 14132.100, as amended by SB 184 (2022 Session). (Accessed Jun. 2023).

Indian Health Services, Memorandum of Understanding Agreement (IHS-MOA)

Refer to fee-for-service policy. All consent for homeless patients must be documented.

SOURCE: CA Department of Health Care Services (DHCS). Indian Health Services, Memorandum of Agreement (MOA) 638, Clinics Manual. Jan. 2023. Pg. 8. (Accessed Jun. 2023).

Vision Care

Providers must include a record of the written or verbal request for the consultation by the referring provider or other source in the medical record.  Verbal and written informed consent from the patient or the patient’s legal representative is required if the consulting provider has ultimate authority over the care or primary diagnosis of the patient.

SOURCE: CA Department of Health Care Services, Vision Care: Professional Services Manual. (Oct. 2022), Pg. 5. (Accessed Jun. 2023).

Local Education Agency Services

All of the following shall be communicated by a health care provider to a Medi-Cal beneficiary, in writing or verbally, on at least one occasion prior to, or concurrent with, initiating the delivery of one or more health care services via telehealth to a Medi-Cal beneficiary:

• An explanation that beneficiaries have the right to access covered services that may be delivered via telehealth through an in-person, face-to-face visit;
• An explanation that the use of telehealth is voluntary and that consent for the use of telehealth can be withdrawn at any time by the Medi-Cal beneficiary without affecting their ability to access covered Medi-Cal services in the future;
• An explanation of the availability of Medi-Cal coverage for transportation services to inperson visits when other available resources have been reasonably exhausted; and
• The potential limitations or risks related to receiving services through telehealth as compared to an in-person visit, to the extent any limitations or risks are identified by the provider.

Documentation of written or verbal consent to receive services via telehealth must be maintained in the student’s file. Consent requirements outlined in the Local Educational Agency provider manual section related to accessing public benefits or insurance or releasing medical information in personally identifiable form from the student’s education record must also be followed.

SOURCE: CA Department of Health Care Services (DHCS). Local Education Agency (LEA) Telehealth. Jun. 2023. Pg. 7. (Accessed Jun. 2023).

Last updated 06/29/2023

Definitions

“Telehealth” means the mode of delivering health care services and public health via information and communication technologies to facilitate the diagnosis, consultation, treatment, education, care management and self-management of a patient’s health care. Telehealth facilitates patient self-management and caregiver support for patients and includes synchronous interactions and asynchronous store-and-forward transfers.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth (Jan. 2023). Pg. 1. (Accessed Jun. 2023).

“Telehealth” means the mode of delivering health care services and public health via information and communication technologies to facilitate the diagnosis, consultation, treatment, education, care management and self-management of a patient’s health care. Telehealth facilitates patient self-management and caregiver support for patients and includes synchronous, real-time interactions between a patient and a health care provider located at a distant site.

SOURCE: CA Department of Health Care Services. Medi-Cal LEA Telehealth Manual. Jun. 2023. Pg. 1. (Accessed Jun. 2023).

Last updated 06/29/2023

Email, Phone & Fax

For services or benefits provided via synchronous telephone or other real-time interactive audio-only telecommunications systems, the health care provider bills with modifier 93.

Modifier 93 must be used for Medi-Cal covered benefits or services delivered via synchronous, telephone or other interactive audio-only telecommunications systems. Only the portion(s) of the telehealth service rendered at the distant site are billed with modifier 93. The use of modifier 93 does not alter reimbursement for the CPT or HCPCS code.

Health care providers must use an interactive audio-only telecommunications system that permits real-time communication between the provider at the distant site and the patient at the originating site. The audio telehealth system used must, at a minimum, have the capability of meeting the procedural definition of the code provided through telehealth. The telecommunications equipment must be of a quality or resolution to adequately complete all necessary components to document the level of service for the CPT code or HCPCS code billed.

The totality of the communication of information exchanged between the provider and the patient during the audio-only service must be of an amount and nature that is sufficient to meet the key components and/or requirements of the same service when rendered via a face-to-face interaction.

Providers must document in the patient’s medical file that the patient has given a written or verbal consent to the audio-only telehealth encounter.

See Telehealth Modifier Reference Sheet- Organized by Delivery System​​ ​for more information on modifiers.

Brief Virtual Communications and Check-ins

Virtual or telephonic communication includes a brief communication with an established patient not physically present (face-to-face). Medi-Cal providers may be reimbursed using HCPCS codes G2010 and G2012 for brief virtual communications.

HCPCS code G2012: Brief communication technology-based service, e.g., virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5 to 10 minutes of medical discussion. G2012 can be billed when the virtual communication via a telephone call.

Establishing a Relationship

Providers may establish a relationship with new patients via audio-only synchronous interaction only if one or more of the following applies:

• The visit is related to sensitive services as defined in subsection (n) or Section 56.06 of the Civil Code. Section 56.06 of the Civil Code defines “sensitive services” as all health care services related to mental or behavioral health, sexual and reproductive health, sexually transmitted infections, substance use disorder, gender-affirming care, and intimate partner violence, and includes services described in Sections 6924 through 6930 of the Family Code, and Sections 121020 and 124260 of the Health and Safety Code, obtained by a patient at or above the minimum age specified for consenting to the service specified in the section.
• The patient requests an audio-only modality.
• The patient attests they do not have access to video.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth (Jan. 2023). Pg. 3, 6-7, 10. (Accessed Jun. 2023).

The department shall reimburse health care providers of applicable health care services delivered via synchronous audio-only modality at payment amounts that are not less than the amounts the provider would receive if the services were delivered via in-person, face-to-face contact, so long as the services or settings meet the applicable standard of care and meet the requirements of the service code being billed.

Pursuant to an effective date designated by the department that is no sooner than January 1, 2024, a Medi-Cal provider furnishing applicable health care services via audio-only synchronous interaction shall also offer those same health care services via video synchronous interaction to preserve beneficiary choice. The department may provide specific exceptions to this requirement specified in subparagraph based on a Medi-Cal provider’s access to requisite technologies, which shall be developed in consultation with affected stakeholders and published in departmental guidance.

Pursuant to an effective date designated by the department that is no sooner than January 1, 2024, a provider furnishing services through video synchronous interaction or audio-only synchronous interaction shall also do one of the following:

• Offer those services via in-person, face-to-face contact.
• Arrange for a referral to, and a facilitation of, in-person care that does not require a patient to independently contact a different provider to arrange for that care.
• In implementing this subdivision, the department shall consider additional recommendations from affected stakeholders regarding the need to maintain access to in-person services without unduly restricting access to telehealth services.

A health care provider shall not establish a new patient relationship with a Medi-Cal beneficiary via telephonic (audio-only) synchronous interaction except:

• when the visit is related to sensitive services, as defined in subdivision (n) of Section 56.05 of the Civil Code, and when established in accordance with department specific requirements and consistent with federal and state law, regulations and guidance
• when the patient requests an audio-only modality or attests they do not have access to video, and when established in accordance with department specific requirements and consistent with federal and state laws, regulations and guidance.

SOURCE: Welfare and Institutions Code 14132.725. (Accessed Jun. 2023).

FQHCs/RHCs 

An audio-only synchronous interaction is eligible for reimbursement if provided by a billable provider and FQHC or RHC patient.

Medi-Cal benefits or services being provided are clinically appropriate and meet the procedural and billing requirements that would have applied if the applicable services were delivered via a face-to-face encounter

A patient may not be “established” using an audio-only synchronous interaction unless the visit is related to a “sensitive service”, as defined in the California Civil Code, section 56.05, subdivision (n), or if the patient requests “audio only” or does not have access to video.

SOURCE: CA Dept. Health Care Services, Medi-Cal Part 2 RHCs and FQHCs Manual, (Jan. 2023), p 14.  (Accessed Jun. 2023).

Visits shall also include an encounter between an FQHC or RHC patient and a physician, physician assistant, nurse practitioner, certified nurse-midwife, clinical psychologist, licensed clinical social worker, visiting nurse, comprehensive perinatal services program practitioner, dental hygienist, dental hygienist in alternative practice, or marriage and family therapist using audio-only synchronous interaction, when services delivered through that modality meet the applicable standard of care. A visit described in this clause shall be reimbursed at the applicable FQHC’s or RHC’s per-visit PPS rate to the extent the department determines that the FQHC or RHC has met all billing requirements that would have applied if the applicable services were delivered via a face-to-face encounter.

An FQHC or RHC may not establish a new patient relationship using an audio-only synchronous interaction. Notwithstanding this prohibition, the department may provide for specific exceptions to this prohibition, which shall be developed in consultation with affected stakeholders and published in departmental guidance. Exceptions shall include but not be limited to:

• An FQHC or RHC may establish a new patient relationship using an audio-only synchronous interaction when the visit is related to sensitive services, as defined in subdivision (n) of Section 56.05 of the Civil Code, or when the patient requests an audio-only modality or attests they do not have access to video – in accordance with department-specific requirements and consistent with federal and state laws, regulations, and guidance.

Pursuant to an effective date designated by the department that is no sooner than January 1, 2024, an FQHC or RHC furnishing applicable health care services via audio-only synchronous interaction shall also offer those same health care services via video synchronous interaction to preserve beneficiary choice. The department may provide specific exceptions to the requirement based on an FQHC’s or RHC’s access to requisite technologies, which shall be developed in consultation with affected stakeholders and published in departmental guidance.

Effective on the date designated by the department pursuant to above, an FQHC or RHC furnishing services through video synchronous interaction or audio-only synchronous interaction shall also do one of the following:

• Offer those services via in-person, face-to-face contact.
• Arrange for a referral to, and a facilitation of, in-person care that does not require a patient to independently contact a different provider to arrange for that care.

