North Carolina

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: Yes*
  • Remote Patient Monitoring: Yes
  • Audio Only: Yes

PRIVATE PAYER LAW

  • Law Exists: No
  • Payment Parity: No

PROFESSIONAL REQUIREMENTS

  • Licensure Compacts: ASLP-IC, CC, NLC, OT, 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: North Carolina Medicaid
  2. Administrator: Dept. of Health and Human Services, Division of Medical Assistance
  3. Regional Telehealth Resource Center: Mid-Atlantic 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 11/03/2022

Audio-Only Delivery

Medicaid:  Bulletin on Telehealth and Virtual Patient Communication for Family Planning

STATUS: Policy flexibilities that are outlined in this bulletin that have not been made permanent by bulletin #237 expired June 30, 2022.

Medicaid: Bulletin on Telehealth for Hybrid Telemedicine with Supporting Home Visit

STATUS: Varies. Some policies are permanent and others are in review for permanent policy placement. See bulletin #237

Medicaid: Bulletin on Innovations and TBI Appendix K and Developmental Disability Plans

STATUS: Permanent, per pg. 8 Special Bulletin #237

Medicaid: Bulletin on Telehealth for Postpartum Depression Screening

STATUS: Active, this is in review for permanent placement in policy. See pg. 41 of bulletin #237

Medicaid: Bulletin on Telehealth for Interim Perinatal Care

STATUS: Active, this is in review for permanent placement in policy. See pg. 40 of bulletin #237

Medicaid: Bulletin on Telehealth for Outpatient Specialized Therapies and Dental Services

STATUS: Varies. Some policies expired and others are permanent. See pg. 30 of bulletin #237

Medicaid: Telehealth Definitions, Eligible Providers, Services and Codes

STATUS: Varies. Some policies expired and others are permanent. See pg. 25 of bulletin #237

Medicaid: Guidance for Perinatal Care Providers

STATUS: Varies. See bulletin #237

Medicaid:  Telehealth Billing Code Summary

STATUS: Varies, some sections expired while others are under review.

Medicaid: Bulletin #237 Extension Document Audio-Only

Status: Active

Medicaid 1915(c) Waiver: Appendix K – NC Innovations

STATUS: Active, until six months following the end of the Public Health Emergency (see below)

Medicaid 1915(c) Waiver: Appendix K Addendum – NC Innovations

STATUS: Active, until six months following the end of the Public Health Emergency

Medicaid 1915(c) Waiver: Appendix K – CAP/DA

STATUS: Active, until six months following the end of the Public Health Emergency (see below)

Medicaid 1915(c) Waiver: Appendix K Addendum – CAP/DA

STATUS: Active, until six months following the end of the Public Health Emergency

Medicaid 1915(c) Waiver: Appendix K – Community Alternatives for Children

STATUS: Active, until six months following the end of the Public Health Emergency (see below)

Medicaid 1915(c) Waiver: Appendix K Addendum – Community Alternatives for Children

STATUS: Active, until six months following the end of the Public Health Emergency

Medicaid 1915(c) Waiver: Appendix K – NC TBI Waiver

STATUS: Active, until six months following the end of the Public Health Emergency (see below)

Medicaid 1915(c) Waiver: Appendix K Addendum – NC TBI Waiver

STATUS: Active, until six months following the end of the Public Health Emergency

Last updated 11/03/2022

Cross-State Licensing

Medical Board: Telemedicine FAQs

STATUS: Active

Last updated 11/03/2022

Easing Prescribing Requirements

Medical Board: Telemedicine FAQs

STATUS: Active

Last updated 11/04/2022

Originating Site

Medicaid: Bulletin on Telehealth for Maternal Support

STATUS: Varies. Maternal support services, including birthing classes and nonphysical provider, per session via telemedicine interactive audio-visual communication (HCPCS S9442) made permanent. Other policies sunset June 30, 2022 or are under review for permanent placement in policy.

