Last updated 01/11/2023
Live Video
POLICY
CO Medicaid will cover medically necessary medical and surgical services furnished to eligible members.
Telemedicine services may be provided under two arrangements.
- The first arrangement is when a member receives services via a live audio/visual connection from a single provider. This is the predominant arrangement for telemedicine.
- The second arrangement is when a member and a provider are physically in the same location and additional services are provided by a second (distant) provider via a live audio/visual connection. In this arrangement the provider who is present with the member is called the “originating provider”, and the provider located at a different site, acting as a consultant, is called the “distant provider”.
The member must be present during any Telemedicine visit.
It is acceptable to use Telemedicine to facilitate live contact directly between a member and a provider.
SOURCE: CO Department of Health Care Policy and Financing. “Telemedicine Billing Manual,” 10/22 (Accessed Jan. 2023).
In-person contact between a health care or mental health care provider and a patient is not required under the state’s medical assistance program for health care or mental health care services delivered through telemedicine that are otherwise eligible for reimbursement under the program. Any health care or mental health care service delivered through telemedicine must meet the same standard of care as an in-person visit. Telemedicine may be provided through interactive audio, interactive video, or interactive data communication, including but not limited to telephone, relay calls, interactive audiovisual modalities, and live chat as long as the technologies are compliant with HIPAA. The health care or mental health care services are subject to reimbursement policies developed pursuant to the medical assistance program. This section also applies to managed care organizations that contract with the state department pursuant to the statewide managed care system only to the extent that:
- Health care or mental health care services delivered through telemedicine are covered by and reimbursed under the Medicaid per diem payment program; and
- Managed care contracts with managed care organizations are amended to add coverage of health care or mental health care services delivered through telemedicine and any appropriate per diem rate adjustments are incorporated.
Reimbursement rate must be, at minimum, the same as a comparable in-person services.
SOURCE: CO Revised Statutes 25.5-5-320 (Accessed Jan. 2023).
Interim Therapeutic Restorations
In-person contact between a health care provider and a recipient is not required under the state’s medical assistance program for the diagnosis, development of a treatment plan, instruction to perform an interim therapeutic restoration procedure, or supervision of a dental hygienist performing an interim therapeutic restoration procedure. A health care provider may provide these services through telehealth, including store-and-forward, and is entitled to reimbursement for the delivery of those services via telehealth to the extent the services are otherwise eligible for reimbursement under the program when provided in person. The services are subject to the reimbursement policies developed pursuant to the state medical assistance program.
SOURCE: CO Revised Statutes 25.5-5-321.5. (Accessed Jan. 2023).
ELIGIBLE SERVICES/SPECIALTIES
Colorado Medicaid will reimburse for medical and mental health services delivered through telemedicine that are otherwise eligible for reimbursement under the program.
Health care or mental health care services includes speech therapy, physical therapy, occupational therapy, hospice care, home health care and pediatric behavioral health care.
SOURCE: CO Revised Statutes 25.5-5-320. (Accessed Jan. 2023).
Services may be rendered via telemedicine when the service is:
- A covered Health First Colorado benefit,
- Within the scope and training of an enrolled provider’s license, and
- Appropriate to be rendered via telemedicine.
All services provided through telemedicine shall meet the same standard of care as in-person care.
Refer to ‘Telemedicine Website’ for list of billing codes.
The reimbursement rate for a telemedicine service shall, as a minimum, be set at the same rate as the medical assistance program rate for a comparable in-person service.
Providers may only bill procedure codes which they are already eligible to bill.
Additionally, modifiers FQ and FR can be added to POS 2 and 10:
- FQ: The service was furnished using audio-only communication technology.
- FR: The supervising practitioner was present through two-way, audio/video communication technology.
SOURCE: CO Department of Health Care Policy and Financing. “Telemedicine – Provider Information”, CO Department of Health Care Policy and Financing, CO Department of Health Care Policy and Financing. “Telemedicine Billing Manual”, 10/22. (Accessed Jan. 2023).
Physician services may be provided as telemedicine. Any health benefits provided through telemedicine shall meet the same standard of care as in-person care.
SOURCE: Colorado Adopted Rule 8.200.3.B. (Accessed Jan. 2023).
