Indiana

Disclaimer

PLEASE NOTE: CCHP is providing the following for informational purposes only. We are not providing legal advice or interpretation of the laws and regulations and policies. CCHP encourages you to check with the appropriate state agency for further information and direction. This information should not be construed as legal counsel. Consult with an attorney if you are seeking a legal opinion.

At A Glance
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MEDICAID REIMBURSEMENT

  • Live Video: Yes
  • Store-and-Forward: No
  • Remote Patient Monitoring: Yes
  • Audio Only: Yes

PRIVATE PAYER LAW

  • Law Exists: Yes
  • Payment Parity: No

PROFESSIONAL REQUIREMENTS

  • Licensure Compacts: ASLP-IC, EMS, IMLC, NLC, PSY, PTC
  • Consent Requirements: Yes

FQHCs

  • Originating sites explicitly allowed for Live Video:  Yes
  • Distant sites explicitly allowed for Live Video:  Yes
  • Store and forward explicitly reimbursed:  No
  • Audio-only explicitly reimbursed:  Yes
  • Allowed to collect PPS rate for telehealth:  Yes

STATE RESOURCES

  1. Medicaid Program: Indiana Medicaid
  2. Administrator: Indiana Health Coverage Programs
  3. Regional Telehealth Resource Center: Upper Midwest Telehealth Resource Center
Disclaimer

PLEASE NOTE: CCHP is providing the following for informational purposes only. We are not providing legal advice or interpretation of the laws and regulations and policies. CCHP encourages you to check with the appropriate state agency for further information and direction. This information should not be construed as legal counsel. Consult with an attorney if you are seeking a legal opinion.

Last updated 10/30/2022

Audio Only Delivery

Medicaid: Telehealth Policy Update

STATUS: Permanent, except audio-only, which is currently allowed, but being evaluated for long term use.

Medicaid:  Telemedicine FAQs

STATUS: Active.

Medicaid: Updated Telemedicine FAQs

STATUS: Active, until end of National PHE

Medicaid:  COVID-19 Telemedicine Billing Guidance

STATUS: IN PHE Expired, updates in BT 202142 and BT202145 for permanent policies.

Medicaid 1915(c) Waiver: Appendix K – Aged & Disabled Waiver (A&D) and Traumatic Brain Injury Waiver (TBI) Waiver

STATUS: Expired February 28, 2021; extended for up to six months after the national PHE ends.

Medicaid 1915(c) Waiver: Appendix K – Family Supports Waiver (FSW)

STATUS: Expired August 31, 2020; extended for up to six months after the national PHE ends.

Medicaid 1915(c) Waiver: Appendix K Extension – Family Supports Waiver

STATUS: Expired February 28, 2021; extended for up to six months after the national PHE ends.

Medicaid 1915(c) Waiver: Appendix K – Community Integration and Habilitation (CIH)

STATUS: Expired August 31, 2020; extended for up to six months after the national PHE ends.

Medicaid 1915(c) Waiver: Appendix K Extension – Community Integration and Habilitation (CIH)

STATUS: Expired February 28, 2021; extended for up to six months after the national PHE ends.

Medicaid 1915(c) Waiver: Appendix K Extension- Community Integration and Habilitation (CIH)

STATUS: Active, for up to six months after the national PHE ends.

Last updated 10/30/2022

Cross State Licensing

Professional Licensing Agency: COVID-19 Actions

STATUS: Active

Professional Licensing Agency: COVID-19 Temporary Healthcare Provider Registry

STATUS: Extended to at least June 13, 2022. HB 1003 Extends until end of federal PHE.

Last updated 10/30/2022

Easing Prescribing Requirements

Medicaid:  COVID-19 Telemedicine Billing Guidance

STATUS: IN PHE Expired, updates in BT 202142 and BT202145 for permanent policies.

Office of the Governor: Executive Order on Medicaid Telemedicine

STATUS: IN PHE Expired.

Professional Licensing Agency: COVID-19 Actions

STATUS: Active

Last updated 10/30/2022

Miscellaneous

Office of the Governor: Rescinded previous orders with very limited exceptions that have since expired.

STATUS: Effective March 3, 2022.

Medicaid:  Updates on Telemedicine Policy

STATUS: Current expansions are under review

Office of the Governor: Extension of Executive Order 20-02

STATUS: Rescinded.

Medicaid 1915(c) Waiver: Appendix K – Aged & Disabled Waiver (A&D) and Traumatic Brain Injury Waiver (TBI) Waiver

STATUS: Expired, February 28, 2021; extended for up to six months after the national PHE ends.

Medicaid 1915(c) Waiver: Appendix K – Aged & Disabled Waiver (A&D) and Traumatic Brain Injury Waiver (TBI) Waiver

STATUS: Active, for up to six months after the national PHE ends.

Medicaid 1915(c) Waiver: Appendix K – Family Supports Waiver (FSW)

STATUS: Expired August 31, 2020; extended for up to six months after the national PHE ends.

Medicaid 1915(c) Waiver: Appendix K Extension – Family Supports Waiver

STATUS: Expired February 28, 2021; extended for up to six months after the national PHE ends.

Medicaid 1925(c) Waiver: Appendix K Extension- Family Supports Waiver

STATUS: Active, extended for up to six months after the national PHE ends.

Medicaid 1915(c) Waiver: Appendix K – Community Integration and Habilitation (CIH)

STATUS: Expired August 31, 2020; extended for up to six months after the national PHE ends.

Medicaid 1915(c) Waiver: Appendix K Extension- Community Integration and Habilitation (CIH)

STATUS: Active, for up to six months after the national PHE ends.

Office of the Governor: Executive Order 21-26

STATUS: Rescinded

Last updated 10/30/2022

Originating Site

Medicaid:  Telemedicine FAQs

STATUS: Active during COVID-19 public health emergency.

Medicaid: Updated Telemedicine FAQs

STATUS: Active, some policies updated by BT 202142 and BT202145.

Medicaid: IHCP rescinds certain COVID-19 policy changes

STATUS: Active, although end dates for directives vary.

Medicaid: IHCP clarifies rescinded COVID-19 policies

STATUS: Active

Medicaid:  Home Health and Telemedicine Policy

STATUS: Rescinded by Executive Order 21-17 and July 1, 2021 Bulletin. Certain elements made permanent, See June 8, 2021 Bulletin.

Last updated 10/30/2022

Private Payer

No active waiver found.

Last updated 10/30/2022

Provider Type

Medicaid:  Telemedicine FAQs

STATUS: Active.

Medicaid: Updated Telemedicine FAQs

STATUS: Active, some policies updated by BT 202142 and BT202145.

Medicaid:  Home Health and Telemedicine Policy

STATUS: Rescinded by Executive Order 21-17 and July 1, 2021 Bulletin. Certain elements made permanent, See June 8, 2021 Bulletin.

Medicaid:  COVID-19 Telemedicine Billing Guidance

STATUS: Expired, refer to BT 202142 and BT202145 for permanent policies.

Medicaid: COVID-19 Telemedicine Revised  Billing Guidance

STATUS: STATUS: Expired, refer to BT 202142 and BT202145 for permanent policies.

Medicaid 1915(c) Waiver: Appendix K – Aged & Disabled Waiver (A&D) and Traumatic Brain Injury Waiver (TBI) Waiver

STATUS: Active, extended for up to six months after the national PHE ends.

Medicaid 1915(c) Waiver: Appendix K – Family Supports Waiver (FSW)

STATUS: Active, extended for up to six months after the national PHE ends.

Medicaid 1915(c) Waiver: Appendix K – Community Integration and Habilitation (CIH)

STATUS: Active, extended for up to six months after the national PHE ends.

Medicaid 1915(c) Waiver: Appendix K Extension – Community Integration and Habilitation (CIH)

STATUS: Active, extended for up to six months after the national PHE ends.

Last updated 10/30/2022

Service Expansion

Medicaid: Continuation of Flexibilities through PHE

STATUS: Active, until end of the National PHE

Medicaid: Telehealth Policy Update certain policies revised by July 1, 2021 Bulletin

STATUS: Permanent. Bulletin itself rescinded; Clarification of some of those policies.

Medicaid:  Telemedicine FAQs

STATUS: Active until end of PHE

Medicaid: Updated Telemedicine FAQs

STATUS: Active, until end of federal PHE

Medicaid:  Home Health and Telemedicine Policy

STATUS: Rescinded by Executive Order 21-17 and July 1, 2021 Bulletin. Certain elements made permanent. Also, see June 8, 2021 Bulletin and August 5, 2021 Bulletin. 

Medicaid: Facility Fees and revised on Sept. 24, 2020

STATUS: IN PHE Expired, however, IN Medicaid has not issued a new bulletin with other instructions.

Medicaid:  COVID-19 Telemedicine Billing Guidance

STATUS: IN PHE Expired, updates in BT 202142 and BT202145 for permanent policies.

Medicaid: COVID-19 Telemedicine Revised  Billing Guidance

STATUS: IN PHE Expired, updates in BT 202142 and BT202145 for permanent policies.

Medicaid: Telemedicine Services Codes

STATUS: Permanent, different codes have different effective dates.

Medicaid: IHCP Covid-19 Response

STATUS: Active for up to six months after the national PHE ends.

Medicaid 1915(c) Waiver: Appendix K – Aged & Disabled Waiver (A&D) and Traumatic Brain Injury Waiver (TBI) Waiver

STATUS: Active, extended for up to six months after the national PHE ends.

Medicaid 1915(c) Waiver: Appendix K – Aged & Disabled Waiver (A&D) and Traumatic Brain Injury Waiver (TBI) Waiver

STATUS: Active, extended for up to six months after the national PHE ends.