Medicaid: Bulletin on Telehealth for Hybrid Telemedicine with Supporting Home Visit

STATUS: Varies. Some policies are permanent and others are in review for permanent policy placement. See bulletin #237

Medicaid:  Bulletin on Telehealth for ESRD Services

STATUS: Permanent, per pg. 33 Special Bulletin #237

Medicaid: Bulletin on Telehealth for Outpatient Respiratory Therapy

STATUS: Varies. Some policies expired and others are permanent. See pg. 44 of bulletin #237

Medicaid: Bulletin on Telehealth for Interim Perinatal Care

STATUS: Active, this is in review for permanent placement in policy. See pg. 40 of bulletin #237

Medicaid: Telehealth Definitions, Eligible Providers, Services and Codes

STATUS: Varies. Some policies expired and others are permanent. See pg. 25 of bulletin #237

Medicaid: Guidance for Perinatal Care Providers

STATUS: Varies. See bulletin #237

Medicaid:  Telehealth Billing Code Summary

STATUS: Varies, some sections expired while others are under review.

Medicaid 1915(c) Waiver: Appendix K – NC Innovations

STATUS: Active, until six months following the end of the Public Health Emergency (see below)

Medicaid 1915(c) Waiver: Appendix K Addendum – NC Innovations

STATUS: Active, until six months following the end of the Public Health Emergency

Medicaid 1915(c) Waiver: Appendix K – CAP/DA

STATUS: Active, until six months following the end of the Public Health Emergency (see below)

Medicaid 1915(c) Waiver: Appendix K Addendum – CAP/DA

STATUS: Active, until six months following the end of the Public Health Emergency

Medicaid 1915(c) Waiver: Appendix K – Community Alternatives for Children

STATUS: Active, until six months following the end of the Public Health Emergency (see below)

Medicaid 1915(c) Waiver: Appendix K Addendum – Community Alternatives for Children

STATUS: Active, until six months following the end of the Public Health Emergency

Medicaid 1915(c) Waiver: Appendix K – NC TBI Waiver

STATUS: Active, until six months following the end of the Public Health Emergency (see below)

Medicaid 1915(c) Waiver: Appendix K Addendum – NC TBI Waiver

STATUS: Active, until six months following the end of the Public Health Emergency

Last updated 11/03/2022

Private Payer

Department of Insurance:  Payer COVID-19 Telehealth Policies

STATUS: Active

Department of Insurance: Telehealth Delivery of Services

STATUS: Active

 

 

Last updated 11/03/2022

Provider Type

Medicaid: Bulletin on Telehealth for Outpatient Respiratory Therapy

STATUS: Varies. Some policies expired and others are permanent. See pg. 44 of bulletin #237

Medicaid: Bulletin on Telehealth for Well Child Visits

STATUS: Varies. Some policies expired and others are in review for permanent placement in policy. See pg. 52 of bulletin #237

Medicaid: Bulletin on Telehealth for Postpartum Depression Screening

STATUS: Active, this is in review for permanent placement in policy. See pg. 41 of bulletin #237

Medicaid: Bulletin on Telehealth for Interim Perinatal Care

STATUS: Active, this is in review for permanent placement in policy. See pg. 40 of bulletin #237

Medicaid:  Bulletin on Telehealth for Physiologic Monitoring Services

STATUS: Permanent, per pg. 6 Special Bulletin #237

Medicaid: Bulletin on Telehealth for Outpatient Specialized Therapies and Dental Services

STATUS: Varies. Some policies expired and others are permanent. See pg. 30 of bulletin #237

Medicaid: Telehealth Definitions, Eligible Providers, Services and Codes

STATUS:Varies. Some policies are expired, permanent, or ending at/after Federal PHE. See bulletin #237

Medicaid: Guidance for Perinatal Care Providers

STATUS: Varies. See bulletin #237

Medicaid:  Telehealth Billing Code Summary

STATUS: Varies, some sections expired while others are under review.