The following are listed under the covered services heading in the Telemedicine Manual:
- Physician services may be provided as telemedicine
- Providers may only bill procedure codes which they are already eligible to bill
- Any health benefits provided through telemedicine shall meet the same standard of care as in-person care.
SOURCE: CO Department of Health Care Policy and Financing. “Telemedicine – Provider Information”, CO Department of Health Care Policy and Financing, CO Department of Health Care Policy and Financing. (Accessed Jan. 2023).
Place of Services codes 02 and 10 can be used during telehealth encounters:
- POS 02: Telehealth provided other than in the patient’s home. The location where health services and health related services are provided or received, through telecommunication technology. Patient is not located in their home when receiving health services or health related services through telecommunication technology.
- POS 10: Telehealth Provided in Patient’s Home. The location where health services and health related services are provided or received through telecommunication technology. Patient is located in their home (which is a location other than a hospital or other facility where the patient receives care in a private residence) when receiving health services or health related services through telecommunication technology.
SOURCE: CO Department of Health Care Policy and Financing. “Telemedicine Billing Manual”, 10/22. (Accessed Jan. 2023).
Procedure codes listed below under “Telemedicine Modifier GT” will receive an additional $5.00 to the fee listed on the most recent Health First Colorado Fee Schedule when billed using modifier GT.
SOURCE: CO Department of Health Care Policy and Financing. “Telemedicine Billing Manual” 10/22. (Accessed Jan. 2023).
All Colorado Medicaid clients are eligible for medical and behavioral services delivered by telemedicine.
Covered Telemedicine services must:
- Meet the same standard of care as in-person care;
- Be compliant with state and federal regulations regarding care coordination;
- Be services the Department has approved for delivery through Telemedicine;
- Be within the provider’s scope of practice and for procedure codes the provider is already eligible to bill;
- Be provided only where contact with the provider was initiated by the member for the services rendered; and
- Be provided only after the member’s consent, either verbal or written, to receive telemedicine services is documented.
The reimbursement rate for a Telemedicine service shall, as a minimum, be set at the same rate as the Colorado Medicaid rate for a comparable in-person service.
SOURCE: Colorado Adopted Rule 8.095.2, 8.095.4, 8.095.7. (Accessed Jan. 2023).
Durable Medical Equipment Encounters
Face-to-face encounters for durable medical equipment, prosthetics, orthotics, and supplies may be performed via telehealth if available.
SOURCE: CO Department of Health Care Policy and Financing. “Durable Medical Equipment, Prosthetics, Orthotics, and Supplies”, 1/23. (Accessed Oct. 2022).
Pediatric Behavioral Therapy
Pediatric Behavioral Therapists are covered under the telemedicine policy.
SOURCE: CO Department of Health Care Policy and Financing. “Pediatric Behavioral Therapies Billing Manual”, 1/23 (Accessed Jan. 2023).
Pediatric behavioral therapy services are based in the home and community, as are Electronic Visit Verification (EVV) mandated services. Pediatric behavioral therapy providers will be required to collect EVV for Telehealth to streamline EVV requirements for providers and ensure services are delivered to members across service delivery methods.
Effective October 1, 2022, pediatric behavioral therapy services performed in the following places of service will require EVV prior to claims processing. If EVV is incomplete or not present, the claim will not pay.
- 02 – Telehealth Provided Other than in Patient’s Home
- 10 – Telehealth Provided in Patient’s Home
Providers are responsible to ensure that the member’s location is correctly captured when services are rendered by Telehealth/Telemedicine. Guidance on Telehealth/Telemedicine and Alternate Location can be found in the EVV Program Manual.
SOURCE: CO Medicaid Provider News & Resources. Aug. 29, 2022. (Accessed Jan. 2023).
Screening Brief Intervention Treatment
Screening Brief Intervention Treatment may be provided via telemedicine (simultaneous audio and video transmission or by telephone audio-only) with the member.
SOURCE: CO Department of Health Care Policy and Financing. “Screening, Brief Intervention and Referral to Treatment”, 10/21. (Accessed Jan. 2023).
Education-Only Services
Colorado Medicaid provides reimbursement for education-only services provided through telemedicine. This includes services such as Diabetes Self-Management Education and Support (DSMES) and tobacco cessation counseling.