Medicaid 1915(c) Waiver: Appendix K – Family Supports Waiver (FSW)

STATUS: Expired August 31, 2020; extended for up to six months after the national PHE ends.

Medicaid 1915(c) Waiver: Appendix K Extension – Family Supports Waiver

STATUS: Expired February 28, 2021; extended for up to six months after the national PHE ends.

Medicaid 1925(c) Waiver: Appendix K Extension- Family Supports Waiver

STATUS: Active, until 6 months after the end of the Federal PHE

Medicaid 1915(c) Waiver: Appendix K – Community Integration and Habilitation (CIH)

STATUS: Expired August 31, 2020; extended for up to six months after the national PHE ends.

Medicaid 1915(c) Waiver: Appendix K Extension – Community Integration and Habilitation (CIH)

STATUS: Expired February 28, 2021; extended for up to six months after the national PHE ends.

Medicaid 1915(c) Waiver: Appendix K Extension- Community Integration and Habilitation (CIH)

STATUS: Active, for up to six months after the national PHE ends.

Office of the Governor: Executive Order on Medicaid Telemedicine

STATUS: Rescinded, by EO 21-17 effective Jun. 30, 2021

Last updated 10/30/2022

Definitions

“Telehealth services” means health care services delivered by use of technology allowed under IC 25-1-9.5-6, including the following:

  • Medical exams and consultations
  • Behavioral health, including substance abuse evaluations and treatment

SOURCE: IN Code, 27-8-34-5 & 27-13-1-34. (Accessed Oct. 2022)

Last updated 10/30/2022

Parity

SERVICE PARITY

Coverage must be provided in accordance with the same clinical criteria as would be provided in-person.

SOURCE: IN Code, 27-8-34-6 & 27-13-7-22. (Accessed Oct. 2022).


PAYMENT PARITY

No explicit payment parity.

Last updated 10/30/2022

Requirements

Accident and sickness insurance (dental or vision insurance is excluded) policies and individual or group contracts must provide coverage for telehealth services in accordance with the same clinical criteria as would be provided for services provided in-person.

Coverage for telehealth services may not be subject to a dollar limit, deductible or coinsurance requirement that is less favorable to a covered individual than those applied to the same health services delivered in-person.

This section does not do any of the following:

  • Require an individual contract or a group contract to provide coverage for a telehealth service that is not a covered health care service under the individual contract or group contract.
  • Require the use of telehealth services when the treating provider has determined that telehealth services are inappropriate.
  • Prevent the use of utilization review concerning coverage for telehealth services in the same manner as utilization review is used concerning coverage for the same health care services delivered to an enrollee in person.

A separate consent cannot be required.

If a policy provides coverage for telehealth services via:

  • Secure video conferencing;
  • Store and forward technology; or
  • Remote patient monitoring technology;

between a provider in one (1) location and a patient in another location, the policy may not require the use of a specific information technology application for those services.

SOURCE: IN Code, 27-8-34-6 & 27-13-7-22. (Accessed Oct. 2022)

Last updated 10/30/2022

Definitions

Telehealth means the delivery of healthcare services between a practitioner in one location (the distant site) and a patient in another location (the originating site), using interactive electronic communications and information technology, in compliance with the federal Health Insurance Portability and Accountability Act (HIPAA), including any of the following:

  • Secure videoconferencing
  • Store-and-forward technology
  • Remote patient monitoring technology

SOURCE: Indiana Health Coverage Programs, Telehealth and Virtual Services, Policies and Procedures (Sept. 27, 2022), p. 1.  (Accessed Oct. 2022).

Telehealth means the delivery of healthcare services using interactive electronic communications and information technology, in compliance with the federal Health Insurance Portability and Accountability Act (HIPAA), including: secure videoconferencing, store-and-forward technology or remote patient monitoring technology, between a provider in one location and a patient in another location. The term does not include the use of the following unless the practitioner has an established relationship with the patient: electronic mail, an instant messaging conversation, facsimile, internet questionnaire or an internet consultation.

SOURCE: IHCP Bulletin BT202142 (June 8, 2021). (Accessed Oct. 2022).

Telehealth services has the same meaning as telehealth in IN Code 25-1-9.5-6.

SOURCE: IN Code, 12-15-5-11. (Accessed Oct. 2022).

“Telehealth services” means the use of telecommunications and information technology to provide access to health assessment, diagnosis, intervention, consultation, supervision, and information across a distance.

SOURCE: IN Admin Code Title 405, Sec. 5-2-27 & (Home Health Services) IN Admin Code Title 405 1-4.2-2, (Accessed Oct. 2022).

Last updated 10/30/2022

Email, Phone & Fax

Most telehealth services must be provided via video and audio, although a few designated telehealth services can be provided via audio only. Audio-only delivery is allowable for all nonhealthcare virtual services.

Unless the practitioner has an established relationship with the patient, telehealth does not include the use of electronic mail, an instant messaging conversation, facsimile, internet questionnaire or an internet consultation.

SOURCE:  Indiana Health Coverage Programs, Provider Reference Module, Telehealth and Virtual Services (Sept. 27, 2022), p. 1.  (Accessed Oct 2022).

For certain telehealth services, an audio-only modifier (93) can be used to signify when a service is delivered via audio-only telehealth. Services eligible for reimbursement when billed with this new modifier are identified within this finalized code set. All other codes must be delivered via video and audio telehealth.  See Bulletin for code set.  Effective July 21, 2022 through end of 2022 at which point they will be re-evaluated for 2023.

SOURCE: Indiana Health Coverage Programs (IHCP) Bulletin, BT 202239 (May 19, 2022). (Accessed Oct. 2022).

The IHCP will continue to allow and offer reimbursement for audio-only telehealth. The IHCP will continue to explore the option of audio-only telehealth and its effectiveness in delivering healthcare services and provide updates when more specific policy details have been determined. Until further notice, audio-only telehealth services should be billed according to the guidance released in BT2020106 and used only when the care can be properly delivered via audio-only telehealth.

SOURCE: Indiana Health Coverage Programs (IHCP) Bulletin, BT202142, June 8, 2021, (Accessed Oct. 2022).

Physical Therapy

The physical therapy assistant (PTA) is precluded from performing or interpreting tests, conducting initial or subsequent assessments, or developing treatment plans. See the Covered Procedures for Physical Therapist Assistants section for details. The PTA is required to meet with the supervising physical therapist each working day to review treatment, unless the physical therapist or physician is on the premises to provide constant supervision. The consultation can be either face-to-face or by telephone.

SOURCE: IN Therapy Services Module, Oct. 1, 2020, p. 4, (Accessed Oct. 2022).

Last updated 10/30/2022

Live Video

POLICY

The Indiana Health Coverage Programs (IHCP) covers select medical, dental and remote patient monitoring services delivered via telehealth. IHCP coverage is also available for the virtual delivery of certain nonhealthcare services (such as case management) for members who are eligible to receive such services. For applicable procedure codes, see Telehealth and Virtual Services Codes, accessible from the Code Sets page at in.gov/medicaid/providers.

SOURCE: Indiana Health Coverage Programs, Telehealth and Virtual Services, Provider Reference Module (Sept. 27, 2022), p. 1.  (Accessed Oct. 2022).

Indiana Code requires reimbursement for medically necessary telehealth services for Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs), Community Mental Health Centers, Critical Access Hospitals, a home health agency under IC 16-27-1, and a provider determined by the office to be eligible, providing a covered telehealth service.

SOURCE: IN Code, 12-15-5-11 (Accessed Oct. 2022).

All services delivered through telehealth are subject to the same limitations and restrictions as they would be if delivered in-person

SOURCE: Indiana Health Coverage Programs (IHCP) Bulletin, BT202142, June 8, 2021, (Accessed Oct. 2022).

In any telemedicine encounter, there will be the following:

  • A distant site;
  • An originating site;
  • An attendant to connect the patient to the provider at the distant site; and
  • A computer or television monitor at the distant and originating sites to allow the patient to have real-time, interactive; and face-to-face communication with the distant provider via IATV technology.

SOURCE: IN Admin. Code, “Article 5,” Title 405, 5-38-3 & 4., p. 185 (Accessed Oct. 2022).


ELIGIBLE SERVICES/SPECIALTIES

Providers are allowed to use telehealth for the medical, dental and remote patient monitoring services listed in Telehealth and Virtual Services Codes, accessible from the Code Sets page at in.gov/medicaid/providers. This code set is in effect for dates of service on or after July 21, 2022, and will expire at the end of 2022. The codes will be reevaluated for 2023. The following services may not be provided using telehealth:

  • Surgical procedures
  • Radiological services
  • Laboratory services
  • Anesthesia services
  • Durable medical equipment (DME)/home medical equipment (HME) services
  • Transportation services

Office visits conducted via telehealth are subject to existing service limitations for office visits. Telehealth office visits billed using applicable codes from Telehealth and Virtual Services Codes (accessible from the Code Sets page at in.gov/medicaid/providers) are counted toward the member’s office visit limit. See the Evaluation and Management Services module for information about office visit limitations.

SOURCE: Indiana Health Coverage Programs, Telehealth and Virtual Services, Provider Reference Module (Sept. 27, 2022), p. 2-3.  Indiana Health Coverage Programs (IHCP) Bulletin, BT202142, p. 2 June 8, 2021, (Accessed Oct. 2022).