Medicaid 1915(c) Waiver: Appendix K – NC Innovations

STATUS: Active, until six months following the end of the Public Health Emergency (see below)

Medicaid 1915(c) Waiver: Appendix K Addendum – NC Innovations

STATUS: Active, until six months following the end of the Public Health Emergency

Last updated 11/04/2022

Service Expansion

Medicaid:  Bulletin on Telehealth and Virtual Patient Communication for Family Planning

STATUS: Policy flexibilities that are outlined in this bulletin that have not been made permanent by bulletin #237 expired June 30, 2022.

Medicaid: Bulletin on Telehealth for Maternal Support

STATUS: Varies. Maternal support services, including birthing classes and nonphysical provider, per session via telemedicine interactive audio-visual communication (HCPCS S9442) made permanent. Other policies sunset June 30, 2022 or are under review for permanent placement in policy.

Medicaid: Bulletin on Telehealth for Hybrid Telemedicine with Supporting Home Visit

STATUS: Varies. Some policies are permanent and others are in review for permanent policy placement. See bulletin #237

Medicaid:  Bulletin on Telehealth for ESRD Services

STATUS: Permanent, per pg. 33 Special Bulletin #237

Medicaid: Bulletin on Innovations and TBI Appendix K and Developmental Disability Plans

STATUS: Permanent, per pg. 8 Special Bulletin #237

Medicaid: Bulletin on Telehealth for Outpatient Respiratory Therapy

STATUS: Varies. Some policies expired and others are permanent. See pg. 44 of bulletin #237

Medicaid: Bulletin on Telehealth for Well Child Visits

STATUS: Varies. Some policies expired and others are in review for permanent placement in policy. See pg. 52 of bulletin #237

Medicaid: Bulletin on Telehealth for Postpartum Depression Screening

STATUS: Active, this is in review for permanent placement in policy. See pg. 41 of bulletin #237

Medicaid: Bulletin on Suspending copays

STATUS: Active, until end of calendar quarter of the federal PHE

Medicaid: Bulletin on Telehealth for Interim Perinatal Care

STATUS: Active, this is in review for permanent placement in policy. See pg. 40 of bulletin #237

Medicaid:  Bulletin on Telehealth for Physiologic Monitoring Services

STATUS: Permanent, per pg. 6 Special Bulletin #237

Medicaid:  Bulletin on Telehealth for Self-Measured Blood Pressure Monitoring

STATUS: Permanent, per pg. 6 Special Bulletin #237

Medicaid: Bulletin on Telehealth for Outpatient Specialized Therapies and Dental Services

STATUS: Varies. Some policies expired and others are permanent. See pg. 30 of bulletin #237

Medicaid: Telehealth Definitions, Eligible Providers, Services and Codes

STATUS: Varies. Some policies expired and others are permanent. See pg. 25 of bulletin #237

Medicaid: Guidance for Perinatal Care Providers

STATUS: Varies. See bulletin #237

Medicaid:  Telehealth Billing Code Summary

STATUS: Varies, some sections expired while others are under review.

Medicaid: Special Bulletin COVID-19 #237: Extension of NC State of Emergency Temporary Flexibilities

STATUS: Active

Last updated 11/04/2022

Definitions

No reference found.

Last updated 11/04/2022

Parity

SERVICE PARITY

No Reference Found


PAYMENT PARITY

No Reference Found

Last updated 11/04/2022

Requirements

No Reference Found

Last updated 11/03/2022

Definitions

“Telehealth is the use of two-way real-time interactive audio and video to provide and support health care services when participants are in different physical locations.”

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, p. 2, Oct. 1, 2022. (Accessed Oct. 2022).

Last updated 11/04/2022

Email, Phone & Fax

No reference found for email or fax.

Covered virtual communication services include: telephone conversations (audio only); virtual portal communications (secure messaging); and store and forward (transfer of data from beneficiary using a camera or similar device that records (stores) an image that is sent by telecommunication to another site for consultation).