SOURCE: Welfare and Institutions Code 14132.100, as amended by SB 184 (2022 Session) and AB 32 (2022 Session). (Accessed Jun. 2023).

Telehealth services, telephonic services and other specified services must be reimbursed when provided by specific entities during or immediately following an emergency, subject to the Department obtaining federal approval and matching funds and Department guidance.

SOURCE: Welfare and Institutions Code Sec. 14132.723. (Accessed Jun. 2023).

The department shall seek any federal approvals it deems necessary to extend the approved waiver or flexibility implemented pursuant to subdivision (a), as of July 1, 2021, that are related to the delivery and reimbursement of services via telehealth modalities in the Medi-Cal program, including audio-only. The department shall implement those extended waivers or flexibilities for which federal approval is obtained, to commence on the first calendar day immediately following the last calendar day of the federal COVID-19 public health emergency period, and through December 31, 2022.

For purposes of informing the 2022–23 proposed Governor’s Budget, released in January 2022, the department shall convene an advisory group consisting of consultants, subject matter experts, and other affected stakeholders to provide recommendations to inform the department in establishing and adopting billing and utilization management protocols for telehealth modalities to increase access and equity and reduce disparities in the Medi-Cal program. The advisory group shall analyze the impact of telehealth in increased access for patients, changes in health quality outcomes and utilization, best practices for the appropriate mix of in-person visits and telehealth, and the benefits or liabilities of any practice or care model changes that have resulted from telephonic visits.

SOURCE: AB 133, Sec. 380 (2021 Session). (Accessed Jun. 2023).

IHS-MOA

An audio-only visit is eligible for reimbursement if provided by a billable provider, regardless of the location of the patient or provider.

SOURCE: DHCS IHS Manual. May 2023. Pg. 9. (Accessed Jun. 2023).

Vision Services

Asynchronous telecommunications system (store and forward telehealth) in single media format does not include telephone calls, images transmitted via facsimile machine, and text messages without visualization of the patient (electronic mail).

SOURCE: CA Department of Health Care Services. Medi-Cal Professional Services Manual. Page 6. (Dec. 2022). (Accessed Jun. 2023).

LEA Services

Allowable services delivered via telehealth must be synchronous telehealth service rendered via a real-time interactive audio and video telecommunications system only.

SOURCE: CA Department of Health Care Services. Medi-Cal Local Educational Agency (LEA) Telehealth Manual. Page 3. (Jun. 2023). (Accessed Jun. 2023).

SOURCE: CA Department of Health Care Services. Family PACT Clinical Services manual. Jun. 2023. Pg. 7. (Accessed Jun. 2023).

A Family PACT provider may enroll and recertify clients through synchronous video or audio-only synchronous telehealth modalities. See manual for more information.

SOURCE: CA Department of Health Care Services. Family PACT Client Eligibility Manual. Apr. 2023. Pg. 1. (Accessed Jun. 2023).

CCS Service Code Groupings

Effective for dates of service on or after July 1, 2023, CPT^® codes 99358 (Prolonged evaluation and management service before and/or after direct patient care; first hour) and 99359 (Prolonged evaluation and management service before and/or after direct patient care; each additional 30 minutes) have been added to the California Children’s Services (CCS) Service Code Grouping (SCG).

SOURCE: CA Dept. of Health Care Services. CCS Service Code Groupings Policy Update. June 2023. (Accessed Jul. 2023).

Last updated 06/29/2023

Live Video

POLICY

Synchronous Interaction

“Synchronous interaction” means a real-time interaction between a patient and a health care provider located at a distant site.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth (Aug. 2020). Pg. 2. (Accessed Jun. 2023). 

Medi-Cal covered benefits or services, identified by CPT or HCPCS codes and subject to all existing Medi-Cal coverage and reimbursement policies, including any treatment authorization request requirements, may be provided via a telehealth modality, as outlined in this section, only if all of the following are satisfied:

• The treating health care provider at the distant site believes that the benefits or services being provided are clinically appropriate based upon evidence-based medicine and/or best practices to be delivered via telehealth;
• The benefits or services delivered via telehealth meet the procedural definition and components of the CPT or HCPCS code(s), as defined by the American Medical Association (AMA), associated with the Medi-Cal covered service or benefit, as well as any extended guidelines as described in this section of the Medi-Cal provider manual;
• The benefits or services provided via telehealth meet all laws regarding confidentiality of health care information and a patient’s right to his or her medical information.

Covered benefits or services provided via a telehealth modality are reimbursable when billed in one of two ways:

• For services or benefits provided via synchronous, interactive audio and visual telecommunications systems, the health care provider bills with modifier 95.
• For services or benefits provided via asynchronous store and forward telecommunications systems, the health care provider bills with modifier GQ.
• For services or benefits provided via synchronous telephone or other real-time interactive audio-only telecommunications systems, the health care provider bills with modifier 93.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth (Jan. 2023). Pg. 6. (Accessed Jun. 2023).

Recently enacted legislation requires CA Medicaid and Medi-Cal managed care plans to reimburse health care providers of applicable health care services delivered via video synchronous interaction, synchronous audio-only modality, or asynchronous store and forward, as applicable, at payment amounts that are not less than the amounts the provider would receive if the services were delivered via in-person, face-to-face contact, so long as the services or settings meet the applicable standard of care and meet the requirements of the service code being billed.

In-person, face-to-face contact between a health care provider and a patient is not required under the Medi-Cal program for covered health care services and provider types designated by the department, when provided by video synchronous interaction, asynchronous store and forward, as defined in subdivision (a) of Section 2290.5 of the Business and Professions Code, audio-only synchronous interaction, remote patient monitoring, or other permissible virtual communication modalities, when those services and settings meet the applicable standard of care and meet the requirements of the service code being billed.

Applicable health care services appropriately provided through video synchronous interaction, asynchronous store and forward, audio-only synchronous interaction, remote patient monitoring, or other permissible virtual communication modalities are subject to billing, reimbursement, and utilization management policies imposed by the department. Utilization management protocols adopted by the department pursuant to this section shall be consistent with, and no more restrictive than, those authorized for health care service plans pursuant to Section 1374.13 of the Health and Safety Code.

Pursuant to an effective date designated by the department that is no sooner than January 1, 2024, a provider furnishing services through video synchronous interaction or audio-only synchronous interaction shall also do one of the following:

• Offer those services via in-person, face-to-face contact.
• Arrange for a referral to, and a facilitation of, in-person care that does not require a patient to independently contact a different provider to arrange for that care.

In implementing this subdivision, the department shall consider additional recommendations from affected stakeholders regarding the need to maintain access to in-person services without unduly restricting access to telehealth services.

SOURCE: Welfare and Institutions Code 14132.725, as amended by SB 184 (2022 Session). (Accessed Jun. 2023).

In-person contact between a health care provider and a patient shall not be required under the Medi-Cal program for services appropriately provided through telehealth, subject to reimbursement policies adopted by the department to compensate a licensed health care provider who provides health care services through telehealth that are otherwise reimbursed pursuant to the Medi-Cal program.

SOURCE: Sec. 14132.72 of the Welfare and Institutions Code. (Accessed Jun. 2023).

Providers may establish a relationship with new patients via synchronous video telehealth visits.

SOURCE: Welfare and Institutions Code 14132.725; CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth (Jan. 2023). Pg. 3. (Accessed Jun. 2023).

Brief Virtual Communications and Check-ins

Virtual or telephonic communication includes a brief communication with an established patient not physically present (face-to-face). Medi-Cal providers may be reimbursed using HCPCS codes G2010 and G2012 for brief virtual communications.

HCPCS code G2012: Brief communication technology-based service, e.g., virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5 to 10 minutes of medical discussion. G2012 can be billed when the virtual communication via a telephone call.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth (Jan. 2023). Pg. 10. (Accessed Jun. 2023).

Federally Qualified Health Center (FQHC) & Rural Health Clinic (RHC) 

Telehealth services must meet all billing requirements that would have applied if the applicable services were delivered via a face-to-face encounter with a billable provider and meet the applicable standard of care.

Services rendered via telehealth must be FQHC or RHC covered services.  Synchronous interaction means a real-time audio-visual, two-way interaction between a new or established patient and an FQHC or RHC billable provider at a distant site. Medi-Cal benefits or services being provided are clinically appropriate and meet the procedural and billing requirements that would have applied if the applicable services were delivered via a face-to-face encounter. An FQHC patient who receives telehealth services shall otherwise be eligible to receive in-person services from the FQHC pursuant to the federal Health Resources Services Administration requirements.

See manual for billing examples.

SOURCE: CA Dept. of Health Care Services, Part 2 Manual, Medi-Cal Rural Health Clinics and Federally Qualified Health Centers (Jan. 2023), p. 11, 13-14.  (Accessed Jun. 2023).

Visits shall also include an encounter between an FQHC or RHC patient and a physician, physician assistant, nurse practitioner, certified nurse-midwife, clinical psychologist, licensed clinical social worker, visiting nurse, comprehensive perinatal services program practitioner, dental hygienist, dental hygienist in alternative practice, or marriage and family therapist using video synchronous interaction, when services delivered through that interaction meet the applicable standard of care. A visit described in this clause shall be reimbursed at the applicable FQHC’s or RHC’s per-visit PPS rate to the extent the department determines that the FQHC or RHC has met all billing requirements that would have applied if the applicable services were delivered via a face-to-face encounter.

An FQHC or RHC is not precluded from establishing a new patient relationship through video synchronous interaction.