SOURCE: CO Department of Health Care Policy and Financing. Provider Bulletin B1900434. Aug. 2019. (Accessed Jan. 2023).
Education-only services was removed from the list of “Not Covered Services” section in the provider manual in June 2019.
SOURCE: CO Department of Health Care Policy and Financing. “Telemedicine Billing Manual” 10/22. (Accessed Jan. 2023).
Abortion Services
Certain medicinal abortion services may be provided by telemedicine. Physicians (MDs/DOs), Certified Nurse Midwives (CNMs), Advanced Practice Nurses (APNs) or Physician Assistants (PAs) who wish to prescribe Mifepristone must complete a Prescriber Agreement Form prior to ordering and dispensing Mifepristone. The medicinal abortion method (not available for use in maternal life-endangering situations) can be provided by these identified provider types and identified places of service effective May 21, 2021, when prescribed or dispensed and provided by eligible Mifepristone-prescribing practitioners.
HCPCS S0199 covers:
- Office visit #1 or telemedicine counseling/communications
- Patient check-in or telemedicine services, all counseling and consultation
- Confirmation of pregnancy and fetal gestational age (either by hCG or ultrasound)
- Follow-up, may include a second office visit or consultation via telemedicine
- Patient consultation: may include telemedicine consult or office visit check-in with in-person consult.
- Confirmation of pregnancy termination (either by hCG or ultrasound)
Please see Provider Bulletin for further billing information and related requirements.
SOURCE: CO Department of Health Care Policy and Financing. Provider Bulletin B2200472. Jan. 2022. (Accessed Jan. 2023).
Community Mental Health Centers/Clinics
Group psychotherapy services shall be face-to-face, or interactive audio (including but not limited to telephone and relay calls), interactive video (including but not limited to interactive audiovisual modalities), or interactive data communication (including but not limited to live chat and excluding text messaging, electronic mail, and facsimile transmission) services that are insight-oriented, behavior modifying, and that involve emotional interactions of the group members. Group psychotherapy services shall assist in providing relief from distress and behavior issues with other clients who have similar problems and who meet regularly with a practitioner. Any health benefits provided through interactive audio, interactive video, or interactive data communication must meet the same standard of care as in-person care.
Individual psychotherapy services shall be face-to-face, or interactive audio (including but not limited to telephone and relay calls), interactive video (including but not limited to interactive audiovisual modalities), or interactive data communication (including but not limited to live chat and excluding text messaging, electronic mail, and facsimile transmission) services that are tailored to address the individual needs of the client. Services shall be insight-oriented, behavior modifying and/or supportive with the client in an office or outpatient facility setting. Individual psychotherapy services are limited to thirty-five visits per State fiscal year. Any health benefits provided through interactive audio, interactive video, or interactive data communication must meet the same standard of care as in-person care.
SOURCE: Colorado Adopted Rule 8.750.3.B. (Accessed Jan. 2023).
FQHC/RHC
When a Federally Qualified Health Center or a Rural Health Clinic provides care through telemedicine, the claim must include the modifier GT on line(s) identifying the service(s).
When used by an FQHC or RHC, the modifier GT identifies the services as being delivered through telemedicine modality. There is no enhanced payment to FQHCs and RHCs when using the modifier GT.
SOURCE: CO Department of Health Care Policy and Financing. “Telemedicine Billing Manual” 10/22. (Accessed Jan. 2023).
For Health First Colorado a billable encounter at an FQHC is an in person or telemedicine face to face visit with a Health First Colorado member.
Telemedicine services are limited to the procedure codes identified on the Telemedicine-Provider Information web page at the Provider Telemedicine web page.
When a Federally Qualified Health Center or a Rural Health Clinic provides care through telemedicine, the claim must include the modifier GT on line(s) identifying the service(s).
Additionally, modifiers FQ and FR can be added to the claim:
- FQ: The service was furnished using audio-only communication technology.
- FR: The supervising practitioner was present through two-way, audio/video communication technology.
SOURCE: CO FQHC & RHC Billing Manual 8/22. (AccessedJan. 2023).