Covered virtual communication services include telephone evaluation and management codes (audio only): 99441-99443 and G2012.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, p. 2 & 14, Oct. 1, 2022. (Accessed Nov. 2022).

A special COVID-19 Medicaid bulletin lists telephone E/M codes that have been made permanently eligible for reimbursement that have not yet been incorporated into the 1H Telehealth, Virtual Communication and Remote Patient Monitoring provider manual.

SOURCE: NC Medicaid Special Bulletin COVID-19 #237, Oct. 2022, (Accessed Nov.  2022).

Outpatient Behavioral Health

Telephonic services may be transmitted between a patient and provider in a manner that is consistent with the CPT code definition for those services. This service delivery method is reserved for circumstances when:

  • The beneficiary’s physical or behavioral health status prevents them from participating in in-person or telehealth services; or
  • Access issues (e.g., transportation, telehealth technology) prevent the beneficiary from participating in in-person or telehealth services.

Excluding psychotherapy for crisis services, Medicaid and NCHC shall require prior approval for services provided via the telephonic, audio-only communication method.

See Outpatient Behavioral Health manual for telephone-specific criteria, eligible providers, and covered codes.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 8C, Outpatient Behavioral Health Services, p. 4, 6-7, 10, 37-39, Sept. 1, 2021. (Accessed Nov. 2022).

FQHCs/RHCs

FQHCs and RHCs may conduct telephonic evaluation and management services using HCPCS code G0071. Eligible providers include physicians, nurse practitioners, psychiatric nurse practitioners, physician assistants, and certified nurse midwives.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1D-4, Core Services Provided in Federally Qualified Health Centers and Rural Health Clinics, p. 19, Dec. 1, 2020. (Accessed Nov. 2022).

Enhanced Mental Health and Substance Abuse Services

Telephonic response is covered to assess the crisis and determine the risk, mental status, medical stability, and appropriate response.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy Enhanced Mental Health and Substance Abuse Services, p. 31, Apr. 1, 2022 (Accessed Nov. 2022).

Research-Based Behavioral Health Treatment (RB-BHT) for Autism Spectrum Disorder (ASD)

Telephonic services my be transmitted between a patient and provider in a manner that is consistent with the CPT code and definition for those services.

This service delivery method is reserved for circumstances when:

  • The caregiver’s physical or behavioral health status prevents them from participating in in-person or telehealth services; or
  • Access issues (e.g., transportation, telehealth technology) prevent the caregiver from participating in in-person or telehealth services.

Refer to Subsection 3.2.5 for Telephonic-Specific Criteria ; Subsections 5.1 and 5.2 for Prior Approval requirements; and Subsection 7.1 for Compliance requirements.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No. 8F, Research-Based Behavioral Health Treatment (RB-BHT) for Autism Spectrum Disorder (ASD), pgs. 6,9-10, 12 & 17, Amended Dec. 1, 2020, (Accessed Nov. 2022). 

Peer Support Services

As outlined in Attachment A, select services within this clinical coverage policy may be provided via the telephonic, audio-only communication method. Telephonic services may be transmitted between a beneficiary and provider in a manner that is consistent with the CPT and HCPCS code definition for those services.

Refer to subsection 3.2.5.1 for Telephonic-Specific Criteria; and subsection 7.1 for Compliance requirements.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No. 8G, Peer Support Services pgs. 5, 7 &17  & Attachment A, pgs. 20-21, Amended Aug. 15, 2022. (Accessed Nov. 2022).

 

 

Last updated 11/04/2022

Live Video

POLICY

All telehealth services must be provided over a secure HIPAA compliant technology with live audio and video capabilities including (but not limited to) smart phones, tablets and computers.