Effective on a date designated by the department that is no sooner than January 1, 2024, an FQHC or RHC furnishing services through video synchronous interaction or audio-only synchronous interaction shall also do one of the following:

• Offer those services via in-person, face-to-face contact.
• Arrange for a referral to, and a facilitation of, in-person care that does not require a patient to independently contact a different provider to arrange for that care.

SOURCE: Welfare and Institutions Code 14132.100, as amended by SB 184 (2022 Session) and AB 32 (2022 Session). (Accessed Jun. 2023).

Family PACT

Family PACT providers must ensure that the covered Family PACT service or benefit being delivered via telehealth meets the procedural definition and components of the CPT or HCPCS code(s) associated with the Family PACT covered service or benefit, as well as any other requirements described in this manual. In addition, Family PACT services rendered by the use of a telehealth modality must follow ICD-10-CM diagnosis code billing policy as noted in this manual. All healthcare practitioners rendering Family PACT covered benefits or services under this policy must comply with all applicable state and federal laws.

SOURCE: CA Department of Health Care Services.  Family Planning, Access, Care and Treatment Program. Benefits Manual. Jun. 2023, Pg. 6. (Accessed Jun. 2023).

A Family PACT provider may enroll and recertify clients through synchronous video or audio-only synchronous telehealth modalities. See manual for more information.

SOURCE: CA Department of Health Care Services. Family PACT Client Eligibility Manual. Apr. 2023. Pg. 1. (Accessed Jun. 2023).

Managed Care

To ensure proper payment and record of Covered Services provided via Telehealth, all Providers must use the modifiers defined in the Medi-Cal Provider Manual with the appropriate CPT-4 or HCPCS codes when coding for services delivered through both synchronous interactions and asynchronous store and forward telecommunications. Regarding the rate of reimbursement, unless otherwise agreed to by the MCP and Provider, MCPs must reimburse Network Providers at the same rate, whether a Covered Service is provided in-person or through Telehealth, if the service is the same regardless of the modality of delivery, as determined by the Provider’s description of the service on the claim.

SOURCE: CA Department of Health Care Services (DHCS). All Plan Letter 23-007: Telehealth Services Policy. Apr. 10, 2023. (Accessed Jun. 2023).

Indian Health Services, Memorandum of Understanding Agreement (IHS-MOA)

Services rendered via telehealth must be IHS-MOA covered services.

Services provided through synchronous telehealth for an established patient are subject to the same program restrictions, limitations and coverage that exist when the service is provided in-person.

• IHS-MOA clinics must submit claims for telehealth services using the appropriate per visit IHS-MOA billing codes, modifiers and related claims submission requirements. Providers may refer to the Indian Health Services (IHS), Memorandum of Agreement (MOA) 638, Clinics: Billing Codes section in the appropriate Part 2 manual.
• IHS-MOA clinics are not eligible to bill an originating site fee or transmission charges. The costs of these services should be included in the IHS-MOA rate.

See manual for billing examples.

SOURCE: CA Department of Health Care Services (DHCS).  Indian Health Services, Memorandum of Agreement (MOA) 638, Clinics Manual. Jan. 2023. Pg. 8. (Accessed Jun. 2023). 

Local Educational Agency (LEA)

For dates of service on or after May 12, 2023, LEAs may bill for covered direct medical services under the LEA Medi-Cal Billing Option Program according to the following guidelines. All LEA services covered under the LEA Medi-Cal Billing Option Program may be billed by participating LEAs when performed via telehealth, except for services that preclude a telehealth modality, such as specialized medical transportation services. Services delivered via telehealth must meet the requirements described in the Medi-Cal provider manual.

Practitioners must use the “LEA Services Billing Codes Chart” in the Local Educational Agency (LEA) Billing Codes and Reimbursement Rates provider manual section to find LEA services that are reimbursable when rendered by telehealth. The first column of the chart indicates “Add modifier 95 if via telehealth” when the telehealth service is reimbursable under the LEA Medi-Cal Billing Option Program.

SOURCE: CA Department of Health Care Services (DHCS). Local Education Agency (LEA) Telehealth. Jun. 2023. Pg. 1, 5.  (Accessed Jun. 2023). 

Dental Services

The Department of Health Care Services has opted to permit the use of teledentistry (including live video) as an alternative modality for the provision of select dental services.

Synchronous interaction, or live transmission, is a real-time interaction between a member and a provider located at a distant site. Live transmissions are limited to 90 minutes per member per provider, per day.  Please note, live transmissions may be provided at the member’s request or if the health care provider believes the service is clinically appropriate.  See manual for billing codes.

SOURCE: CA Department of Health Care Services (DHCS). Dental Provider Handbook. (2023) Pg. 4-22 – 4-24 (Accessed Jun. 2023).

Drug Medi-Cal Treatment Program

A county that enters into a Drug Medi-Cal Treatment Program contract with the department shall reimburse Drug Medi-Cal certified providers for medically necessary Drug Medi-Cal reimbursable services, as defined in Section 14124.24, provided by a licensed practitioner of the healing arts, or a registered or certified alcohol or other drug counselor or other individual authorized by the department to provide Drug Medi-Cal reimbursable services when those services meet the standard of care, meet the requirements of the service code being billed, and are delivered through video synchronous interaction or audio-only synchronous interaction.

SOURCE: Welfare and Institutions Code 14132.731, as amended by SB 184 (2022 Session). (Accessed Jun. 2023).

ELIGIBLE SERVICES/SPECIALTIES

Medi-Cal covered benefits or services, identified by CPT or HCPCS codes and subject to all existing Medi-Cal coverage and reimbursement policies, including any treatment authorization request requirements, may be provided via a telehealth modality if all of the following are satisfied:

• The treating health care provider at the distant site believes that the benefits or services being provided are clinically appropriate based upon evidence-based medicine and/or best practices to be delivered via telehealth;
• The benefits or services delivered via telehealth meet the procedural definition and components of the CPT or HCPCS code(s), as defined by the American Medical Association, associated with the Medi-Cal covered service or benefit, as well as any extended guidelines as described in this section of the Medi-Cal provider manual; and
• The benefits or services provided via telehealth meet all laws regarding confidentiality of health care information and a patient’s right to his or her medical information.

Covered benefits or services provided via a telehealth modality are reimbursable when billed in one of two ways:

• For services or benefits provided via synchronous, interactive audio and visual telecommunications systems, the health care provider bills with modifier 95.
• For services or benefits provided via asynchronous store and forward telecommunications systems, the health care provider bills with modifier GQ.
• For services or benefits provided via synchronous telephone or other real-time interactive audio-only telecommunications systems, the health care provider bills with modifier 93.

Certain types of benefits or services that would not be expected to be appropriately delivered via telehealth include, but are not limited to, benefits or services that are performed in an operating room or while the patient is under anesthesia, require direct visualization or instrumentation of bodily structures, involve sampling of tissue or insertion/removal of medical devices and/or otherwise require the in-person presence of the patient for any reason.

The amount paid by DHCS and Medi-Cal managed care plans for a service rendered via telehealth is the same as the amount paid for the applicable service when rendered in-person.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth (Jan. 2023). Pg. 4, 6. (Accessed Jun. 2023).  

Medi-Cal covers an ‘e-visit’ which are communications between a patient and their provider through an online patient portal.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth (Jan. 2023). Pg. 2. (Accessed Jun. 2023).

Federally Qualified Health Center (FQHC) & Rural Health Clinic (RHC)

Synchronous interaction means a real-time audio-visual, two-way interaction between a new or established patient and an FQHC or RHC billable provider at a distant site.

Medi-Cal benefits or services being provided are clinically appropriate and meet the procedural and billing requirements that would have applied if the applicable services were delivered via a face-to-face encounter.

SOURCE: CA Department of Health Care Services (DHCS).  Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHC) Outpatient Services Manual. Jan. 2023. Pg. 13-14. (Accessed Jun. 2023).

Indian Health Services, Memorandum of Understanding Agreement (IHS-MOA)

Services provided through synchronous telehealth for an established patient are subject to the same program restrictions, limitations and coverage that exist when the service is provided in-person.

• IHS-MOA clinics must submit claims for telehealth services using the appropriate per visit IHS-MOA billing codes, modifiers and related claims submission requirements. Providers may refer to the Indian Health Services (IHS), Memorandum of Agreement (MOA) 638, Clinics: Billing Codes section in the appropriate Part 2 manual.

SOURCE: CA Department of Health Care Services (DHCS).  Indian Health Services, Memorandum of Agreement (MOA) 638, Clinics Manual. Jan. 2023. Pg. 7-8. (Accessed Jun. 2023). 

Dental Services

Synchronous interaction, or live transmission, is a real-time interaction between a member and a provider located at a distant site. Live transmissions are limited to 90 minutes per member per provider, per day. Please note, live transmissions may be provided at the member’s request or if the health care provider believes the service is clinically appropriate. All dental information transmitted during the delivery of Medi-Cal covered benefits or services via a telehealth modality must become part of the patient’s dental record maintained by the Medi-Cal provider at the distant site.

SOURCE: CA Department of Health Care Services (DHCS). Denti-Cal Manual. Jan. 2023. Pg. 4-24. (Accessed Jun. 2023).

Home Health & Durable Medical Equipment

Telehealth may be used to deliver a face-to-face encounter related to the primary reason a recipient requires home health services or a durable medical equipment item.

SOURCE: Department of Health Care Services. Home Health Agencies (HHA) Provider Handbook. (Feb. 2021), Pg. 3. & Department of Health Care Services. Durable Medical Equipment (DME): An Overview. (July 2021), Pg. 6. (Accessed Jun. 2023).