IHCP reimbursement for telehealth services is limited to the medical, dental and remote patient monitoring procedure codes listed in the telehealth code set (see the Telehealth Services Allowed and Excluded section). Additionally, the rendering NPI on the claim must be enrolled in the IHCP under one of the specialties allowable for telehealth services (see the Practitioners Eligible to Provide Telehealth Services section). All services delivered via telehealth must be billed with one of the following place of service (POS) codes:

  • 02 – Telehealth provided other than in patient’s home
  • 10 – Telehealth provided in the patient’s home

In addition, an appropriate telehealth modifier may be required, depending on the type of service:

Medical services – All medical services delivered via telehealth (with the exception of services delivered through a Home- and Community-Based Services [HCBS] or Money Follows the Person [MFP] program) require one of the following modifiers:

  • 95 – Synchronous telemedicine service rendered via real-time interactive audio and video telecommunications system
  • 93 – Synchronous telemedicine service rendered via telephone or other real-time interactive audio-only telecommunications system

SOURCE: Indiana Health Coverage Programs, Telehealth and Virtual Services, Provider Reference Module (Sept. 27, 2022), p. 3-4  Indiana Health Coverage Programs ICHP Bulletin BT202249 (June 30, 2022). (Accessed Oct. 2022).

In the future, the IHCP plans to return to using a procedure code set for allowable services provided via telehealth, as written in policy prior to the public health emergency. However, the code set will be expanded to allow for healthcare services that can be provided by the practitioners outlined in SB 3 and will incorporate the ability to provide audio-only telehealth. Until the code set is updated and published, IHCP providers should follow the billing guidance released in BT2020106.

SOURCE: Indiana Health Coverage Programs (IHCP) Bulletin, BT202142, p. 2 June 8, 2021, (Accessed Oct. 2022).

For the remainder of 2022, services that are delivered via telehealth will continue to be reimbursed at the same reimbursement rates as if the service were delivered in person. The new code set is in effect for dates of service on or after July 21, 2022, and will expire at the end of 2022. It will be reevaluated for 2023. This coverage and PA policy apply to all IHCP programs that offer such services – including but not limited to Healthy Indiana Plan (HIP), Hoosier Care Connect, Hoosier Healthwise and Traditional Medicaid. The new code set will be used by fee-for-service (FFS) and managed care delivery systems. For DOS on or after July 21, 2022, practitioners will be reimbursed only for services featured on the telehealth and virtual services code set when rendering services via telehealth, with the appropriate place of service (POS) codes and modifiers included on the claim submission. For dates of service prior to July 21, 2022, practitioners are required to continue to bill for services using the same protocols established during the public health emergency (PHE) announced in BT2020106.  Specific code sets in BT 202239 and BT202249.

SOURCE: Indiana Health Coverage Programs ICHP Bulletin BT 202239 (May 19, 2022).  (Accessed Oct. 2022).

Use of Modifier 93 for synchronous telehealth service rendered via telephone or other real-time interactive audio-only telecommunication system. Providers are encouraged to continue using the GT modifier when billing for telehealth services and to follow guidelines outlined in BT2020106. the use of the modifier will be expanded upon in future updates to the telehealth code set.  See Bulletin for codes list.

SOURCE: Indiana Health Coverage Programs ICHP Bulletin BT202227 (March 31, 2022), p. 8.  (Accessed Oct. 2022).

A valid FQHC or RHC encounter is defined as a face-to-face visit (either in person or via telehealth) between an IHCP member and a qualifying practitioner (see the Rendering Providers section) at an FQHC, RHC or other qualifying, nonhospital setting. te: When billing valid encounters provided by telehealth, FQHC and RHC providers must use POS code 02 with both the encounter code (T1015 or D9999) as well as the procedure codes for the specific allowable services provided during the telemedicine encounter. Modifier 95 is also required for all services provided via telehealth, with the exception of dental services

SOURCE: Medicaid Federally Qualified Health Centers and Rural Health Clinics Module, (Jan 2022 edition, published May 19, 2022), p. 4-5, (Accessed Oct. 2022).

When the FQHC or RHC is the distant site, the service provided by the FQHC or RHC must meet the requirements both for a valid encounter and for an approved telehealth service. The claim must include the following:

  • Encounter code T1015 (or D9999 for valid dental encounters), billed with POS code 02, 03, 04, 10, 11, 12, 31, 32, 50 or 72
  • One or more appropriate procedure codes for the specific services rendered, billed with modifier 93 or 95, and a POS code of either 02 or 10, depending on the originating site/location of the patient

NOTE: The IHCP authorized the use of POS 10 for FQHCs and RHCs for date of service on and after July 21, 2022.

SOURCE:  Indiana Health Coverage Programs, Telehealth and Virtual Services, Provider Reference Module (Sept. 27, 2022), p. 6   (Accessed Oct. 2022).

For purposes of a community mental health center, telehealth services satisfy any face to face meeting requirement between a clinician and consumer.

SOURCE: IN Code, 12-15-5-11(f) (Accessed Oct. 2022).

Behavioral and Primary Healthcare Coordination (BPHC) Services

Telehealth may be used for clinical evaluations in the BPHC application process, for developing the Individualized Integrated Care Plan (IICP), and ongoing review of the IICP.

SOURCE: Indiana Health Coverage Programs, Provider Reference Module, Behavioral and Primary Healthcare Coordination Services (July 28, 2022), p. 26, 43, 46.  (Accessed Oct. 2022).

Nonhealthcare Virtual Services

Nonhealthcare virtual services are services centering on patient wellness and case management that are delivered between a patient and a provider via interactive electronic communications technology. A licensed practitioner listed under IC 25-1-9.5-3.5 is not required to perform these services, as they are not considered healthcare services under the definition listed in IC 25-1-9.5-2.5. For a list of nonhealthcare procedure codes allowable for virtual delivery, see the Procedure Codes for Nonhealthcare Virtual Services table in Telehealth and Virtual Services Codes, accessible from the Code Sets page at in.gov/medicaid/providers.

Nonhealthcare virtual services must be billed with POS code 02 or 10. These services and do not require modifiers 93 or 95. All services in this category can be provided either through audio and video technology or via audio only.

NOTE:  The nonhealthcare virtual services code set does not include all Home- and Community-Based Services (HCBS) waiver services that were approved to be delivered virtually under Appendix K authority, as part of the federal response to the coronavirus disease 2019 (COVID-19) public health emergency. IHCP waiver providers will continue to be allowed to deliver approved Appendix K support services remotely no later than six months after the end of the public health emergency.

SOURCE: Indiana Health Coverage Programs, Telehealth and Virtual Services, Provider Reference Module (Sept. 27, 2022), p. 4-5 (Accessed Oct. 2022).

Nonhealthcare virtual services take place between a patient and a provider via interactive electronic communications technology. These services do not require a licensed practitioner listed in IC 25-1-9.5-3.5 to perform the service virtually, as the services are not considered healthcare services under the definition listed in IC 25-1-9.5-2.5 and, therefore, do not fall under the definition of telehealth by the IHCP. As specified in Table 2, nonhealthcare virtual services must be billed with a POS of 02 or 10, and do not require modifiers 93 or 95. All services in this category can be provided via audio only.

SOURCE: Indiana Health Coverage Programs IHCP Bulletin BT 202239 (May 19, 2022). (Accessed Oct. 2022).

Telehealth Dental Services

Dental services listed in Table 3 are covered when provided through telehealth. These services must be billed with POS code 02 or 10, and do not require modifiers 93 or 95. These services cannot be billed via audio-only telehealth.

SOURCE: Indiana Health Coverage Programs, Telehealth and Virtual Services, Provider Reference Module (Sept. 27, 2022), p. 4, Indiana Health Coverage Programs IHCP Bulletin BT 202239 (May 19, 2022).  (Accessed Oct. 2022).

Intensive Outpatient Treatment via Telehealth

The IHCP reimburses for intensive outpatient treatment (IOT) services (procedure codes H0015 and S9480) when delivered via telehealth. The IHCP is approaching this temporary policy expansion as a pilot initiative, where any healthcare provider engaging in telehealth IOT will be opting in to the analysis of the efficacy of this model through data collection and analysis. This data collection and analysis will be administered through the state and is intended to have a minimal administrative impact on providers. All providers submitting claims for telehealth IOT will automatically be included in the study and are expected to participate by providing data if requested. Telehealth IOT will be available for 12 months after which the data collected will be analyzed by the Division of Mental Health and Addiction (DMHA). IOT requires prior authorization for medical necessity, regardless of whether it is delivered in person or via telehealth.  See manual for other criteria.

SOURCE: Indiana Health Coverage Programs, Telehealth and Virtual Services, Provider Reference Module (Sept. 27, 2022), p. 6-7 (Accessed Oct. 2022).

After receiving feedback from providers over an allotted 30-day period, the IHCP has determined that IOT services (procedure codes H0015 and S9480) will be reimbursable when delivered via telehealth. This service will be added to the 2022 telehealth and virtual services code set.  See bulletin for more instructions.

SOURCE: Indiana Health Coverage Programs IHCP Bulletin BT 202239 (May 19, 2022).  (Accessed Oct. 2022).

With the exception of services billed by a federally qualified health center (FQHC) or rural health clinic (RHC) (see the Telehealth Services for FQHCs and RHCs section) or RPM services billed by a home health agency (see the RPM Billing and Reimbursement for Home Health Agencies section), the payment for telehealth services is equal to the current Fee Schedule amount for the procedure codes billed (see the IHCP Fee Schedules page at in.gov/medicaid/providers).

SOURCE: Indiana Health Coverage Programs, Telehealth and Virtual Services, Provider Reference Module (Sept. 27, 2022), p. 4,  (Accessed Oct. 2022).