The beneficiary must be enrolled in either the NC Medicaid program or the NC Health Choice Program.  Provider(s) shall verify each Medicaid or NCHC beneficiary’s eligibility each time a service is rendered.  The Medicaid beneficiary may have service restrictions due to their eligibility category that would make them ineligible for this service.  For example, to participate in the NC Health Choice Program, a beneficiary must be between 6 and 18 years old.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, p. 3 & 8, Oct. 1, 2022. (Accessed Nov. 2022).


ELIGIBLE SERVICES/SPECIALTIES

A range of services may be delivered via telehealth, virtual communication, and remote patient monitoring to Medicaid and NCHC beneficiaries. All telehealth, virtual communication, and remote monitoring services must be delivered in a manner that is consistent with the quality of care provided in-person.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, p. 6, Oct. 1, 2022. (Accessed Nov. 2022).

A special COVID-19 Medicaid bulletin lists a variety of services that have been made permanently eligible for telehealth reimbursement that have not yet been incorporated into the 1H Telehealth, Virtual Communication and Remote Patient Monitoring provider manual.

SOURCE: NC Medicaid Special Bulletin COVID-19 #237, Oct. 2022, (Accessed Nov. 2022).

Medicaid or NCHC shall cover procedures, products, and services related to this policy when they are medically necessary, and:

  • The procedure, product, or service is individualized, specific, and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the beneficiary’s needs;
  • The procedure, product, or service can be safely furnished, and no equally effective and more conservative or less costly treatment is available statewide; and
  • The procedure, product, or service is furnished in a manner not primarily intended for the convenience of the beneficiary, the beneficiary’s caretaker, or the provider.

Services NOT Covered

  • The beneficiary does not meet the eligibility requirements;
  • The beneficiary does not meet the criteria listed above;
  • The procedure, product, or service duplicates another provider’s procedure, product, or service; or
  • The procedure, product, or service is experimental, investigational, or part of a clinical trial.

See p. 5 of manual for specific criteria that must be met before a telehealth service can be rendered to a NC Medicaid beneficiary.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, p. 5 & 7, Oct. 1, 2022 & NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 8C, Outpatient Behavioral Health Services, p. 4 & 7-8, Sept. 1, 2021. (Accessed Nov. 2022).

Additional Criteria not covered under NC Health Choice

Except as otherwise provided for eligibility, fees, deductibles, copayments, and other cost sharing charges, health benefits coverage provided to children eligible under the Program shall be equivalent to coverage provided for dependents under North Carolina Medicaid Program except for the following:

  • No services for long-term care.
  • No nonemergency medical transportation.
  • No EPSDT.
  • Dental services shall be provided on a restricted basis in accordance with criteria adopted by the Department to implement this subsection.

Unless otherwise required for a specific service, Medicaid and NCHC shall not require prior approval for 1H, Telehealth, Virtual Communications and Remote Patient Monitoring. Prior authorization or an initial in-person examination is not required in order to receive care via telehealth, virtual patient communication, or remote patient monitoring; however, when establishing a new relationship with a patient via these modalities, the provider shall meet the prevailing standard of care and complete all appropriate exam requirements and documentation dictated by relevant CPT or HCPCS coding guidelines.

Special provisions apply for the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) program.  See manual.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, p. 3-8, Oct. 1, 2022. (Accessed Nov. 2022).

Telehealth, including:

  • office or other outpatient services and office and inpatient consultation codes; and
  • hybrid telehealth visit with supporting home visit codes.

Virtual communication, including:

  • online digital evaluation and management codes;
  • telephonic evaluation and management;
  • telephonic evaluation and management and virtual communication codes; and
  • interprofessional assessment and management codes.

Virtual patient communications must be transmitted between a patient and provider, or between two providers, in a manner that is consistent with the CPT code definition for those services. Provider(s) shall follow all applicable HIPAA rules.