CA Children’s Services (CCS)

CA Children’s Services Program lists eligible CPT/HCPCS codes in Numbered Letters 16-1217 & 09-0718.  Codes specifically include tele-speech, tele-auditory verbal therapy, tele-auditory habilitation and tele-auditory rehabilitation services in the home, with the parent or guardian working with the speech therapist at the distant site.

SOURCE: Department of Health Care Services. Numbered letter 16-1217 to the CA Children’s Services Program and Genetically Handicapped Persons Program (GHPP).  Dec. 22, 2017. & Number Letter 09-0718 to CA Children’s Services Program.  Jul. 10, 2018.  (Accessed Jun. 2023). 

Opioid Use Disorder Treatment Services

Outpatient treatment services for opioid use disorder (OUD), which include management, care coordination, psychotherapy and counseling are reimbursable using HCPCS codes G2086, G2087 and G2088. At least one psychotherapy service must be furnished in order to bill for HCPCS codes G2086 thru G2088. Although the descriptions for these codes refer to “office-based treatment,” these services may be delivered via telehealth when they meet Medi-Cal requirements. See Medi-Cal Telehealth Provider Manual.

HCPCS codes G2086 thru G2088 are not reimbursable for treatment in state-licensed Opioid Treatment Programs as defined in Health and Safety Code Section 11875. HCPCS codes G2086 and G2087 each have a frequency limit of once per calendar month, per recipient, any provider and G2088 has a frequency limit of two per calendar month, per recipient, any provider. Only one provider can be reimbursed for HCPCS code G2086, G2087 or G2088 per calendar month.

SOURCE: Department of Health Care Services. Evaluation & Management Manual. Page 47-48. Dec. 2022. (Accessed Jun. 2023).

ELIGIBLE PROVIDERS

The health care provider rendering Medi-Cal covered benefits or services provided via a telehealth modality must meet the requirements of Business and Professions Code (B&P Code), Section 2290.5(a)(3), or must be otherwise designated by the Department of Health Care Services (DHCS) pursuant to Welfare and Institutions Code (WIC) 14132.725 (b)(2)(A).

A licensed health care provider rendering Medi-Cal covered benefits or services via a telehealth modality must be licensed in California, enrolled as a Medi-Cal rendering provider or non-physician medical practitioner (NMP) and affiliated with an enrolled Medi-Cal provider group.

The enrolled Medi-Cal provider group for which the health care provider renders services via telehealth must meet all Medi-Cal program enrollment requirements and must be located in California or a border community.

For purposes of telehealth [the distant site] can be different from the administrative location.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth (Jan. 2023). Pg. 2-3. (Accessed Jun. 2023). 

Federally Qualified Health Center (FQHC) & Rural Health Clinic (RHC)

Billable providers are eligible to deliver covered FQHC/RHC services. Providers may refer to “RHC/FQHC Covered Services” in this manual section.

SOURCE: CA Department of Health Care Services (DHCS).  Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHC) Outpatient Services Manual. Jan. 2023. Pg. 11. (Accessed Jun. 2023).

Indian Health Services, Memorandum of Understanding Agreement (IHS-MOA)

Billable providers are eligible to deliver available services offered under IHS-MOA services.

SOURCE: CA Department of Health Care Services (DHCS). Indian Health Services, Memorandum of Agreement (MOA) 638, Clinics Manual. Jan. 2023. Pg. 7-8. (Accessed Jun. 2023). 

Dental Professionals

For Medi-Cal dental benefits or services, Medi-Cal enrolled dentists and allied dental professionals (under the supervision of a dentist) may render limited services via synchronous/live transmission teledentistry, so long as such services are within their scope of practice, when billed using CDT code D9995 for dates of service on or after May 16, 2020.

SOURCE: CA Department of Health Care Services (DHCS). Denti-Cal Manual. Jan. 2023. Pg. 4-24-25. (Accessed Jun. 2023).

Psychiatrists

Psychiatrists may bill for services delivered through telehealth in accordance with the Medicaid state plan.

SOURCE: Sec. 14132.73 of the Welfare and Institutions Code. (Accessed Jun. 2023).

Doula, Community Health Worker (CHW) and Asthma Preventive Services

Doulas may provide services described in the Doula Services manual via telehealth.

Community Health Workers (CHWs) may provide services described in the Community Health Worker (CHW) Preventive Services manual via telehealth

Asthma preventive education and training services described in the Asthma Preventive Services (APS) manual may be provided via telehealth by unlicensed asthma preventive service providers. In-home environmental trigger assessments for asthma may not be conducted via telehealth and must be conducted in-person.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth (Jan 2023). Pg. 4. (Accessed Jun. 2023).

ELIGIBLE SITES

For purposes of reimbursement for covered treatment or services provided through telehealth, the type of setting where services are provided for the patient or by the health care provider is not limited (Welfare and Institutions Code [WIC] Section 14132.72(e)). This may include, but is not limited to, a hospital, medical office, community clinic, or the patient’s home.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth (Jan. 2023). Pg. 2. (Accessed Jun. 2023).

Federally Qualified Health Center (FQHC) & Rural Health Clinic (RHC)

The billable provider, employed or under direct contract with an FQHC or RHC can respond from any location, including their home, during a time that they are scheduled to work for the FQHC or RHC.

For the purposes of payment for covered treatment or services provided through telehealth, the department shall not limit the type of setting where services are provided for the patient or by the health care provider.

SOURCE: CA Department of Health Care Services (DHCS).  Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHC) Outpatient Services Manual. Jan. 2023. Pg. 15. (Accessed Jun. 2023).

Indian Health Services, Memorandum of Understanding Agreement (IHS-MOA)

Refers to fee-for-service policy for the definition of an ‘originating site’ and ‘distant site’.

SOURCE: CA Department of Health Care Services (DHCS). Indian Health Services, Memorandum of Agreement (MOA) 638, Clinics Manual. Jan. 2023. Pg. 7. (Accessed Jun. 2023).

Family PACT

Family PACT telehealth policy follows Medi-Cal telehealth policy to the extent it is applicable to the Family PACT Program and covered services. Exceptions include the definition for distant site:

•  For Family PACT, the distant site must be the enrolled service site. In Medi-Cal, the distant site can be different than the administrative location, as stated in the Medicine: Telehealth section of the appropriate Part 2 Medi-Cal provider manual.

SOURCE: CA Department of Health Care Services. Medi-Cal Provider Bulletin. Family PACT Update. Jun. 2023. (Accessed Jun. 2023).

GEOGRAPHIC LIMITS

No Reference Found

FACILITY/TRANSMISSION FEE

The originating site facility fee is reimbursable only to the originating site when billed with HCPCS code Q3014 (telehealth originating site facility fee).  Transmission costs incurred from providing telehealth services via audio/video communication is reimbursable when billed with HCPCS code T1014 (telehealth transmission, per minute, professional services bill separately).

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth (Jan. 2023). Pg. 11. (Accessed Feb. 2023). 

FQHC & RHC/IHS-MOA

FQHCs/RHCs/IHS-MOA are not eligible to bill an originating site fee or transmission charges. The costs of these services should be included in the PPS/AIR/IHS-MOA rates, as applicable.

SOURCE: CA Department of Health Care Services (DHCS).  Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHC) Outpatient Services Manual. Jan. 2023. Pg. 12; CA Department of Health Care Services (DHCS). Indian Health Services, Memorandum of Agreement (MOA) 638, Clinics Manual. Jan. 2023. Pg. 8.  (Accessed Jun. 2023).

Local Education Agency

The facility and transmission fee are not covered.

SOURCE: CA Department of Health Care Services (DHCS). Local Education Agency (LEA) Telehealth. Jun. 2023. Pg. 5 (Accessed Jun. 2023).

Every Woman Counts Program

Effective retroactively for dates of service on or after November 1, 2013, HCPCS codes Q3014 (telehealth originating site facility fee) and T1014 (telehealth transmission, per minute, professional services bill separately) are benefits of the Every Woman Counts (EWC) program.

SOURCE: Department of Health Care Services. Every Woman Counts Program Manual. Pgs. 39-40. Feb. 2023. (Accessed Jun. 2023).

Last updated 06/29/2023

Miscellaneous

Establishing New Patients via Telehealth

Providers may establish a relationship with new patients via synchronous video telehealth visits. Providers may establish a relationship with new patients via audio-only synchronous interaction only if one or more of the following applies:

• The visit is related to sensitive services as defined in subsection (n) or Section 56.06 of the Civil Code. Section 56.06 of the Civil Code defines “sensitive services” as all health care services related to mental or behavioral health, sexual and reproductive health, sexually transmitted infections, substance use disorder, gender-affirming care, and intimate partner violence, and includes services described in Sections 6924 through 6930 of the Family Code, and Sections 121020 and 124260 of the Health and Safety Code, obtained by a patient at or above the minimum age specified for consenting to the service specified in the section.
• The patient requests an audio-only modality.
• The patient attests they do not have access to video.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth. (Jan. 2023), Pg. 3. (Accessed Jun. 2023).

Documentation

All health care practitioners providing covered benefits or services to Medi-Cal patients must maintain appropriate documentation to substantiate the corresponding technical and professional components of billed CPT® or HCPCS codes. Documentation for benefits or services delivered via telehealth should be the same as for a comparable in-person service. The distant site provider can bill for Medi-Cal covered benefits or services delivered via telehealth using the appropriate CPT or HCPCS codes with the corresponding modifier and is responsible for maintaining appropriate supporting documentation. This documentation should be maintained in the patient’s medical record.