ELIGIBLE PROVIDERS

The practitioners listed in IC 25-1-9.5-3.5 are authorized to provide telehealth services under the scope of their licensure within the state of Indiana.

The IHCP will allow these practitioners to provide telehealth services and receive reimbursement for IHCP services, within the established IHCP billing rules and policies. Providers not on this list are not allowed to practice telehealth or receive IHCP reimbursement for such services, even under the supervision of one of these listed practitioners. Providers rendering services within the state of Indiana are encouraged to have a telehealth provider certification filed with the Indiana Professional Licensing Agency. Providers rendering services out of state are required to have a telehealth provider certification under IC 25-1-9.5-9; see the Out-of-State Telehealth Providers section for more information.

NOTE:  Not all practitioners that are authorized to provide telehealth services are allowed to enroll as rendering providers in the IHCP. Those that are not eligible for IHCP enrollment must bill under the IHCP-enrolled supervising practitioner’s National Provider Identifier (NPI), using the appropriate modifiers (as applicable). The rendering NPI entered on the claim must be enrolled under a specialty that is allowable for telehealth.

SOURCE: Indiana Health Coverage Programs, Telehealth and Virtual Services, Provider Reference Module (Sept. 27, 2022), p. 2,  (Accessed Oct. 2022).

For a provider to be reimbursed for telehealth services under the IHCP, the provider must be enrolled with the IHCP and be a licensed practitioner listed in IC 25-1-9.5-3.5. Providers rendering services in state are also encouraged to have a telehealth provider certification filed with the Indiana Professional Licensing Agency. Providers rendering services out of state are required to have a telehealth provider certification under IC 25-1-9.5-9.

SOURCE: Indiana Health Coverage Programs IHCP Bulletin BT 202239 (May 19, 2022). (Accessed Oct. 2022).

The IHCP will allow these providers to provide telehealth services and receive reimbursement for IHCP services, within the established IHCP billing rules and policies:

  • A behavior analyst licensed under IC 25-8.5
  • A chiropractor licensed under IC 25-10
  • A dental hygienist licensed under IC 25-13*
  • The following:
    • A dentist licensed under IC 25-14
    • An individual who holds a dental residency permit issued under IC 25-14-1-5*
    • An individual who holds a dental faculty licensed under IC 25-14-1-5.5*
  • A diabetes educator licensed under IC 25-14.3*
  • A dietitian licensed under IC 25-14.5*
  • A genetic counselor licensed under IC 25-17.3
  • The following:
    • A physician licensed under IC 25-22.5
    • An individual who holds a temporary medical permit under IC 22-22.5-5-4*
  • A nurse licensed under IC 25-23*
  • An occupational therapist licensed under IC 25-23.5
  • Any behavioral health and human services professional licensed under IC 25-23.6
  • An optometrist licensed under IC 25-24
  • A pharmacist licensed under IC 25-26*
  • A physical therapist licensed under IC 25-27
  • A physician assistant licensed under IC 5-27.5
  • A podiatrist licensed under IC 25-29
  • A psychologist licensed under IC 25-33
  • A respiratory care practitioner licensed under IC 25-34.5*
  • A speech-language pathologist or audiologist licensed under IC 25-35.6

Some providers (within the licensure citations above) marked with an asterisk may not be able to enroll as rendering providers in the IHCP and must bill under the IHCP-enrolled supervising practitioner’s National Provider Identifier (NPI) using the appropriate modifiers (as applicable). In addition, providers not on this list are not allowed to practice telehealth and/or receive IHCP reimbursement for such services, even under the supervision of one of these listed practitioners.

SOURCE: Indiana Health Coverage Programs (IHCP) Bulletin, BT202142, June 8, 2021, (Accessed Oct. 2022).

Providers that can deliver healthcare services via telehealth must be listed as an authorized practitioner in SB 3(SEA 3). Providers not listed as authorized practitioners in SB 3(SEA 3) are not permitted to practice telehealth and/or receive IHCP reimbursement for telehealth services, even under the supervision of one of these listed practitioners.

SOURCE: Indiana Health Coverage Programs (IHCP) Bulletin, BT202145, June 17, 2021. (Accessed Oct. 2022).

The office shall reimburse the following Medicaid providers for medically necessary telehealth services:

  • A federally qualified health center
  • A rural health clinic
  • A community mental health center
  • A critical access hospital
  • A home health agency licensed under IC 16-27-1.
  • A provider, as determined by the office to be eligible, providing a covered telehealth service.

SOURCE: IN Admin Code, “Article 5” 405 5-38-4(3) p. 183IN Code, 12-15-5-11 (Accessed Apr. 2022). (Accessed Oct. 2022).

The office may not impose any distance restrictions on providers of telehealth activities or telehealth services.  Subject to federal law, the office may not impose any location requirements concerning the originating site or distant site in which a telehealth service is provided to a Medicaid recipient.

SOURCE: IN Code, 12-15-5-11 (Accessed Oct. 2022).

Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs)

Special billing considerations apply for federally qualified health center (FQHC) and rural health clinic (RHC) providers. FQHC and RHC providers may bill for telehealth services if the service rendered is considered a valid FQHC or RHC encounter (as defined in the Federally Qualified Health Centers and Rural Health Clinics module) and a covered telehealth service (as defined by the Telehealth and Virtual Services Codes, accessible from the Code Sets page at in.gov/medicaid/providers). Subject to the following criteria, reimbursement is available to FQHCs and RHCS when they are serving as either the distant site or the originating site for telehealth services.

SOURCE: Indiana Health Coverage Programs, Telehealth and Virtual Services, Provider Reference Module (Sept. 27, 2022), p. 5,  (Accessed Oct. 2022).

A valid FQHC or RHC encounter is defined as a face-to-face visit (either in person or via telemedicine) between an IHCP member and a qualifying practitioner (see the Rendering Providers section) at an FQHC, RHC, or other qualifying, non-hospital setting.

SOURCE: Medicaid Federally Qualified Health Centers and Rural Health Clinics Module, Jan. 1, 2022 (published May 19, 2022), p. 4, (Accessed Oct. 2022).

Non-Eligible Providers

IHCP does not reimburse the following provider types for telemedicine:

  • Ambulatory surgical centers;
  • Outpatient surgical services;
  • Home health agencies or services (For information about home health agency reimbursement for telehealth services, see the Telehealth Services section);
  • Radiological services;
  • Laboratory services;
  • Long-term care facilities, including nursing facilities, intermediate care facilities, or community residential facilities for the developmentally disabled;
  • Anesthesia services or nurse anesthetist services;
  • Audiological services;
  • Chiropractic services;
  • Care coordination services;
  • Durable medical equipment, and home medical equipment providers
  • Optical or optometric services;
  • Podiatric services;
  • Physical therapy services;
  • Transportation services;
  • Services provided under a Medicaid home and community-based services waiver.
  • Provider to provider consultations

SOURCE: IN Admin. Code, “Article 5” Title 405, 5-38-4, p. 183 (Accessed Oct. 2022).


ELIGIBLE SITES

Telehealth services may be rendered in an inpatient, outpatient or office setting. The provider and/or patient may be located in their home during the time of these services. For IHCP reimbursement of telehealth services, the member must be physically present at the originating site and must participate in the visit.

SOURCE: Indiana Health Coverage Programs, Telehealth and Virtual Services, Provider Reference Module (Sept. 27, 2022), p.1 ,  (Accessed Oct. 2022).

The office may not impose any distance restrictions on providers of telehealth activities or telehealth services.  Subject to federal law, the office may not impose any location requirements concerning the originating site or distant site in which a telehealth service is provided to a Medicaid recipient.

SOURCE: IN Code, 12-15-5-11 (Accessed Oct. 2022).

Separate reimbursement for a provider at the originating site is payable only if that provider’s presence is medically necessary. Documentation must be maintained in the patient’s medical record to support the need for the provider’s presence at the originating site during the visit. Such documentation is subject to post-payment review. If a healthcare provider’s presence at the originating site is medically necessary, billing of the appropriate evaluation and management code is permitted.

SOURCE: IN Admin. Code, “Article 5” Title 405, 5-38-4, p. 183 (Accessed Oct. 2022).


GEOGRAPHIC LIMITS

The office may not impose any distance restrictions on providers of telehealth activities or telehealth services.  Subject to federal law, the office may not impose any location requirements concerning the originating site or distant site in which a telehealth service is provided to a Medicaid recipient.

SOURCE: IN Code 12-15-5-11 (Accessed Oct. 2022)


FACILITY/TRANSMISSION FEE

If the member is located in a medical facility (such as a hospital, clinic or physician’s office) while receiving the telehealth service, and it is medically necessary for a medical professional to be physically present with the member during the service, the IHCP covers Healthcare Common Procedure Coding System (HCPCS) code Q3014 – Telehealth originating site facility fee, billed with modifier 95, for the provider e at the originating site.

If the originating site is a hospital or other location that bills on an institutional claim, HCPCS code Q3014 is reimbursable when billed with revenue code 780 – Telemedicine – General. If a different, separately reimbursable treatment room revenue code is provided on the same day as the telehealth service, the appropriate treatment room revenue code should also be included on the claim. Documentation must be maintained in the patient’s record to indicate that services were provided separately from the telehealth visit.

If the originating site is a physician’s office, clinic or other location that bills on a professional claim, POS code 02 must be used for Q3014, along with modifier 95. If other services are provided on the same date as the telehealth service, the medical professional should bill Q3014 as a separate line item from other professional services.

If the originating site is an FQHC or RHC, additional billing requirements apply. See the Telehealth Services for FQHCs and RHCs section.