Hybrid Telehealth with Supporting Home Visit (Hybrid Model)

Eligible providers may conduct telehealth visits with a supporting home visit by a delegated staff member (“hybrid model”) with new or established patients, for a range of scenarios including (but not limited to):

  • Chronic Disease Management: Providers shall use the home visit codes in this policy with appropriate modifiers.
  • Perinatal Care: Providers shall only use the home visit codes in this policy with appropriate modifiers if they are not billing the pregnancy global package codes. Providers billing the pregnancy global package codes shall refer to clinical coverage policy 1E-5, Obstetrical Services  for billing guidance for this model.

Well-child services are not eligible to be delivered via the hybrid model. See manual for additional requirements.

FQHCs, FQHC-Lookalikes, and RHCs may utilize this hybrid model but shall not bill the home visit codes in table C.1.; FQHCs, FQHC-Lookalikes and RHCs may bill their core service code (T1015) and an originating site facility fee (Q3014) for hybrid model visits to reflect the additional cost of the delegated staff person attending the beneficiary’s home. To be reimbursed for the originating site facility fee, all of the following requirements must be met for each home visit:

  • The assistance delivered in the home must be given by an appropriately trained delegated staff person.
  • The fee must be billed for the same day that the home visit is conducted.
  • HCPCS code Q3014 must be appended with the GT modifier and billed with a place of service ‘12’ to designate that the originating site was the home.
  • The core service code (T1015) must be billed separately from the originating site facility fee code (Q3014).

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, p. 6 , 13 &14 Oct. 1, 2022. (Accessed Nov. 2022).

See Attachment A of manual for billable codes (pgs. 12-16).

When the GT modifier is appended to a code billed for professional services, the service is paid at the allowed amount of the fee schedule.

  • For hospitals, this is a covered service for both inpatient and outpatient and is part of the normal hospital reimbursement methodology.
  • Reimbursement for these services is subject to the same restrictions as face-to-face contacts (such as; place of service, allowable providers, multiple service limitations, prior authorization).

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, p. 17-18, Oct. 1, 2022. (Accessed Nov. 2022).

Outpatient Behavioral Health

NC Medicaid covers a range of outpatient behavioral health services via audio-visual and audio-only modalities. See Outpatient Behavioral Health manual for criteria and covered services.

Medicaid and NCHC shall not cover Outpatient Behavioral Health Services for the following:

  • sleep therapy for psychiatric disorders;
  • when services are not provided in-person or in accordance with Attachment A.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 8C, Outpatient Behavioral Health Services, p. 4-8, Sept. 1, 2021. (Accessed Nov. 2022).

FQHCs/RHCs

Core Visit Services: Federally Qualified Health Center (FQHC) and Rural Health Clinic (RHC) core service providers may deliver core services via telehealth if the service is:

  • Defined as a core visit service in Section 5.3 of Clinical Coverage Policy 1D-4: Core Services Provided in Federally Qualified Health Centers and Rural Health Clinics; and,
  • Covered as a telehealth-eligible core visit service in Attachment A, Section C.1.

Non-Core Visit Services: FQHCs and RHCs may also deliver a select set of services via telehealth, virtual patient communications, and remote patient monitoring that are not defined as a core visit service in Section 5.3 of Clinical Coverage Policy 1D-4: Core Services Provided in Federally Qualified Health Centers and Rural Health Clinics. FQHCs and RHCs would be reimbursed on a fee-for-service basis for delivering non-core visit services via telehealth, virtual patient communications, or remote patient monitoring. See Attachment A, Section C.1 of this policy for further guidance for billing virtual patient communications and remote patient monitoring codes.

In addition, FQHC and RHC core service providers may conduct telehealth visits with a supporting home visit by a delegated staff member (“hybrid model”) with new or established patients and bill using HCPCS code T1015 (or T1015-HI, T1015-SC), for a range of scenarios including (but not limited to) chronic disease management and perinatal visits.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1D-4, Core Services Provided in Federally Qualified Health Centers and Rural Health Clinics, p. 8-9 & 19 Dec. 1, 2020. (Accessed Nov. 2022).