The visit definition for a FQHC includes interactive audio (including but not limited to telephone and relay calls), interactive video (including but not limited to interactive audiovisual modalities), or interactive data communication (including but not limited to live chat and excluding text messaging, electronic mail, and facsimile transmission) encounters. Any health benefits provided through interactive audio (including but not limited to telephone and relay calls), interactive video (including but not limited to interactive audiovisual modalities), or interactive data communication (including but not limited to live chat and excluding text messaging, electronic mail, and facsimile transmission) must meet the same standard of care as in-person care.
SOURCE: Colorado Adopted Rule 8.700.1. (Accessed Jan. 2023).
The visit for a RHC means a face-to-face encounter, or an interactive audio (including but not limited to telephone and relay calls), interactive video (including but not limited to interactive audiovisual modalities), or interactive data communication (including but not limited to live chat and excluding text messaging, electronic mail, and facsimile transmission) encounter between a clinic client and any health professional providing the services set forth in 8.740.4. Any health benefits provided through interactive audio, interactive video, or interactive data communication must meet the same standard of care as in-person care.
SOURCE: Colorado Adopted Rule 8.740.1. (Accessed Jan. 2023).
ELIGIBLE PROVIDERS
Any licensed provider enrolled with Colorado Medicaid is eligible to provide telemedicine services within the scope of the provider’s practice.
SOURCE: Colorado Adopted Rule 8.095.3. CO Department of Health Care Policy and Financing. “Telemedicine Billing Manual” 10/22. (Accessed Oct. 2022).(Accessed Jan. 2023).
The following distant provider types may bill using modifier GT:
- Physician
- Clinic
- Osteopath
- FQHC
- Doctorate Psychologist
- MA Psychologist
- Physician Assistant
- Nurse Practitioner
- RHC
A primary care provider (PCP) is eligible to be reimbursed as the ‘originating provider’ when present with the patient. In order for a PCP to be reimbursed as a distant provider, the PCP must be able to facilitate an in-person visit in the state of CO if necessary for treatment of the member’s condition.
A specialist is eligible to be an originating provider (if present with the patient) or distant provider.
The distant provider may participate in the telemedicine interaction from any appropriate location.
SOURCE: CO Department of Health Care Policy and Financing. “Telemedicine Billing Manual” 10/22. (Accessed Jan. 2023).
A telemedicine service meets the definition of a face-to-face encounter for a rural health clinic, Indian health service, or federally qualified health center. The reimbursement rate for a telemedicine service provided by a rural health clinic or federal Indian health service or federally qualified health center must be set at a rate that is no less than the medical assistance program rate for a comparable face-to-face encounter or visit.
SOURCE: CO Statute, Sec. 25.5-5-320. (Accessed Oct. 2022).
eHealth Entities
Providers that meet the definition of an eHealth Entity shall enroll as the eHealth specialty. Electronic Health Entity (eHealth Entity) means a group practice that delivers services exclusively through telemedicine and is enrolled in a provider type that has an eHealth specialty. eHealth entities:
-
- Cannot be Primary Care Medical Providers
- Primary Care Medical Provider (PCMP) means an individual physician, advanced practice nurse or physician assistant, who contracts with a Regional Accountable Entity (RAE) in the Accountable Care Collaborative (ACC), with a focus on primary care, general practice, internal medicine, pediatrics, geriatrics, or obstetrics and gynecology.
- Can be either in-state or out-of-state.
eHealth Entities shall only provide Covered Telemedicine services, including Facilitated Visits. A Facilitated Visit means a Telemedicine visit where the rendering provider is at a distant site and the member is physically present with a support staff team member who can assist the provider with in-person activities. eHealth Entities must maintain a Release of Information in compliance with current HIPAA standards to facilitate communication with the member’s PCMP.
SOURCE: Colorado Adopted Rule 8.095.1, 8.095.3, 8.095.4, 8.095.6. (Accessed Oct. 2022).
As of October 30th, 2022, there is a provider specialty type for Clinic and Non-Physician Practitioner groups that meet the following definition:
- An eHealth entity is defined as a group practice that delivers services exclusively through telemedicine and is enrolled in a provider type that has an eHealth specialty. Providers who meet this definition must update their enrollment to this provider specialty type.