SOURCE: Indiana Health Coverage Programs, Telehealth and Virtual Services, Provider Reference Module (Sept. 27, 2022), p. 5.  (Accessed Oct. 2022).

When the FQHC or RHC is the originating site (the location where the patient is physically located), the FQHC or RHC may be reimbursed if it is medically necessary for a medical professional to be present with the member, and the service provided includes all components of a valid encounter code. The claim must include the following:

  • Encounter code T1015 (or D9999 for valid dental encounters), billed with POS code 02, 03, 04, 11, 12, 31, 32, 50 or 72
  • Procedure code Q3014 – Telehealth originating site facility fee, billed with POS code 02 and modifier 95
  • One or more appropriate procedure codes for the specific services rendered, billed with modifier 93 or 95, and a POS code of either 02 or 10, depending on the originating site/location of the patient

Note: The procedure code must appear on one of the code tables in this bulletin, and must be on the list of procedure codes allowable for an FQHC/RHC medical or dental encounter.

SOURCE: Indiana Health Coverage Programs IHCP Bulletin BT 202239 (May 19, 2022). IHCP Bulletin BT 202253 (July 14, 2022). (Accessed Oct. 2022).

Last updated 10/30/2022

Miscellaneous

Special Considerations for Telehealth

The following special circumstances apply to telehealth services:

  • The practitioner who will be examining the patient from the distant site must determine if it is medically necessary for a medical professional to be at the originating site. Separate reimbursement for a provider at the originating site is payable only if that provider’s presence is medically necessary. Documentation must be maintained in the patient’s medical record to support the need for the provider’s presence at the originating site during the visit. Such documentation is subject to postpayment review. If a healthcare provider’s presence at the originating site is medically necessary, billing of the appropriate evaluation and management code is permitted.
  • When ongoing services are provided, the member should be seen by a physician for a traditional clinical evaluation at least once a year, unless otherwise stated in policy. In addition, the distant provider should coordinate with the patient’s primary care physician.
  • Office visits conducted via telehealth are subject to existing service limitations for office visits. Telehealth office visits billed using applicable codes from Telehealth and Virtual Services Codes (accessible from the Code Sets page at in.gov/medicaid/providers) are counted toward the member’s office visit limit. See the Evaluation and Management Services module for information about office visit limitations.
  • Although reimbursement for end-stage renal disease (ESRD)-related services is permitted in the telehealth setting, the IHCP requires at least one monthly visit for ESRD-related services to be a traditional clinical encounter to examine the vascular access site.
  • A provider can use telehealth to prescribe a controlled substance to a patient who has not been previously examined. Opioids, however, cannot be prescribed via telehealth, except in cases in which the opioid is a partial agonist (such as buprenorphine) and is being used to treat or manage opioid dependence.

Providers should always give the member the choice between a traditional clinical encounter versus a telehealth visit. Appropriate consent from the member must be obtained by the provider prior to delivering services. Providers must have written protocols for circumstances when the member requires a hands-on visit with the provider.

SOURCE:  Indiana Health Coverage Programs, Provider Reference Manual, Telehealth and Virtual Services (Sept. 27, 2022), p. 2-3.  (Accessed Oct. 2022).

All services delivered through telehealth are subject to the same limitations and restrictions as they would be if delivered in-person.

Documentation must be maintained by the provider to substantiate the services provided and that consent was obtained. Documentation must indicate that the services were rendered via telehealth, clearly identify the location of the provider and patient and be available for post-payment review.

SOURCE: Indiana Health Coverage Programs (IHCP) Bulletin, BT202142, June 8, 2021, (Accessed Oct. 2022).

A Medicaid recipient waives confidentiality of any medical information discussed with the health care provider that is:

  • Provided during a telehealth visit; and
  • Heard by another individual in the vicinity of the Medicaid recipient during a health care service or consultation.

SOURCE: IN Code, 12-15-5-11(e) (Accessed Oct. 2022).

Last updated 10/30/2022

Out of State Providers

Out-of-state providers can perform telehealth services without fulfilling the out-of-state prior authorization requirement if they have the subtype “Telemedicine” attached to their enrollment.  See Module for requirements.

SOURCE:  Indiana Health Care Coverage Program, Provider Reference Module, Telehealth and Virtual Services (Sept. 27, 2022), p. 10.  (Accessed Oct. 2022).

Prior Authorization for Out-of-State Services

All out-of-state services rendered to IHCP members require prior authorization (PA), with the following exceptions: …

  • Telemedicine services if providers have the subtype “telemedicine” attached to their enrollment – See the Telemedicine and Telehealth Services module for more information (IHCP has marked the Telemedicine and Telehealth Services module “obsolete.”)

SOURCE: IN Medicaid Out-of-State Providers Module (Sept. 27, 2022) p. 1, (Accessed Oct. 2022).

Subject to federal law, the office may not impose any location requirements concerning the originating site or distant site in which a telehealth service is provided to a Medicaid recipient.

SOURCE: IN Code 12-15-5-11(d) (Accessed Oct. 2022)

Last updated 10/30/2022

Overview

Indiana Medicaid reimburses for live video telemedicine for certain services and providers and remote patient monitoring (RPM).  Indiana Medicaid does not reimburse for store-and-forward although store-and-forward can still be used to facilitate other reimbursable services.  Certain services may be provided via audio-only and be reimbursed by the program.

 

Last updated 10/30/2022

Remote Patient Monitoring

POLICY

Remote patient monitoring (RPM) is the scheduled monitoring of clinical data transmitted through technologic equipment in the member’s home. Data is transmitted from the member’s home to the provider location to be read and interpreted by a qualified practitioner. The technologic equipment enables the provider to detect minute changes in the member’s clinical status, which allows providers to intercede before the member’s condition advances and requires emergency intervention or inpatient hospitalization.

The IHCP has implemented a single RPM coverage and prior authorization policy to be used for fee-forservice (FFS) and managed care delivery systems. This coverage and PA policy applies to all IHCP programs that offer such services – including but not limited to Healthy Indiana Plan (HIP), Hoosier Care Connect, Hoosier Healthwise and Traditional Medicaid.

The IHCP covers the RPM services listed in the Procedure Codes Covered for Remote Patient Monitoring table on Telehealth and Virtual Services Codes, accessible from the Code Sets page at in.gov/medicaid/providers. The service must be billed with POS code 02 or 10 and with modifier 95, as described in the Billing and Reimbursement for Telehealth Services section.

Prior authorization is required for specified RPM services, as indicated in the Procedure Codes for Remote Patient Monitoring Services table, in Telehealth and Virtual Services Codes, accessible from the Code Sets page at in.gov/medicaid/providers.

See manual for further details.

SOURCE:  Indiana Health Coverage Programs, Provider Reference Module, Telehealth and Virtual Services (Sept. 27, 2022), p. 8.  (Accessed Oct. 2022).

Effective for dates of service on or after July 21, 2022, procedure codes 99091, 99453, 99454, 99457 and 99458 will be covered RPM services. RPM or “remote patient monitoring technology” is listed under the definition of telehealth services per Indiana Code IC 25-1-9.5-6.

The IHCP is implementing a single RPM coverage and prior authorization (PA) policy to be used for fee-for service (FFS) and managed care delivery systems. This coverage and PA policy apply to all IHCP programs that offer such services – including but not limited to Healthy Indiana Plan (HIP), Hoosier Care Connect, Hoosier Healthwise and Traditional Medicaid.

See Bulletin for more information.

SOURCE: Indiana Health Coverage Programs IHCP Bulletin BT 202238 (May 17, 2022).  (Accessed Oct 2022).

Indiana Code requires Medicaid to reimburse providers who are licensed as a home health agency for telehealth services.

SOURCE: IN Code, 12-15-5-11(b)(5). (Accessed Oct. 2022).

Medicaid will reimburse Home Health Agencies for telehealth services.

SOURCE: IN Admin Code Title 405, 1-4.2-3 & 5-16-2 & IHCP Home Health Services (Oct. 7, 2022), p. 2. (Accessed Oct. 2022).


CONDITIONS

The member must meet one or more of the following criteria to receive prior authorization for an RPM service:

  • Received an organ transplantation within one year following the date of surgery
  • Had a surgical procedure (three-month service authorization following the date of surgery)
  • Had one or more uncontrolled chronic conditions that significantly impaired the patient’s health or resulted in two or more related hospitalizations or emergency department visits in the previous 12 months
  • Had been readmitted within 30 days for the same or similar diagnosis or condition
  • Identified as having a high-risk pregnancy (up to three-month service authorization postpartum); see the Obstetrical and Gynecological Services provider reference module for more information about high-risk pregnancy

The duration of initial service authorization is six months, unless otherwise indicated. Reauthorizations will be permitted for select services as appropriate.

SOURCE: Indiana Health Coverage Programs, Provider Reference Module, Telehealth and Virtual Services (Sept. 27, 2022), p. 9.  Accessed Oct. 2022).

The member must be receiving services from a home health agency.  Member must initially have two or more of the following events related to one of the conditions listed below within the previous twelve months:

  • Emergency room visit
  • Inpatient hospital stay

An emergency room visit that results in an inpatient hospital admission does not constitute two separate events.

The two qualifying events must be for the treatment of one of the following diagnoses:

  • Chronic obstructive pulmonary disease
  • Congestive heart failure
  • Diabetes

SOURCE: IN Admin Code, “Article 5” Title 405, 5-16-3.1(d), p. 42 (Accessed Nov. 2022).


PROVIDER LIMITATIONS

Reimbursement for home health agencies under certain conditions.  A registered nurse must perform the reading of transmitted health information provided from the member in accordance with the written order of the physician.