Providers should note the following:

• Health care providers at the distant site must determine that the covered Medi-Cal service or benefit being delivered via telehealth meets the procedural definition and components of the CPT or HCPCS code(s) associated with the Medi-Cal covered service or benefit as well as any other requirements described in this section of the Medi-Cal provider manual.
• Health care providers are not required to document a barrier to an in-person visit for Medi-Cal coverage of services provided via telehealth (W&I Code, Section 14132.72[d]).
• Health care providers at the distant site are not required to document cost effectiveness of telehealth to be reimbursed for telehealth services or store and forward services.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth. (Jan. 2023), Pg. 4. (Accessed Jun. 2023).

Family PACT

Documentation for benefits or services delivered via telehealth should be the same as for a comparable in-person service. The distant site provider can bill for Family PACT covered benefits or services delivered via telehealth using the appropriate CPT® or HCPCS codes with the corresponding modifier and is responsible for maintaining appropriate supporting documentation. This documentation must be maintained in the client’s medical record

SOURCE: CA DHCS Medi-Cal Provider Enrollment and Responsibilities Manual. (June 2023). Pg. 18. (Accessed Jun. 2023).

Disabled Individuals

Telehealth services and supports are among the services and supports authorized to be included by individual program plans developed for disabled individuals by regional centers that contract with the State Department of Developmental Disabilities.

SOURCE: Welfare and Institutions Code Sec. 4512. (Accessed Jun. 2023).

Network Adequacy

Medicaid must ensure that all managed care covered services are available and accessible to enrollees of Medicaid managed care plans in a timely manner. Telehealth can be used as a means to meet time and distance standards in some circumstances. See APL for details.

SOURCE: CA Welfare and Institutions Code Sec. 14197. & CA Department of Health Care Services (DHCS). All Plan Letter 23-001: Network Certification Requirements. Jan. 6, 2023. (Accessed Jun. 2023).

Emergency Clinic Telephonic Services

Telehealth services, telephonic services and other specified services must be reimbursed when provided by specific entities during or immediately following an emergency, subject to the Department obtaining federal approval and matching funds. The Department is required to issue guidance for entities to facilitate reimbursement for telehealth or telephonic services in emergency situations by July 1, 2020.

SOURCE: Welfare and Institutions Code Sec. 14132.723 & 724 (AB 1494 – 2019 Legislative Session). (Accessed Jun. 2023).

Privileges/Credentialing

Issues of privileges and credentialing for distant physicians to care for patients via telehealth are determined by the policies of the originating hospital. Hospitals can accept the privileges and credentials for providers at distant hospitals.

SOURCE: Telehealth FAQs, Providers. March 2021. (Accessed Jun. 2023).

COVID Telehealth Flexibilities

The department shall seek any federal approvals it deems necessary to extend the approved waiver or flexibility implemented pursuant to subdivision (a), as of July 1, 2021, that are related to the delivery and reimbursement of services via telehealth modalities in the Medi-Cal program. Subject to subdivision (e), the department shall implement those extended waivers or flexibilities for which federal approval is obtained, to commence on the first calendar day immediately following the last calendar day of the federal COVID-19 public health emergency period, and through December 31, 2022.

The department may authorize the use of remote patient monitoring as an allowable telehealth modality for covered health care services and provider types it deems appropriate for dates of service on or after July 1, 2021. The department may establish a fee schedule for applicable health care services delivered via remote patient monitoring.

For purposes of informing the 2022–23 proposed Governor’s Budget, released in January 2022, the department shall convene an advisory group consisting of consultants, subject matter experts, and other affected stakeholders to provide recommendations to inform the department in establishing and adopting billing and utilization management protocols for telehealth modalities to increase access and equity and reduce disparities in the Medi-Cal program. The advisory group shall analyze the impact of telehealth in increased access for patients, changes in health quality outcomes and utilization, best practices for the appropriate mix of in-person visits and telehealth, and the benefits or liabilities of any practice or care model changes that have resulted from telephonic visits.

SOURCE: AB 133, Sec. 380 (2021 Session). (Accessed Jun. 2023).

Consent

The department shall develop, in consultation with affected stakeholders, an informational notice to be distributed to fee-for-service Medi-Cal beneficiaries and for use by Medi-Cal managed care plans in communicating to their enrollees. Information in the notice shall include, but not be limited to, all of the following:

• The availability of Medi-Cal covered telehealth services.
• The beneficiary’s right to access all medically necessary covered services through in-person, face-to-face visits, and a provider’s and Medi-Cal managed care plan’s responsibility to offer or arrange for that in-person care, as applicable.
• An explanation that use of telehealth is voluntary and that consent for the use of telehealth can be withdrawn by the Medi-Cal beneficiary at any time without affecting their ability to access covered Medi-Cal services in the future.
• An explanation of the availability of Medi-Cal coverage for transportation services to in-person visits when other available resources have been reasonably exhausted.
• Notification of the beneficiary’s right to make complaints about the offer of telehealth services in lieu of in-person care or about the quality of care delivered through telehealth.

The informational notice shall be translated into threshold languages determined by the department pursuant to subdivision (b) of Section 14029.91 and provided in a format that is culturally and linguistically appropriate.

This subdivision does not apply to Medi-Cal covered services delivered by providers via any telehealth modality to eligible inmates in state prisons, county jails, or youth correctional facilities.

SOURCE: Welfare and Institutions Code 14132.725 (e), as amended by SB 184 (2022 Session). (Accessed Jun. 2023).

DHCS Telehealth Research and Evaluation Plan

On or before January 1, 2023, the department shall develop a research and evaluation plan that does all of the following:

• Proposes strategies to analyze the relationship between telehealth and the following: access to care, access to in-person care, quality of care, and Medi-Cal program costs, utilization, and program integrity.
• Examines issues using an equity framework that includes stratification by available geographic and demographic factors, including, but not limited to, race, ethnicity, primary language, age, and gender, to understand inequities and disparities in care.
• Prioritizes research and evaluation questions that directly inform Medi-Cal policy.

SOURCE: Welfare and Institutions Code 14132.725 (g), as amended by SB 184 (2022 Session). (Accessed Jun. 2023).

HIPAA/Privacy Compliance

Applicable health care services provided through asynchronous store and forward, video synchronous interaction, audio-only synchronous interaction, remote patient monitoring, or other permissible virtual communication modalities as described in this section shall comply with the privacy and security requirements contained in the federal Health Insurance Portability and Accountability Act of 1996 found in Parts 160 and 164 of Title 45 of the Code of Federal Regulations, the Medicaid State Plan, and any other applicable state and federal statutes and regulations.

SOURCE: Welfare and Institutions Code 14132.725 (h), as amended by SB 184 (2022 Session). (Accessed Jun. 2023).

Telehealth Requirements

Pursuant to an effective date designated by the department that is no sooner than January 1, 2024, a Medi-Cal provider – including FQHCs/RHCs – furnishing applicable health care services via audio-only synchronous interaction shall also offer those same health care services via video synchronous interaction to preserve beneficiary choice. The department may provide specific exceptions to the requirement based on a Medi-Cal provider’s access to requisite technologies, which shall be developed in consultation with affected stakeholders and published in departmental guidance. In making such exceptions, the department may also take into consideration the availability of broadband access based on speed standards set by the Federal Communications Commission or other applicable federal law or regulation.

Pursuant to an effective date designated by the department that is no sooner than January 1, 2024, a Medi-Cal provider – including FQHCs/RHCs – furnishing applicable health care services via synchronous video interaction or audio-only synchronous interaction shall also offer those same health care services in-person or facilitate access to in-person services for the patient. The department shall consider additional recommendations from affected stakeholders regarding the need to maintain access to in-person services without unduly restricting access to telehealth services.

SOURCE: Welfare and Institutions Code 14132.725 & Welfare and Institutions Code 14132.100, as amended by SB 184 (2022 Session) and AB 32 (2022 Session). (Accessed Jun. 2023).

Medi-Cal Enrollment Procedure and Exemptions for Remote Mental Health Services

Effective March 29, 2023, the Department of Health Care Services (DHCS) is establishing Medi-Cal provider enrollment requirements and procedures that will be exempt from certain established place of business requirements for the following modes of service:

• Remote service providers who offer mental health services exclusively through telehealth modalities, and
• Transportation providers located in California.

In accordance with Welfare & Institutions (W&I) Code Section 14043.75(b), enrollment requirements and procedures are established for providers offering Medi-Cal covered mental health services exclusively through telehealth modalities, including non-specialty mental health services (NSMHS) covered under Medi-Cal Fee-For-Service and Medi-Cal Managed Care Plans and Specialty Mental Health Services (SMHS) covered by county mental health plans, and for Non-Emergency Medical Transportation (NEMT) and Non-Medical Transportation (NMT) providers.

The following provider types are able to apply for enrollment as remote service-only providers:

• Licensed Clinical Social Workers;
• Licensed Marriage and Family Therapists;
• Licensed Professional Clinical Counselors;
• Nurse Practitioners specializing in Psychiatry;
• Physicians specializing in Psychiatry; and
• Psychologists

Remote service providers requesting consideration for enrollment in the Medi-Cal program must complete and submit an application for their appropriate provider type through the Provider Application and Validation for Enrollment (PAVE) portal with the required supporting documents and a completed and signed Remote Services-Only Provider Attestation. For more detailed information, providers may refer to the Requirements and Procedures for the Medi-Cal Enrollment of Providers Offering Services Remotely or Indirectly from their Business Address located on the Provider Enrollment page of the Medi-Cal Provider website.