SOURCE: CO Department of Health Care Policy and Financing. “Telemedicine Billing Manual” 10/22. (Accessed Jan. 2023).
The telemedicine rule 10 CCR 2505-10 8.095 regarding eHealth entities is effective as of October 30, 2022. An eHealth entity is defined as a group practice that delivers services exclusively through telemedicine and is enrolled in a provider type that has an eHealth specialty.
- Telemedicine-only providers are to use Specialty Code 878.
- Telemedicine and in-person providers will continue to use the appropriate specialty code for their chosen provider type.
SOURCE: CO Department of Health Care Policy and Financing, Health First CO Provider Bulleting B2200485, (Nov. 2022), (Accessed Jan. 2023).
ELIGIBLE SITES
If no originating provider is present during a Telemedicine Services appointment, then the location of the originating site is at the member’s discretion and can include the member’s home. However, members can be required to choose a location suitable to delivery of telemedicine services that may include adequate lighting and environmental noise levels suitable for easy conversation with a provider.
Services can be provided via telemedicine between a member and a distant provider when a member is located in their home or other location of their choice.
SOURCE: CO Department of Health Care Policy and Financing. “Telemedicine Billing Manual” 10/22. (Accessed Jan. 2023).
A primary care provider (PCP) is eligible to be reimbursed as the ‘originating provider’ when present with the patient. In order for a PCP to be reimbursed as a distant provider, the PCP must be able to facilitate an in-person visit in the state of CO if necessary for treatment of the member’s condition.
A specialist is eligible to be an originating provider (if present with the patient) or distant provider.
SOURCE: CO Department of Health Care Policy and Financing. “Telemedicine Billing Manual” 10/22. (Accessed Jan. 2023).
Telemedicine can work:
- From a provider office: You can connect through video with a provider in another office. Both offices must have telemedicine equipment.
- From your home or other location like a library: You may be able to use your mobile phone, tablet or desktop computer to connect to a provider. Health First Colorado will not pay for the equipment.
SOURCE: CO Department of Health Care Policy and Financing. “Telemedicine”, (Accessed Jan. 2023).
Speech Therapy
Telemedicine POS 02 and Telehealth POS 10 are allowed place of service codes.
SOURCE: CO Department of Health Care Policy and Financing. “Speech Therapy”, 6/22. (Accessed Jan. 2023).
Eligible place of service includes Telemedicine, including interactive audio (including but not limited to telephone and relay calls), interactive video (including but not limited to interactive audiovisual modalities), or interactive data communication (including but not limited to live chat and excluding text messaging, electronic mail, and facsimile transmission). Any health benefits provided through interactive audio (including but not limited to telephone and relay calls), interactive video (including but not limited to interactive audiovisual modalities), or interactive data communication (including but not limited to live chat and excluding text messaging, electronic mail, and facsimile transmission) must meet the same standard of care as in-person care.
SOURCE: Colorado Adopted Rule 8.200.3.B.3.D.2.c.7 (Accessed Jan. 2023).
Therapy Providers
POS Code 02 or 10 should be used to report services delivered via telecommunication depending on the location of the member when receiving telehealth services. POS 02 is used when the member is receiving telehealth service in a place that is not their home. POS 10 is used when a member is receiving telehealth services when the member is located in their home.
Outpatient physical, occupational, and speech therapy services must have an interactive audio/visual connection with the member to be provided via telemedicine.
SOURCE: CO Department of Health Care Policy and Financing. Provider Bulletin B2200480. July 2022. (Accessed Jan. 2023).
Home Health Services
Services shall be provided in the client’s place of residence or one of the following places of service: Services may be provided using interactive audio (including but not limited to telephone and relay calls), interactive video (including but not limited to interactive audiovisual modalities), or interactive data communication (including but not limited to live chat and excluding text messaging, electronic mail, and facsimile transmission) instead of in-person contact. Any health benefits provided through interactive audio, interactive video, or interactive data communication must meet the same standard of care as in-person care.
SOURCE: Colorado Adopted Rule 8.520.4.B.g (Accessed Jan. 2023).