SOURCE: IN Admin Code, “Article 5” Title 405, 5-16-3.1(d)(5), p. 43. (Accessed Nov. 2022).


OTHER RESTRICTIONS

The IHCP is implementing a single RPM coverage and prior authorization (PA) policy to be used for fee-for service (FFS) and managed care delivery systems. This coverage and PA policy apply to all IHCP programs that offer such services – including but not limited to Healthy Indiana Plan (HIP), Hoosier Care Connect, Hoosier Healthwise and Traditional Medicaid.

See Bulletin for more information.

SOURCE: Indiana Health Coverage Programs IHCP Bulletin BT 202238 (May 17, 2022). (Accessed Nov. 2022).

Treating physician must certify the need for home health services and document that there was a face-to-face encounter with the individual.

SOURCE: IN Admin Code, “Article 5” Title 405, 5-16-3.1(e), p. 43 (Accessed Nov. 2022).

Approved telehealth services are reimbursed separately from other home health services. The unit of reimbursement for telehealth services provided by an HHA is one (1) calendar day.

Reimbursement is available for telehealth services as follows:

  • One-time amount per client of fourteen dollars and forty-five cents ($14.45) related to an initial face-to-face visit necessary to train the member to appropriately operate the telehealth equipment.
  • One (1) payment of nine dollars and eighty-four cents ($9.84) for each day the telehealth equipment is used by a registered nurse (RN) to monitor and manage the client’s care in accordance with the written order from a physician.

Rates for telehealth services shall not be adjusted annually.

SOURCE: IN Admin Code, “Article 1” Title 405, 1-4.2-6, p. 38 (Accessed Nov. 2022).

Last updated 10/30/2022

Store and Forward

POLICY

Telehealth means the delivery of healthcare services between a practitioner in one location (the distant site) and a patient in another location (the originating site), using interactive electronic communications and information technology, in compliance with the federal Health Insurance Portability and Accountability Act (HIPAA), including any of the following:

  • Secure videoconferencing
  • Store-and-forward technology
  • Remote patient monitoring technology

SOURCE: Indiana Health Coverage Programs, Telehealth and Virtual Services, Provider Reference Module (Sept. 27, 2022), p. 1.  (Accessed Oct. 2022).

“Store and forward” means the transmission of a patient’s medical information from an originating site to the practitioner at a distant site without the patient being present for subsequent review by a health care provider at the distant site. Restrictions placed on store and forward reimbursement in this rule shall not disallow the permissible use of store and forward technology to facilitate reimbursable services.

Indiana Medicaid will not reimburse for store-and-forward services. However, restrictions placed on store-and-forward reimbursement shall not disallow the permissible use of store-and-forward technology to facilitate other reimbursable services.

SOURCE: IN Admin. Code, Title 405, “Article 5” 5-38-2 & 4., p. 182-183 (Accessed Nov. 2022)


ELIGIBLE SERVICES/SPECIALTIES

No Reference Found


GEOGRAPHIC LIMITS

No Reference Found


TRANSMISSION FEE

No Reference Found

Last updated 10/30/2022

Cross State Licensing

A practitioner who is physically located outside Indiana is engaged in the provision of health care services in Indiana when the practitioner:

  • Establishes a provider-patient relationship under this chapter with; or
  • Determines whether to issue a prescription under this chapter for;

an individual who is located in Indiana.

A practitioner may not establish a provider-patient relationship with or issue a prescription for an individual who is located in Indiana unless the practitioner and the practitioner’s employer or the practitioner’s contractor, for purposes of providing health care services under this chapter, have certified in writing to the Indiana professional licensing agency, in a manner specified by the Indiana professional licensing agency, that the practitioner and the practitioner’s employer or practitioner’s contractor agree to be subject to:

  • The jurisdiction of the courts of law of Indiana; and
  • Indiana substantive and procedural laws;

Concerning any claim asserted against the practitioner, the practitioner’s employer, or the practitioner’s contractor arising from the provision of health care services under this chapter to an individual who is located in Indiana at the time the health care services were provided. The filing of the certification under this subsection shall constitute a voluntary waiver by the practitioner, the practitioner’s employer, or the practitioner’s contractor of any respective right to avail themselves of the jurisdiction or laws other than those specified in this subsection concerning the claim. However, a practitioner that practices predominately in Indiana is not required to file the certification required by this subsection.

A practitioner shall renew the certification required under subsection (b) at the time the practitioner renews the practitioner’s license.

A practitioner’s employer or a practitioner’s contractor is required to file the certification required by this section only at the time of initial certification.

SOURCE: IN Code, 25-1-9.5-9. (Accessed Oct. 2022).

Telehealth Provider Certification

The Telehealth Provider Certification is required by Indiana Code 25-1-9.5. In order for a practitioner to practice telehealth in Indiana, a copy of their individual certification and their employer’s certification must be filed with the Indiana Professional Licensing Agency. This certification is to ensure that the practitioner and their employer voluntarily agree to be subject to the jurisdiction of Indiana courts and Indiana substantive and procedural laws concerning the care of an individual who is located in Indiana at the time of service. These certifications must be completed before the provider may establish a provider-patient relationship for an individual in Indiana.

SOURCE: Indiana Professional Licensing Agency, Telehealth Home. (Accessed Oct. 2022).

Last updated 10/30/2022

Definitions

“Telehealth means the delivery of health care services using interactive electronic communications and information technology, in compliance with the federal Health Insurance Portability and Accountability Act (HIPAA), including:

  • Secure videoconferencing
  •  store-and-forward technology; or
  • Remote patient monitoring technology;

Between a provider in one location and a patient in another location.  The term does not include:

  • Electronic mail
  • An instant messaging conversation
  • Facsimile
  • Internet questionnaire
  • Internet consultation

The term does not include a health care service provided by:

  • An employee of a practitioner; or
  • An individual who is employed by the same entity that employs the practitioner;

who is performing a health care service listed in previous sections under the direction and that is customarily within the specific area of practice of the practitioner.

SOURCE: IN Code, 25-1-9.5-6 (Accessed Oct. 2022)

 “Telehealth” means a specific method of delivery of services, including medical exams and consultations and behavioral health evaluations and treatment, including those for substance abuse, using technology allowed under IC 25-1-9.5-6 to allow a provider to render an examination or other service to a patient at a distant location.

SOURCE: IN code, 16-18-2-348.5 (Accessed Oct. 2022)

“Telehealth” means the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, or exchange of medical education information by means of real-time video or secure chat or secure e-mail or integrated telephony while the patient is at any location and the health care provider is at any other location.

“Telehealth services” means the use of telecommunications and information technology to provide access to health assessment, diagnosis, intervention, consultation, treatment, supervision, and information across a distance.

SOURCE: IN Administrative Code, 844-Article 5-8-2, “Telehealth Services Pilot Program” p. 27 (Accessed Oct. 2022)

Last updated 10/30/2022

Licensure Compacts

Member of the Interstate Medical Licensing Compact.

SOURCE: Passed Legislation for Medical Licensure Compact (SB 251). & Interstate Medical Licensing Compact. (Accessed Oct. 2022).

Member of the EMS Personnel Licensure Interstate Compact.

SOURCE: IN Code 16-31.5.EMS Compact. (Accessed Oct. 2022).

Member of Nurse Licensure Compact.

SOURCE: Nurse Licensure Compact. NCSBN. (Accessed Oct. 2022).

Member of Physical Therapy Compact

SOURCE: IN Code 25-27-2-1PT Compact, Map, (Accessed Oct. 2022).

Member of the Psychology Interjurisdictional Compact.

SOURCE: PSYPACT Compact Map (Accessed Oct. 2022).

Member of the Audiology and Speech-language Pathology Interstate Compact.

SOURCE: ASLP Compact. Compact Map. (Accessed Oct. 2022).

 

*See Compact websites for implementation and license issuing status and other related requirements.

Last updated 10/30/2022

Miscellaneous

A juvenile court may recommend telehealth services as an alternative to a child receiving a diagnostic assessment. Establishes the Juvenile Behavioral Health Competitive Grant Pilot Program and permits the use of funds to establish telehealth programs, services and supporting mental health evaluations, which include the use of telehealth services.

SOURCE: Indiana Code 31-37-19-11.7. (Accessed Oct. 2022).

Every practitioner who is renewing online a license issued by a board must include the following information related to the practitioner’s work in Indiana under the practitioner’s license during the previous two (2) years:

(1) The practitioner’s specialty or field of practice.

(2) The following concerning the practitioner’s current practice:

  • The location or address.
  • The setting type.
  • The average hours worked weekly.
  • The health care services provided.

(3) The practitioner’s education background and training.

(4) For a practitioner (as defined in IC 25-1-9.5-3.5), whether the practitioner delivers health care services through telehealth (as defined in IC 25-1-9.5-6).

SOURCE: IN Code 25-1-2-10,(Accessed Oct. 2022).

The medical records must be created and maintained by the practitioner under the same standards of appropriate practice for medical records for patients in an in-person setting.

A patient waives confidentiality of any medical information discussed with the practitioner that is:

  • Provided during a telehealth visit; and
  • Heard by another individual in the vicinity of the patient during a health care service or consultation.

An employer may not require a practitioner, by an employment contract, an agreement, a policy, or any other means, to provide a health care service through telehealth if the practitioner believes that providing a health care service through telehealth would:

  • Negatively impact the patient’s health; or
  • Result in a lower standard of care than if the health care service was provided in an in-person setting.