SOURCE: CA Dept. of Health Care Services. Medi-Cal Update – Psychological Services. March 2023. (Accessed Jun. 2023).

Community-Based Adult Services (CBAS)

CBAS Emergency Remote Services (ERS) are authorized under the California Advancing and Innovating Medi-Cal (CalAIM) 1115 Demonstration Waiver (Waiver) that was implemented October 1, 2022. CBAS supports and services delivered in the community, at the doorstep or in the home, and via telehealth allow for immediate response during participant emergencies. DHCS and MCPs are required to cover ERS as part of the CBAS benefit when participants meet the criteria established in ERS policy, including that ERS is determined to be the appropriate service for the participant and their emergency situation, and the CBAS provider meets the criteria specified in this ACL. See ACL for additional information.

SOURCE: CA Dept. of Health Care Services. All Center Letter 22-04. Launch of New CBAS ERS. Aug. 2022. (Accessed Jun. 2023).

Signature Requirement for Medication Delivery

In accordance with W&I Code, Section 14043.341, providers must obtain either a handwritten or electronic signature for prescription medications sent to a client. Providers may obtain the signature of a client or the recipient either before the medication is sent, or upon receipt when delivered to the client.

Signature Prior to Delivery – Providers have two options to obtain a client’s signature when the client is not in person, such as during a telehealth visit:

• Recorded oral signature: Providers must ensure that they are able to collect an audio or video recording that can be stored in the provider’s case record and retrieved upon request. Providers may use either of the following two options for audio or videorecorded signatures
  • Recording only the signature portion of the telehealth visit. When recording only the signature portion of the visit, providers must record the portion of the visit where the client acknowledges and confirms the medications they will be receiving and provides their understanding that the oral signature holds the same weight as a written signature; or –
  • Recording the entire visit with the oral signature included
• Electronic signature: Providers may obtain an electronic signature. Consistent with the Uniform Electronic Transactions Act, California Civil Code Section 1633.2, an “electronic signature” is an electronic sound, symbol, or process attached to or logically associated with an electronic record and executed or adopted by a person with the intent to sign the electronic record. An electronic signature includes a “digital signature” defined in subdivision (d) of Section 16.5 of the Government Code to mean an electronic identifier, created by a computer, intended by the party using it to have the same force and effect as a manual signature. Regardless of the type of electronic signature collected, providers must ensure that they are able to store and/or easily access documentation of the electronic signature in the client’s medical record

Signature upon Receipt of Delivery – Providers may obtain a client’s handwritten or electric signature upon receipt of delivery if the delivery service offers physical or electronic return receipts, such as those offered through the United States Postal Service. Providers must retain documentation of the signature in the client’s medical record.

SOURCE: CA DHCS Medi-Cal Provider Enrollment and Responsibilities Manual. (Aug. 2022). Pg. 20-21. (Accessed Jun. 2023).

Workers’ Compensation

Telehealth is included in the Official Medical Fee Schedule (OMFS) for California’s Workers’ Compensation system and consistent with Medicare’s List of Telehealth Services for Calendar Year 2023 (ZIP).

Recently passed regulations authorize a remote health evaluation or medical-legal evaluations through the use of electronic means of creating a virtual meeting between the physician and injured worker when both parties can visually see and hear each other and may not be in the same physical space or site. Evaluations can be completed through remote health when a hands on physical examination is not necessary and certain conditions are met.

Remote health is defined as remote visits via video-conferencing, video-calling, or such similar technology that allows each party to see and converse with the other via a video and audio connection. The evaluation must be conducted with the same standard of care as in person visit and must comply with all relevant state and federal privacy laws.

SOURCE: CA Division of Workers’ Compensation Order of the Administrative Director – Effective July 1, 2023; CA Code of Regulations, Title 8, Section 9789.1.2 & CA Code of Regulations, Title 8, Section 46.3, as proposed to be added by permanent rule. (Accessed Jun. 2023).

Last updated 06/29/2023

Out of State Providers

Provider must be licensed in CA, enrolled as a Medi-Cal rendering provider or non-physician medical practitioner (NMP) and affiliated with an enrolled Medi-Cal provider group. The enrolled Medi-Cal provider group for which the health care provider renders services via telehealth must meet all Medi-Cal program enrollment requirements and must be located in California or a border community.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth. (Jan. 2023), Pg. 3.; Welfare and Institutions Code 14132.725, as amended by SB 184 (2022 Session). (Accessed Jun. 2023).

Last updated 06/28/2023

Overview

Medi-Cal allows providers to decide what modality, live video, store-and-forward, or audio-only, will be used to deliver eligible services to a Medi-Cal enrollee as long as the service is covered by Medi-Cal and meets all other Medi-Cal guidelines and policies, can be properly provided via telehealth, and meets the procedural and definition components of the appropriate CPT or HCPCS code. Additional requirements apply for specific programs (such as FQHCs/RHCs and Indian Health Services). Medi-Cal also reimburses Medicare CTBS remote patient monitoring codes and one specific e-consult code.

Last updated 06/29/2023

Remote Patient Monitoring

POLICY

Principal care management (PCM) services are provided when medical and/or psychological needs manifested by a single, complex chronic condition are expected to last at least three months. CPT codes 99424 and 99426 each have a frequency limit of once per calendar month, any provider and 99427 has a frequency limit of two per calendar month, any provider.

Remote physiologic monitoring (RPM) services for established patients ages 21 and older are reimbursable when ordered by and billed by physicians or other qualified health professionals (QHP). RPM services may be delivered by auxiliary personnel including contracted employees, when under the supervision of the billing physician or qualified health professional.  See manual for codes.

Prior to or at the time RPM services are furnished, the patient must give consent to receive the services. Consent may be verbal (written consent is not required) but must be documented in the medical record, along with justification for the use of RPM services.

SOURCE: CA DHCS Evaluation and Management Manual (Dec. 2022), p. 39-42. (Accessed Jun. 2023).

The department may authorize the use of remote patient monitoring as an allowable telehealth modality for covered health care services and provider types it deems appropriate for dates of service on or after July 1, 2021. The department may establish a fee schedule for applicable health care services delivered via remote patient monitoring.

SOURCE: Sec. 14124.12 (f)(1)(B) of the Welfare and Institutions Code. As amended by AB 133, Sec. 380 (2021 Session). (Accessed Jun. 2023).

Remote Physiologic Monitoring

Medi-Cal reimburses for 5 remote physiologic monitoring codes (99091, 99453, 99454, 99457, 99458), consistent with Medicare Communication Technology Based Services (CTBS) .

SOURCE: Medi-Cal Rates Information. Dec. 2022. (Accessed Jun. 2023).

Continuous Glucose Monitoring

Effective for dates of service on or after May 1, 2023, CPT^® codes 95250 (ambulatory continuous glucose monitoring [CGM] of interstitial fluid via a subcutaneous sensor for a minimum of 72 hours; physician or other qualified health care professional [office] provided equipment, sensor placement, hook-up, calibration of monitor, patient training, removal of a sensor, and printout of recording) and 95251 (ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours; analysis, interpretation and report) are added as Medi-Cal benefits.

SOURCE: CA Dept. of Health Care Services. Medi-Cal Update Bulletin. April 2023. & Durable Medical Equipment (DME): Billing Codes Manual, Apr. 2023, p. 52. (Accessed Jul. 2023).

Continuous Glucose Monitoring (CGM) is a covered benefit for California Children’s Services (CCS) and the Genetically Handicapped Persons Program (GHPP). CGM systems are minimally invasive devices that measure subcutaneous interstitial fluid glucose. The availability of real-time CGM data allows the individual or caregiver to monitor glucose levels, receive alerts for dangerously high or low blood glucose levels, and adjust diet and medications to avert adverse hypoglycemic or hyperglycemic events.

Effective October 1, 2022, non-therapeutic CGMs are also processed through Medi-Cal Rx according to the Medi-Cal Rx integrated coverage policy. Prior Authorization is required on all CGM requests through Medi-Cal Rx.

• Section 13.4 of the Medi-Cal Rx Provider Manual
• Under Covered continuous Glucose Monitoring (CGM) Systems Medi-Cal Providers | Forms and Information

SOURCE: CA Dept. of Health Care Services. California Children’s Services Numbered Letter 15-1222. CGM as a CCS and GHPP Program Benefit. Dec. 23, 2022. (Accessed Jun. 2023).

CONDITIONS

Continuous Glucose Monitoring

The CCS Program or GHPP client must meet all of the following:

• The client has a diagnosis of type 1 diabetes mellitus, cystic fibrosis (CF) related diabetes, insulin-dependent type 2 diabetes, or sequelae of a CCS Program-eligible condition that requires ongoing insulin use.
• The client requires glucose testing by finger stick or CGM at least three times per day.
• The client requires analog insulin injections at least three times per day or uses an insulin pump.
• The client’s insulin regimen requires frequent adjustment on the basis of finger stick or CGM blood glucose readings.

SOURCE: CA Dept. of Health Care Services. California Children’s Services Numbered Letter 15-1222. CGM as a CCS and GHPP Program Benefit. Dec. 23, 2022. (Accessed Jun. 2023).

PROVIDER LIMITATIONS

Remote Physiologic Monitoring

Remote physiologic monitoring (RPM) services for established patients ages 21 and older are reimbursable when ordered by and billed by physicians or other qualified health professionals (QHP). RPM services may be delivered by auxiliary personnel including contracted employees, when under the supervision of the billing physician or qualified health professional.  See manual for codes.

SOURCE: Department of Health Care Services. Evaluation & Management Manual. Page 41. Dec. 2022. (Accessed Jun. 2023).