Family Planning Services
Eligible places of service include: Telemedicine, including interactive audio (including but not limited to telephone and relay calls), interactive video (including but not limited to interactive audiovisual modalities), or interactive data communication (including but not limited to live chat and excluding text messaging, electronic mail, and facsimile transmission). Any health benefits provided through interactive audio (including but not limited to telephone and relay calls), interactive video (including but not limited to interactive audiovisual modalities), or interactive data communication (including but not limited to live chat and excluding text messaging, electronic mail, and facsimile transmission) must meet the same standard of care as in-person care.
SOURCE: Colorado Adopted Rule 8.730.3.B. (Accessed Jan. 2023).
GEOGRAPHIC LIMITS
No Reference Found.
FACILITY/TRANSMISSION FEE
In some cases, the originating provider site will not be providing clinical services, but only providing a site and telecommunications equipment. In this situation, the telemedicine originating site facility fee is billed using procedure code Q3014.
Originating providers bill as follows:
- If the originating provider is making a room and telecommunications equipment available but is not providing clinical services, the originating provider bills Q3014 (the procedure code for the telemedicine originating site facility fee).
- If the originating provider also provides clinical services to the member, the provider bills the rendering provider’s appropriate procedure code and bills Q3014.
- The originating provider may also bill, as appropriate, on the UB-04 paper claim form or as an 837I transaction for any clinical services provided on-site on the same day that a telemedicine originating site claim is made. The originating provider must submit two separate claims for the member’s two separate services.
Providers eligible for the originating site facility fee include:
- Physician
- Clinic
- Osteopath
- FQHC
- Doctorate Psychologist
- MA Psychologist
- Physician Assistant
- Nurse Practitioner
- RHC
Provider types not listed above may facilitate Telemedicine Services with a distant provider but may not bill procedure code Q3014. Examples include Nursing Facilities, Intermediate Care Facilities, Assisted Living Facilities, etc.
Using modifier GT with specific codes adds $5.00 to the fee listed for the service. A specific list of eligible codes is provided in the manual. Other codes can be billed, but don’t pay the telemedicine transmission fee.
SOURCE: CO Department of Health Care Policy and Financing. “Telemedicine Billing Manual” 10/22. (Accessed Jan. 2023).
The state department shall establish rates for transmission cost reimbursement for telemedicine services, considering, to the extent applicable, reductions in travel costs by health care or mental health care providers and patients to deliver or to access such services and such other factors as the state department deems relevant.
SOURCE: CO Revised Statutes 25.5-5-320(3). (Accessed Jan. 2023).
Last updated 01/11/2023
Remote Patient Monitoring
POLICY
Telehealth monitoring is available for members who are eligible through the Home Health benefit and should not be billed as telemedicine.
SOURCE: CO Department of Health Care Policy and Financing. “Telemedicine Billing Manual” 10/22. (Accessed Jan. 2023).
The CO Medical Assistance Program will reimburse for home health care or home and community-based services through telemedicine at a flat fee set by the state board.
SOURCE: CO Revised Statutes 25.5-5-321. (Accessed Jan. 2023)
Home care agencies and home care placement agencies rules must allow for supervision in person or be telemedicine or telehealth. Any rules adopted by the board shall be in conformity with applicable federal law and must take into consideration the appropriateness, suitability and necessity of the method of supervision permitted.
SOURCE: CO Revised Statutes 25-27.5-104 (Accessed Jan. 2023).
The Home Health Agency shall create policies and procedures for the use and maintenance of the monitoring equipment and the process of telehealth monitoring. The Home Health Agency shall provide monitoring equipment that possesses the capability to measure any changes in the monitored diagnoses and meets all the safety requirements in the regulation. Home Health Telehealth services are covered for clients receiving Home Health Services for telehealth monitoring.
SOURCE: 10 CO Code of Regulation 2505-10 8.520.5.D (Accessed Jan. 2023).
CO Medicaid reimburses telehealth remote monitoring services including installation and on-going remote monitoring of clinical data through technologic equipment in order to detect minute changes in the member’s clinical status that will allow Home Health agencies to intercede before a chronic illness exacerbates requiring emergency intervention or inpatient hospitalization.
SOURCE: CO Medical Assistance Program, Home Health Billing Manual, (10/22), (Accessed Jan. 2023).