Any applicable contract, employment agreement, or policy to provide telehealth services must explicitly provide that a practitioner may refuse at any time to provide health care services if in the practitioner’s sole discretion the practitioner believes:

  • That health quality may be negatively impacted; or
  • The practitioner would be unable to provide the same standards of appropriate practice as those provided in an in-person setting.

SOURCE: IN Code, 25-1-9.5-7. (Accessed Oct. 2022)

Telehealth Services Pilot Program

This rule establishes standards and procedures to implement a telehealth services pilot program utilizing telecommunications and information technology to provide access to health assessment, diagnosis, intervention, consultation, treatment, supervision, and information across a distance. See Article 5 for more details.

SOURCE: IN Administrative Code, 844-5-8-3, p. 27-28 (Accessed Oct. 2022).

Last updated 10/30/2022

Online Prescribing

A documented patient evaluation, including history and physical evaluation adequate to establish diagnoses and identify underlying conditions or contraindications to the treatment recommended or provided, must be obtained prior to issuing prescriptions electronically or otherwise.

SOURCE: IN Admin. Code, “Article 5” Title 844, 5-3-2. p. 9 (Accessed Oct. 2022). 

Telehealth may not be used to provide any abortion, including the writing or filling of a prescription for any purpose that is intended to result in an abortion.

SOURCE: IN code, 16-34-1-11 & 25-1-9.5-8(a)(r) & 25-1-9.5-0.5. (Accessed Oct. 2022).

A practitioner who:

  • Provides health care services through telehealth; or
  • Directs an employee of the practitioner to perform a health care service listed in the chapter;

shall be held to the same standards of appropriate practice as those standards for health care services provided at an in-person setting.

A practitioner who uses telehealth shall, if such action would otherwise be required in the provision of the same health care services in a manner other than telehealth, ensure that a proper provider-patient relationship is established. The provider-patient relationship by a  practitioner who uses telehealth must at a minimum include the following:

  1. Obtain the patient’s name and contact information (see regulation for other related requirements);
  2. Disclose the practitioner’s name and practitioner’s licensure, certification or registration;
  3. Obtain informed consent from the patient;
  4. Obtain the patient’s medical history and information necessary to establish a diagnosis;
  5. Discuss with the patient the diagnosis, evidence for the diagnosis and risks and benefits of the various treatment options;
  6. Create and maintain a medical record for the patient. If a prescription is issued for the patient, and subject to the consent of the patient, the prescriber shall notify the patient’s primary care provider of any prescriptions the provider has issued (see regulation for other related requirements);
  7. Issue proper instructions for appropriate follow-up care
  8. Provide a telehealth visit summary to the patient, including information that indicates any prescriptions that is being prescribed.

SOURCE: IN Code, 25-1-9.5-7. (Accessed Oct. 2022)

A prescription for a controlled substance can be issued for a patient the prescriber has not previously examined if the following conditions are met:

  1. The prescriber has satisfied the applicable standard of care in the treatment of the patient.
  2. The issuance of the prescription is within the prescriber’s scope of practice and certification
  3. The prescription meets the requirements outline in the following section and it is not an opioid.  However, opioids may be prescribed if the opioid is a partial agonist that is used to treat or manage opioid dependence.
  4. The prescription is not for an abortion inducing drug

If the prescription is for a medical device, including an ophthalmic device, the prescriber must use telehealth technology that is sufficient to allow the provider to make an informed diagnosis and treatment plan that includes the medical device being prescribed.

Additionally, the following conditions must be met for a prescription for a controlled substance:

  • The prescriber maintains a valid controlled substance registration under IC 35-48-3.
  • The prescriber meets the conditions set forth in 21 U.S.C. 829 et seq.
  • A practitioner acting in the usual course of the practitioner’s professional practices issues the prescription for a legitimate medical purpose.
  • The telehealth communication is conducted using an audiovisual, real time, two-way interactive communication system.
  • The prescriber complies with the requirements of the INSPECT program (IC 35-48-7).
  • All other applicable federal and state laws are followed.

SOURCE: IN Code 25-1-9.5-8. (Accessed Oct. 2022).

A pharmacy does not violate this chapter if the pharmacy fills a prescription for an opioid and the pharmacy is unaware that the prescription was written or electronically transmitted by a prescriber providing telehealth services under this chapter.

SOURCE: IN Code 25-1-9.5-11. (Accessed Oct 2022)

A prescriber may not issue a prescription for an ophthalmic device unless the following conditions are met:

  • If the prescription is for contact lenses or eyeglasses, the patient must be at least eighteen (18) years of age but not more than fifty-five (55) years of age.
  • The patient must have completed a medical eye history that includes information concerning the following:
    • Chronic health conditions.
    • Current medications.
    • Eye discomfort.
    • Blurry vision.
    • Any prior ocular medical procedures.
  • The patient must have had a prior prescription from a qualified eye care professional that included a comprehensive in person exam that occurred within two (2) years before the initial use of telehealth for a refraction under subdivision (5)(A).
  • If the patient desires a contact lens prescription, at the discretion of the eye care professional, that patient must have had a prior contact lens fitting or evaluation by a qualified eye care professional that occurred within two (2) years before the initial use of telehealth for a refraction under subdivision (5)(A).
  • The patient:
    • May not use telehealth more than two (2) consecutive times within two (2) years from the date of the examination that occurred under subdivision (3) for a refraction without a subsequent in person comprehensive eye exam; and
    • Must acknowledge that the patient has had a comprehensive eye exam as required under clause (A) before receiving an online prescription.
  • The patient may allow the prescriber to access the patient’s medical records using an appropriate HIPAA compliant process.
  • The prescriber must ensure that the transfer of all information, including the vision test and prescription, comply with HIPAA requirements.
  • The prescriber must use technology to allow the patient to have continuing twenty-four (24) hour a day online access to the patient’s prescription as soon as the prescription is signed by the prescriber.

SOURCE: IN Code 25-1-9.5-13. (Accessed Oct. 2022)

If a veterinarian is required to establish a veterinarian-client-patient relationship to perform a health care service, the veterinarian shall ensure that a proper veterinarian-client-patient relationship is established, when providing the service using telehealth.

SOURCE: IN Code 25-1-9.5-15. (Accessed Oct. 2022)

Telehealth Services Pilot Program

Prescriptions may not be issued for a controlled substance or an abortifacient.

Telehealth shall not include any encounter in which the patient is assured that any outcome, including the issuance of a prescription, will be issued as a quid pro quo for the payment of the provider’s consultation fee or solely on the basis of an online questionnaire.

SOURCE: IN Code, 844-Article 5-8-3, p. 27-28. (Accessed Oct. 2022).

Last updated 10/30/2022

Professional Boards Standards

Medical Licensing Board

The board may adopt rules establishing guidelines for the practice of telehealth in Indiana. Adoption of rules may not delay the implementation and provision of telehealth services by a provider under IC 25-1-9.5.

SOURCE: IN Code 25-22.5-2-7(c) (Accessed Oct. 2022).

Ocular Telemedicine and Telehealth

The board may not establish standards concerning the practice of ocular telemedicine or ocular telehealth that are more restrictive than the standards that are set:

  • under this article; or
  • by rule and applicable to the practitioner’s in-person ocular practice.

SOURCE: IN Code 25-24-1-5.5, (Accessed Oct. 2022).

Telehealth Provider Certification

The Telehealth Provider Certification is required by Indiana Code 25-1-9.5. In order for a practitioner to practice telehealth in Indiana, a copy of their individual certification and their employer’s certification must be filed with the Indiana Professional Licensing Agency. This certification is to ensure that the practitioner and their employer voluntarily agree to be subject to the jurisdiction of Indiana courts and Indiana substantive and procedural laws concerning the care of an individual who is located in Indiana at the time of service. These certifications must be completed before the provider may establish a provider-patient relationship for an individual in Indiana.

SOURCE: Indiana Professional Licensing Agency, Telehealth Home. (Accessed Oct. 2022).

Last updated 10/30/2022

Definition of a Visit

A valid FQHC or RHC encounter is defined as a face-to-face visit (either in person or via telehealth) between an IHCP member and a qualifying practitioner (see the Rendering Providers section) at an FQHC, RHC or other qualifying, nonhospital setting.

SOURCE: IHCP Federally Qualified Health Centers and Rural Health Clinics Provider Reference Module (Jan 1, 2022, published May 19, 2022), p. 4. (Accessed Nov. 2022).

Last updated 10/30/2022

Eligible Distant Site

When the FQHC or RHC is the distant site, the service provided by the FQHC or RHC must meet the requirements both for a valid encounter and for an approved telehealth service. The claim must include the following:

  • Encounter code T1015 (or D9999 for valid dental encounters), billed with POS code 02, 03, 04, 10, 11, 12, 31, 32, 50 or 72
  • One or more appropriate procedure codes for the specific services rendered, billed with modifier 93 or 95, and a POS code of either 02 or 10, depending on the originating site/location of the patient

SOURCE: Indiana Health Coverage Programs, Provider Reference Manual, Telehealth and Virtual Services (Sept. 27, 2022), p. 6. (Accessed Oct. 2022).

Subject to the following criteria, reimbursement is available to FQHCs and RHCS when they are serving as either the distant site or the originating site for telehealth services.

SOURCE: IHCP Bulletin BT 202239 (May 19, 2022), p. 3. (Accessed Oct. 2022).

The office shall reimburse the following Medicaid providers for medically necessary telehealth services:

  • A federally qualified health center
  • A rural health clinic
  • A community mental health center
  • A critical access hospital
  • A home health agency licensed under IC 16-27-1.
  • A provider, as determined by the office to be eligible, providing a covered telehealth service.