Continuous Glucose Monitoring

CCS/CHPP – Therapeutic and non-therapeutic CGMs may be prescribed by one of the following:

• A CCS Program-paneled endocrinologist affiliated with an Endocrine Special Care Center (SCC) or SCC nurse practitioner if the physician has ordered CGM for the client, as documented in the medical record.
• A CCS-paneled community pediatric endocrinologist if the client meets certain conditions.
• For GHPP clients, an adult endocrinologist at an approved Endocrine SCC or an adult endocrinologist or internal medicine specialist with an active MediCal provider number treating the GHPP-eligible condition.

SOURCE: CA Dept. of Health Care Services. California Children’s Services Numbered Letter 15-1222. CGM as a CCS and GHPP Program Benefit. Dec. 23, 2022. (Accessed Jun. 2023).

OTHER RESTRICTIONS

Principle Care Management Services

CPT codes 99424 and 99426 each have a frequency limit of once per calendar month, any provider and 99427 has a frequency limit of two per calendar month, any provider.

Remote Physiologic Monitoring

Remote physiologic monitoring (RPM) services are reimbursable for established patients ages 21 and older.

CPT code 99453 is reimbursable once per episode of care but cannot be used for monitoring fewer than 16 days during a 30-day billing period. The interactive communication required for 99457 must be real-time synchronous with two-way audio with a minimum of 20 minutes per month and the patient must have a treatment plan for chronic care management. For additional information regarding minimum duration of service and definition of episode care, refer to the CPT book.

The frequency limit for 99453, 99454 and 99091 is one per 30 days, any provider. The frequency limit for 99457 is one per calendar month, any provider. The frequency limit for 99458 is three per interactive communication session.

Prior to or at the time RPM services are furnished, the patient must give consent to receive the services. Consent may be verbal (written consent is not required) but must be documented in the medical record, along with justification for the use of RPM services.

SOURCE: Department of Health Care Services. Evaluation & Management Manual. Page 39-42. Dec. 2022. (Accessed Jun. 2023).

The department may establish separate fee schedules for applicable health care services delivered via remote patient monitoring or other permissible virtual communication modalities.

SOURCE: Welfare and Institutions Code 14132.725, as amended by SB 184 (2022 Session). (Accessed Jun. 2023).

Continuous Glucose Monitoring

CPT codes 95250 and 95251 cannot be reported more than once per month per patient, any provider, regardless of the duration of professional CGM or the number of times CGM is provided in a single month. CPT 95251 cannot be reported in conjunction with CPT 99091. For prior authorization requirements for CGM systems, see Medi-Cal Rx Provider Manual, Section 13.4.

SOURCE: CA Dept. of Health Care Services. Medi-Cal Update Bulletin. April 2023. & Durable Medical Equipment (DME): Billing Codes Manual, Apr. 2023, p. 52. (Accessed Jul. 2023).

CCS/CHPP – Specific documentation containing certain information must be submitted by the Endocrine SCC or provider to Medi-Cal Rx. See notice for additional information and requirements.

SOURCE: CA Dept. of Health Care Services. California Children’s Services Numbered Letter 15-1222. CGM as a CCS and GHPP Program Benefit. Dec. 23, 2022. (Accessed Jun. 2023).

Last updated 06/29/2023

Store and Forward

POLICY

“Asynchronous store-and-forward” means the transmission of a patient’s medical information from an originating site to the health care provider at a distant site.  Consultations via asynchronous electronic transmission initiated directly by patients, including through mobile phone applications, are not covered under this policy.

“E-consults” fall under the auspice of store-and-forward.  E-consults are asynchronous health record consultation services that provide an assessment and management service in which the patient’s treating health care practitioner (attending or primary) requests the opinion and/or treatment advice of another health care practitioner (consultant) with specific specialty expertise to assist in the diagnosis and/or management of the patient’s health care needs without patient face-to-face contact with the consultant.  E-consults between health care providers are designed to offer coordinated multidisciplinary case reviews, advisory opinions and recommendations of care.  E-consults are permissible only between health care providers.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth (Jan. 2023). Pg. 1. (Accessed Jun. 2023).

Recently enacted legislation requires CA Medicaid and Medi-Cal managed care plans to reimburse health care providers of applicable health care services delivered via video synchronous interaction, synchronous audio-only modality, or asynchronous store and forward, as applicable, at payment amounts that are not less than the amounts the provider would receive if the services were delivered via in-person, face-to-face contact, so long as the services or settings meet the applicable standard of care and meet the requirements of the service code being billed.

A health care provider shall not establish a new patient relationship with a Medi-Cal beneficiary via asynchronous store and forward, telephonic (audio-only) synchronous interaction, remote patient monitoring, or other virtual communication modalities. The department may provide for specific exceptions to this prohibition, which shall be developed in consultation with affected stakeholders and published in departmental guidance. Additional exceptions apply for audio-only in particular as well. See Email, Phone & Fax Section for audio-only exception information.

In-person, face-to-face contact between a health care provider and a patient is not required under the Medi-Cal program for covered health care services and provider types designated by the department, when provided by video synchronous interaction, asynchronous store and forward, as defined in subdivision (a) of Section 2290.5 of the Business and Professions Code, audio-only synchronous interaction, remote patient monitoring, or other permissible virtual communication modalities, when those services and settings meet the applicable standard of care and meet the requirements of the service code being billed.

Applicable health care services appropriately provided through video synchronous interaction, asynchronous store and forward, audio-only synchronous interaction, remote patient monitoring, or other permissible virtual communication modalities are subject to billing, reimbursement, and utilization management policies imposed by the department. Utilization management protocols adopted by the department pursuant to this section shall be consistent with, and no more restrictive than, those authorized for health care service plans pursuant to Section 1374.13 of the Health and Safety Code.

SOURCE: Welfare and Institutions Code 14132.725, as amended by SB 184 (2022 Session) and AB 32 (2022 Session). (Accessed Jun. 2023).

Brief Virtual Communications and Check-ins

Virtual or telephonic communication includes a brief communication with an established patient not physically present (face-to-face). Medi-Cal providers may be reimbursed using HCPCS codes G2010 and G2012 for brief virtual communications.

HCPCS code G2010: Remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 hours, not originating from a related evaluation and management (E/M) service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth (Jan. 2023). Pg. 10. (Accessed Jun. 2023).

FQHCs/RHCs 

Asynchronous store and forward means the transmission of a patient’s medical information from an originating site to the billable provider at a distant site.

Medi-Cal benefits or services being provided are clinically appropriate and meet the procedural and billing requirements that would have applied if the applicable services were delivered via a face-to-face encounter.

A patient may be “established” on an asynchronous store and forward service, if all of the conditions of the “New Patient” requirements in this manual section are met.

Only one visit or store and forward service may be billed at the PPS rate when there is a service payment contract with a non-FQHC/RHC, contractor, or another FQHC or RHC. Conversely, the non-FQHC/RHC or contractor may request fee-for-service reimbursement for a visit or store and forward service directly from the appropriate managed care plan or the Medi-Cal Fiscal Intermediary if no service payment contract exists with the FQHC or RHC.

E-consult is not covered.

SOURCE: CA Department of Health Care Services (DHCS). Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHC) Outpatient Services Manual. Jan. 2023. Pg. 13-15. (Accessed Jun. 2023).  

Visits shall also include an encounter between an FQHC or RHC patient and a physician, physician assistant, nurse practitioner, certified nurse-midwife, clinical psychologist, licensed clinical social worker, visiting nurse, comprehensive perinatal services program practitioner, dental hygienist, dental hygienist in alternative practice, or marriage and family therapist using an asynchronous store and forward modality, when services delivered through that modality meet the applicable standard of care. A visit described in this clause shall be reimbursed at the applicable FQHC’s or RHC’s per-visit PPS rate to the extent the department determines that the FQHC or RHC has met all billing requirements that would have applied if the applicable services were delivered via a face-to-face encounter.

An FQHC or RHC is not precluded from establishing a new patient relationship through an asynchronous store and forward modality, as defined in subdivision (a) of Section 2290.5 of the Business and Professions Code, if the visit meets all of the following conditions:

• The patient is physically present at the FQHC or RHC, or at an intermittent site of the FQHC or RHC, at the time the service is performed.
• The individual who creates the patient records at the originating site is an employee or contractor of the FQHC or RHC, or other person lawfully authorized by the FQHC or RHC to create a patient record.
• The FQHC or RHC determines that the billing provider is able to meet the applicable standard of care.

SOURCE: Welfare and Institutions Code 14132.100, as amended by SB 184 (2022 Session) and AB 32 (2022 Session). (Accessed Jun. 2023).

Family PACT

Family PACT telehealth policy mirrors the fee-for-service policy.

SOURCE: CA Department of Health Care Services. Family Planning, Access, Care and Treatment Program. Benefits Manual. Jun. 2023, Pg. 6. (Accessed Jun. 2023).

Managed Care

To ensure proper payment and record of Covered Services provided via Telehealth, all Providers must use the modifiers defined in the Medi-Cal Provider Manual with the appropriate CPT-4 or HCPCS codes when coding for services delivered through both synchronous interactions and asynchronous store and forward telecommunications. Regarding the rate of reimbursement, unless otherwise agreed to by the MCP and Provider, MCPs must reimburse Network Providers at the same rate, whether a Covered Service is provided in-person or through Telehealth, if the service is the same regardless of the modality of delivery, as determined by the Provider’s description of the service on the claim.

SOURCE: CA Department of Health Care Services (DHCS). All Plan Letter 23-007: Telehealth Services Policy. Apr. 10, 2023, Pg. 5. (Accessed Jun. 2023).