CO Medicaid covers home health telehealth, which includes frequent and ongoing self-monitoring of members through equipment left in the member’s home which is designed to measure the common signs and symptoms of disease exacerbation before a crisis occurs allowing for timely intervention and symptom management.
SOURCE: CO Department of Health Care Policy and Financing. “Home Health Telehealth”. (Accessed Jan. 2023).
CONDITIONS
A member is eligible only if they meet the following criteria:
- Member must receive Home Health services from provider who has opted to provide telehealth services
- Member must require frequent and on-going monitoring/management of their disease or condition
- Member’s home environment must be compatible with the use of the equipment
- Member or caregiver must be willing and able to comply with vital sign self-monitoring
- Member must have one or more of the following diagnoses:
- Congestive Heart Failure
- Chronic Obstructive Pulmonary Disease
- Asthma
- Diabetes
- Other diagnosis or condition deemed appropriate by the Department or its designee
SOURCE: CO Department of Health Care Policy and Financing. “Home Health Telehealth”. (Accessed Jan. 2023).
The following requirements must be met:
- Client is receiving services from a home health provider for at least one of the following: congestive heart failure, chronic obstructive pulmonary disease, asthma, or diabetes, pneumonia; or other diagnosis or medical condition deemed eligible by the Department or its Designee.
- Client requires ongoing and frequent, minimum of 5 times weekly, monitoring to manage their qualifying diagnosis, as defined and ordered by a physician or podiatrist;
- Client has demonstrated a need for ongoing monitoring as evidenced by having been hospitalized two or more times in the last twelve months for conditions related to the qualifying diagnosis; or, if the client has received home health services for less than six months, the client was hospitalized at least once in the last three months, an acute exacerbation of a qualifying diagnosis that requires telehealth monitoring, or new onset of a qualifying disease that requires ongoing monitoring to manage the client in their residence;
- Client or caregiver misses no more than 5 transmissions of the provider and agency prescribed monitoring events in a thirty-day period; and
- Client’s home environment has the necessary connections to transmit the telehealth data to the agency and has space to set up and use the equipment as prescribed.
SOURCE: 10 CO Code of Regulation 2505-10 8.520.5.D. (Accessed Jan. 2023).
PROVIDER LIMITATIONS
Any home health agency is eligible to provide services. A specific list of agencies providing these services via telehealth is listed.
SOURCE: CO Department of Health Care Policy and Financing. “Home Health Telehealth”. (Accessed Jan. 2023).
Acute home health agencies and long-term home health agencies are reimbursed for the initial installation and education of telehealth monitoring equipment and can be billed once per client per agency. The agency can also bill for every day they receive and review the client’s clinical information.
No prior authorization needed, but agencies should notify the Department or its designee when a client is enrolled in the service.
SOURCE: CO Medical Assistance Program, Home Health Billing Manual, (10/22), (Accessed Jan. 2023).
OTHER RESTRICTIONS
Home Health services are covered under Medicaid only when all of the following are met:
- Services are medically necessary.
- Services are provided under a plan of care as defined at Section 8.520.1 DEFINITIONS.
- Services are provided on an intermittent basis, as defined at Section 8.520.1, DEFINITIONS.
- The client meets one of the following:
- The only alternative to Home Health services is hospitalization or emergency room care; or
- Client’s medical records indicate that medically necessary services should be provided in the client’s home instead of other out-patient setting, according to one or more of the following guidelines:
- The client, due to illness, injury or disability, is unable to travel to an outpatient setting for the needed service;
- Based on the client’s illness, injury, or disability, travel to an outpatient setting for the needed service would create a medical hardship for the client;
- Travel to an outpatient setting for the needed service is contraindicated by a documented medical diagnosis;
- Travel to an outpatient setting for the needed service would interfere with the effectiveness of the service; or
- The client’s medical diagnosis requires teaching which is most effectively accomplished in the client’s place of residence on a short-term basis.
- The client is unable to perform the health care tasks for him or herself, and no unpaid family/caregiver is able and willing to perform the tasks; and
- Covered service types are those listed in Service Types, Section 8.520.5.
SOURCE: 10 CO Code of Regulation 2505-10 8.520.4.A. (Accessed Jan. 2023).