SOURCE: IN Admin Code, “Article 5” 405 5-38-4(3) p. 186IN Code, 12-15-5-11 (Accessed Oct. 2022).  

Last updated 10/30/2022

Eligible Originating Site

When the FQHC or RHC is the originating site (the location where the patient is physically located), the FQHC or RHC may be reimbursed if it is medically necessary for a medical professional to be present with the member, and the service provided includes all components of a valid encounter code. The claim must include the following:

  • Encounter code T1015 (or D9999 for valid dental encounters), billed with POS code 02, 03, 04, 11, 12, 31, 32, 50 or 72
  • Procedure code Q3014 – Telehealth originating site facility fee, billed with POS code 02 and modifier 95
  • One or more appropriate procedure codes for the specific services rendered, billed with modifier 93 or 95, and a POS code of either 02 or 10, depending on the originating site/location of the patient

SOURCE:  Indiana Health Coverage Programs, Provider Reference Module, Telehealth and Virtual Services (Sept. 27, 2022), p. 6.  (Accessed Oct. 2022).

When FQHCs and RHCs bill as an originating site, they must also include procedure code Q3014 – Telehealth originating site facility fee, billed with POS code 02 and modifier 95, on the claim.

SOURCE: IHCP Bulletin BT 202253 (July 14, 2022), p. 1. (Accessed Oct. 2022).

Last updated 10/30/2022

Facility Fee

When the FQHC or RHC is the originating site (the location where the patient is physically located), the FQHC or RHC may be reimbursed if it is medically necessary for a medical professional to be present with the member, and the service provided includes all components of a valid encounter code. The claim must include the following:

  • Procedure code Q3014 – Telehealth originating site facility fee, billed with POS code 02 and modifier 95

Separate reimbursement for merely serving as the originating site is not available to FQHCs and RHCs. When the presence of a medical professional is not medically necessary at the originating site, neither the facility fee, as billed by HCPCS code Q3014, nor the facility-specific PPS rate is available, because the requirement of a valid encounter is not met. Pursuant to the Code of Federal Regulations 42 CFR 405.2463, an encounter is defined by the CMS as a face-to-face meeting between an eligible provider and a Medicaid member during which a medically necessary service is performed. Consistent with federal regulations, for an FQHC or RHC to receive reimbursement for services, including those for telehealth, the criteria of a valid encounter must be met.

SOURCE: Indiana Health Coverage Programs, Provider Reference Module, Telehealth and Virtual Services (Sept. 27, 2022), p. 6.  (Accessed Oct. 2022).

Subject to the following criteria, reimbursement is available to FQHCs and RHCS when they are serving as either the distant site or the originating site for telehealth services.

SOURCE: IHCP Bulletin BT 202239 (May 19, 2022), p. 3. (Accessed Oct. 2022).

When FQHCs and RHCs bill as an originating site, they must also include procedure code Q3014 – Telehealth originating site facility fee, billed with POS code 02 and modifier 95, on the claim.

SOURCE: IHCP Bulletin BT 202253 (July 14, 2022), p. 1. (Accessed Oct. 2022).

Last updated 10/30/2022

Home Eligible

To align with national updates by the Centers for Medicare & Medicaid Services (CMS), the IHCP revised the description for POS 02 and authorized the use of POS code 10. For dates of service on and after July 21, 2022, the IHCP requires the use of POS 02 or 10 for telehealth services, including for FQHCs and RHCs.

SOURCE: Indiana Health Coverage Programs, Provider Reference Manual, Telehealth and Virtual Services (Sept. 27, 2022), p. 3.  (Accessed Oct. 2022).

IHCP will allow the use of POS code 10 for federally qualified healthcare centers (FQHCs) and rural health clinics (RHCs) for dates of service (DOS) on or after July 21, 2022.

Any FQHC or RHC claims with DOS before July 21, 2022, will deny if the POS 10 is present on the claim. Please correct these claims using the appropriate POS 02 and resubmit. The definitions for the telehealth POS codes changed on Jan. 1, 2022:

  • POS 02 – Telehealth provided other than in patient’s home
  • POS 10 – Telehealth provided in patient’s home

SOURCE: IHCP Bulletin BT 202253 (July 14, 2022). (Accessed Oct. 2022).

The IHCP reimburses FQHCs and RHCs for services to homebound individuals only in the case of FQHCs and RHCs located in areas with shortages of home health agencies, as determined by the FSSA.

SOURCE: IHCP Federally Qualified Health Centers and Rural Health Clinics Provider Reference Module (Jan 1, 2022, published May 19, 2022), p. 3. (Accessed Oct. 2022).

Last updated 10/30/2022

Modalities Allowed

Live Video

Special billing considerations apply for federally qualified health center (FQHC) and rural health clinic (RHC) providers. FQHC and RHC providers may bill for telehealth services if the service rendered is considered a valid FQHC or RHC encounter (as defined in the Federally Qualified Health Centers and Rural Health Clinics module) and a covered telehealth service (as defined by the Telehealth and Virtual Services Codes, accessible from the Code Sets page at in.gov/medicaid/providers). Subject to the following criteria, reimbursement is available to FQHCs and RHCS when they are serving as either the distant site or the originating site for telehealth services. See manual for additional details.

SOURCE: Indiana Health Coverage Programs, Provider Reference Module, Telehealth and Virtual Services (Sept. 27, 2022), p. 5.  (Accessed Oct. 2022).

FQHCs may provide services via live video if it is a valid encounter and covered service.  IN Medicaid reimburses a specific code list if service is provided via telehealth.  See Bulletin for code list.

SOURCE: IHCP Bulletin 202239 (May 19, 2022), p. 3. (Accessed Oct 2022).


Store and Forward

Store and Forward is not reimbursed by IN Medicaid.


Remote Patient Monitoring

FQHCs are not explicitly mentioned as being eligible to provide remote patient monitoring services.


Audio-Only

FQHCs may provide some services via audio-only, see CPT code list for specific services allowed.

SOURCE: IHCP Bulletin 202239 (May 19, 2022), p. 3. (Accessed Oct 2022).

Last updated 10/30/2022

PPS Rate

In either case, reimbursement for the encounter code (T1015 or D9999) is based on the prospective payment system (PPS) rate specific to the FQHC or RHC facility. All other procedures codes on the claim will deny with EOB 6096 – The CPT/HCPCS code billed is not payable according to the PPS reimbursement methodology.

SOURCE: Indiana Health Coverage Programs, Provider Reference Manual, Telehealth and Virtual Services (Sept. 27, 2022), p. 6.  (Accessed Oct. 2022).

The IHCP implemented a prospective payment system (PPS) for reimbursing FQHCs and RHCs for IHCP-covered services.

FQHC and RHC facilities are required to submit fee-for-service claims for valid encounters as follows:

  • Report valid medical encounters on the professional claim (CMS-1500 claim form, Portal professional claim or 837P transaction) using HCPCS encounter code T1015 – Clinic, visit/ encounter, all-inclusive.
  • Report valid dental encounters on the dental claim (American Dental Association 2012 Dental Claim Form [ADA 2012], Portal dental claim or 837D transaction) using HCPCS encounter code D9999 – Unspecified adjunctive procedure, by report. This guidance applies for dates of service on or after July 1, 2021.

Additionally, all claims for valid FQHC and RHC encounters must include one of the following place-of-service (POS) codes:

  • 02 – Telehealth*
  • 03 – School*
  • 04 – Homeless Shelter*
  • 11 – Office
  • 12 – Home
  • 31 – Skilled nursing facility
  • 32 – Nursing facility
  • 50 – Federally qualified health center
  • 72 – Rural health clinic

* Note: POS codes 02, 03 and 04 were added as allowable for valid FQHC and RHC encounter claims effective July 1, 2021.

FQHC and RHC claims submitted with a POS code of 02, 03, 04, 11, 12, 31, 32, 50 or 72 that do not include the T1015 or D9999 encounter code are denied for EOB 4121 – D9999 & T1015 must be billed with a valid CPT/HCPCS code. Providers can resubmit these claims with the appropriate encounter code properly included on the claim.

When billing valid encounters provided by telehealth, FQHC and RHC providers must use POS code 02 with both the encounter code (T1015 or D9999) as well as the procedure codes for the specific allowable services provided during the telemedicine encounter. Modifier 95 is also required for all services provided via telehealth, with the exception of dental services.

SOURCE: IHCP Federally Qualified Health Centers and Rural Health Clinics Provider Reference Module (Jan 1, 2022, published May 19, 2022), p. 3-5 (Accessed Oct. 2022).

Last updated 10/30/2022

Provider- Patient Relationship

No reference found.

Last updated 10/30/2022

Same Day Encounters

The IHCP allows reimbursement for only one medical encounter code (T1015) per IHCP member, per billing provider, per day – unless the primary diagnosis code differs for each additional encounter. Multiple T1015 encounter claims from an FQHC or RHC for a member on the same date of service that do not include a different primary diagnosis code are denied for EOB 5000 or 5001 – This is a duplicate of another claim.

If a member visits an office twice on the same day with two different diagnoses, a second claim can be submitted for the second visit, using a separate professional claim form or electronic claim submission. However, this policy does not allow a provider to bill multiple claims for a single visit with multiple diagnoses by separating the diagnoses on different claims.

When two valid practitioners, such as a physician and a psychologist, see the same patient in the same day, the principal diagnoses should not be the same.

SOURCE: IHCP Federally Qualified Health Centers and Rural Health Clinics Provider Reference Module (Jan 1, 2022, published May 19, 2022), p. 5. (Accessed Oct 2022).