Indian Health Services, Memorandum of Understanding Agreement (IHS-MOA)

A patient may not be “established” on an asynchronous store and forward service with the exception of a homeless patient. Reimbursement is permitted for an established patient by a billable provider at the distant site.

SOURCE: CA Department of Health Care Services (DHCS). Indian Health Services, Memorandum of Agreement (MOA) 638, Clinics Manual. May 2023. Pg. 9. (Accessed Jun. 2023). 

Local Education Agency

For purposes of LEA policy, the telehealth definition only includes synchronous, real-time interactions between a patient and a health care provider located at a distant site.

SOURCE: CA Department of Health Care Services (DHCS). Local Education Agency (LEA) Telehealth. Jun. 2023. Pg. 1. (Accessed Feb. 2023). 

Dental Services

The Department of Health Care Services has opted to permit the use of teledentistry (includes store-and-forward) as an alternative modality for the provision of select dental services.  See manual for codes and requirements.

DHCS has expanded its teledentistry policy to allow Medi-Cal dental Fee-for-Service (FFS) and Dental Managed Care (DMC) providers the ability to establish new patient relationships through an asynchronous store and forward modality, consistent with Federally Qualified Health Center/Rural health Clinic (FQHC/RHC) providers.

SOURCE: CA Department of Health Care Services (DHCS). Medi-Cal Dental Provider Handbook. Jan. 2023 Pg. 4-22 – 4-23. (Accessed Jun. 2023).

ELIGIBLE SERVICES/SPECIALTIES

Modifier GQ must be used for Medi-Cal covered benefits or services, including, but not limited to, teleophthalmology, teledermatology, teledentistry and teleradiology, delivered via asynchronous store and forward telecommunications systems, including e-consults. Only the service(s) rendered from the distant site must be billed with modifier GQ.

The use of modifier GQ does not alter reimbursement for the CPT or HCPCS code billed. For additional information about policy and billing requirements relating to teledentistry, providers may refer to “Teledentistry” in the Medi-Cal Dental Provider Handbook.

For billing purposes, health care providers must ensure that the documentation, typically images, sent via store and forward be specific to the patient’s condition and adequate for meeting the procedural definition and components of the CPT or HCPCS code that is billed. In addition, all services billed via store and forward, including e-consult, are subject to all existing Medi-Cal coverage and reimbursement policies.

E-Consults

A health care provider at the distant site may bill for an e-consult with the CPT code listed below when the benefits or services delivered meet the procedural definition and components of the CPT code as defined by the AMA as well as any requirements described in this section of the Medi-Cal provider manual.

When billing for e-consults, health care providers at the originating and distant sites must clearly document the following information relating to previous and/or pertinent health care services, maintain this information in the patient’s medical record and make it available to DHCS upon request:

• A health care provider at the originating site must create and maintain the following: A record that the e-consult is the result of patient care that has occurred or will occur and relates to ongoing patient management; and A record of a request for an e-consult by the health care provider at the originating site.
• In order to bill for e-consults, the health care provider at the distant site must create and maintain the following: A record of the review and analysis of the transmitted medical information with written documentation of date of service and time spent; and A written report of case findings and recommendations with conveyance to the originating site.

To bill for e-consults, the health care provider at the distant site (consultant) may use CPT code 99451 in conjunction with the modifier GQ. In accordance with the AMA requirements, CPT code 99451 is not separately reportable or reimbursable if any of the following are true:

• The distant site provider (consultant) saw the patient within the last 14 days.
• The e-consult results in a transfer of care or other face-to-face service with the distant site provider (consultant) within the next 14 days or next available appointment date of the consultant.
• The distant site provider did not spend at least five minutes of medical consultative time, and it did not result in a written report.

If more than one contact or encounter is required to complete the e-consult request, the entirety of the service and cumulative discussion and information review time should be reported only once using CPT code 99451. CPT code 99451 is not reimbursable more than once in a seven-day period for the same patient and health care practitioner. Medi-Cal covered benefits or services provided at the originating site (in-person) with the patient in connection with an e-consult are billed according to standard Medi-Cal policies (without modifier GQ).

E-consults are not applicable for FQHCs, RHCs, or IHS-MOA clinics.

See Telehealth Modifier Reference Sheet- Organized by Delivery System​​ ​for more information on modifiers.

SOURCE: CA Department of Health Care Services.  Medi-Cal Part 2 General Medicine Manual. Telehealth (Jan 2023), Pg. 8-10. (Accessed Jun. 2023).

Medi-Cal covers an ‘e-visit’ which are communications between a patient and their provider through an online patient portal.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth (Jan. 2023). Pg. 2. (Accessed Jun. 2023).

Managed Care

All Providers, with the exception of Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs), and Tribal Health Providers (THPs), are allowed to be reimbursed for consultations provided via a Telehealth modality. These electronic consultations (e-consults) are permissible using the appropriate CPT-4 code, modifier(s), and Medical Record documentation defined in the Medi-Cal Provider Manual. Members cannot initiate e-consults as they are interprofessional interactions, and therefore only permissible between Providers. Providers are permitted to be reimbursed for brief virtual communications that consist of a brief communication with a Member who is not physically present (face-to-face) at the FFS rate. Virtual communications reimbursement for FQHCs, RHCs, and THPs is no longer allowed consistent with the end of the COVID-19 Public Health Emergency on May 11, 2023.

SOURCE: CA Department of Health Care Services (DHCS). All Plan Letter 23-007: Telehealth Services Policy. Apr. 10, 2023. Pg. 3. (Accessed Jun. 2023).

Indian Health Services, Memorandum of Understanding Agreement (IHS-MOA)

A patient may not be “established” on an asynchronous store and forward service with the exception of a homeless patient. Reimbursement is permitted for an established patient by a billable provider at the distant site.

SOURCE: CA Department of Health Care Services (DHCS). Indian Health Services, Memorandum of Agreement (MOA) 638, Clinics Manual. Jan. 2023. Pg. 9. (Accessed Jun. 2023).  

Vision Care

Teleophthalmology by store-and-forward is covered for three specific CPT codes.  Information can be reviewed by a physician or optometrist at a distant site. If the reviewing optometrist identifies a disease or condition requiring consultation or referral pursuant to Section 3041 of the Business and Professions Code, a referral must be made with an appropriate physician and surgeon or ophthalmologist, as required. Teleophthalmology services by store and forward must be billed with modifier GQ (service rendered by store and forward telecommunications system). Only the portion(s) rendered from the distant site (hub) are billed with modifier GQ. The use of modifier GQ does not alter reimbursement for the CPT or HCPCS code billed.

SOURCE: CA Department of Health Care Services, Vision Care: Professional Services Manual. (Dec. 2022), Pg. 5-6.  (Accessed Jun. 2023).

Dental Services

Reimburses for specific teledentistry codes via store-and-forward (see manual).

SOURCE: CA Department of Health Care Services (DHCS). Medi-Cal Dental Provider Manual. Jan. 2023. Pg. 4-23 – 4-24. (Accessed Jun. 2023).

Opioid Use Disorder Treatment Services

Outpatient treatment services for opioid use disorder (OUD), which include management, care coordination, psychotherapy and counseling are reimbursable using HCPCS codes G2086, G2087 and G2088. At least one psychotherapy service must be furnished in order to bill for HCPCS codes G2086 thru G2088. Although the descriptions for these codes refer to “office-based treatment,” these services may be delivered via telehealth when they meet Medi-Cal requirements. See Medi-Cal Telehealth Provider Manual.

HCPCS codes G2086 thru G2088 are not reimbursable for treatment in state-licensed Opioid Treatment Programs as defined in Health and Safety Code Section 11875. HCPCS codes G2086 and G2087 each have a frequency limit of once per calendar month, per recipient, any provider and G2088 has a frequency limit of two per calendar month, per recipient, any provider. Only one provider can be reimbursed for HCPCS code G2086, G2087 or G2088 per calendar month.

SOURCE: Department of Health Care Services. Evaluation & Management Manual. Page 47-48 Dec. 2022. (Accessed Jun. 2023).

GEOGRAPHIC LIMITS

No Reference Found

TRANSMISSION FEE

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth. (Jan. 2023), Pg. 11. (Accessed Jun. 2023).  

FQHC & RHC/IHS-MOA

These sites are not eligible for the facility or transmission fee.

SOURCE: CA Department of Health Care Services (DHCS).  Indian Health Services, Memorandum of Agreement (MOA) 638, Clinics Manual. Jan. 2023. Pg. 8 & Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHC) Outpatient Services Manual. Jan. 2023. Pg. 12. (Accessed Jun. 2023).  

Vision Care

The facility fee is reimbursable to the originating site when billed with HCPCS code Q3014. Transmission costs incurred from providing telehealth services via audio/video communication is also reimbursable for the original site and the consulting provider when billed with HCPCS code T1014. Expenses involving telehealth equipment and telecommunications and transmission costs by Internet service providers will not be reimbursed by Medi-Cal.

SOURCE: CA Department of Health Care Services, Vision Care: Professional Services Manual. (Oct. 2022), Pg. 5. (Accessed Jun. 2023).

Dental Care

The originating site and transmission fee and billing rules are not applicable to Safety Net Clinics (Federally Qualified Health Centers, Rural Health Clinics, Indian Health Services Memorandum of Agreement 683 Clinics). For policy and billing information specific to Safety Net Clinics, please refer to those sections of the Medi-Cal Provider Manual (Rural and Ind Health).

SOURCE: CA Department of Health Care Services (DHCS). Denti-Cal Manual. Jan. 2023. Pg. 4-23. (Accessed Jun. 2023).