Office Based Opioid Treatment (OBOT)

Telehealth services may be used for the medical or counseling portions of OBOT services providing they are in accordance with NC Medicaid clinical coverage policy 1H, Telemedicine and Telepsychiatry. If telehealth is utilized for the medical management portion of OBOT services, the beneficiary shall be located at a facility where a physical exam can be conducted by a nurse practitioner, physician assistant, or MD at the time of the telehealth visit.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1A-41, Office-Based Opioid Treatment, p. 12, July 1, 2021. (Accessed Nov. 2022).

Independent Practitioners

As outlined in Attachment A and in Subsection 3.2.1.3.e, select services within this clinical coverage policy may be provided via telehealth.

A select set of speech and language evaluation and treatment interventions may be provided to a beneficiary using a telehealth delivery method as described in Clinical Coverage Policy 1-H. Telehealth delivery may be medically necessary when a beneficiary’s medical condition is such that exposure to others should be avoided, access to transportation is inconsistent, or if their location is remote or underserved such that access to appropriately qualified providers is limited.

To ensure a beneficiary receives high quality care aligned with best practices, the following criteria must be considered when making decisions about providing care using a telehealth delivery method:

  • Unless in-person care is contraindicated or unavailable, telehealth must be used as an adjunct to in-person care and not as a replacement.
  • Telehealth must be used in the best interest of the beneficiary and not as a convenience for the therapist.
  • Telehealth must never be used solely to increase therapist productivity.

Modifier GT must be appended to the CPT or HCPCS code to indicate that a service has been provided via interactive audio-visual communication. This modifier is not appropriate for virtual communications or remote patient monitoring

SOURCE: NC Div. of Medical Assistance, Independent Practitioners, Clinical Coverage Policy No: 10B, Amended Oct. 1, 2022, pg. 3, 12 & 44 (Accessed Nov. 2022).

Outpatient Specialized Therapies – Local Education Agencies

As outlined in Attachment A and in Subsections 3.5 and 3.8, select services within this clinical coverage policy may be provided via telehealth.

A select set of speech and language evaluation and treatment interventions as well as psychological and counseling treatment interventions may be billed by LEAs when provided to student beneficiaries using a telehealth delivery method as described in Clinical Coverage Policy 1-H. Telehealth delivery may be medically necessary when a student is medically homebound, during an extended school closure, or if their school is remote or underserved such that access to appropriately qualified providers is limited.  See telehealth eligible service codes in manual.

Modifier GT must be appended to the CPT or HCPCS code to indicate that a service has been provided via interactive audio-visual communication. This modifier is not appropriate for virtual patient communications or remote patient monitoring.

SOURCE: NC Div. of Medical Assistance, Outpatient Specialized Therapies, Local Education Agencies, Clinical Coverage Policy, Amended Feb. 1, 2022, pg. 4, 12 & 14, 43, 45, & 46 (Accessed Nov. 2022).

Speech and Language Evaluation and Treatment

A select set of speech and language evaluation and treatment interventions may be provided to a beneficiary using a telehealth delivery method as described in Clinical Coverage Policy 1-H. Telehealth delivery may be medically necessary when a beneficiary’s medical condition is such that exposure to others should be avoided, or if their location is remote or underserved such that access to appropriately qualified providers is limited.

To ensure a beneficiary receives high quality care aligned with best practices, the following criteria must be considered when making decisions about providing care using a telehealth delivery method:

  • Unless in-person care is contraindicated or unavailable, telehealth must be used as an adjunct to in-person care and not as a replacement.
  • Telehealth must be used in the best interest of the beneficiary and not as a convenience for the therapist.
  • Telehealth must never be used solely to increase therapist productivity.

See Speech Language codes for eligible services via telehealth.

SOURCE: NC Div. of Medical Assistance, Independent Practitioners, Clinical Coverage Policy, Amended Oct. 3, 2022, pg. 12 & 41 (Accessed Nov. 2022).

Family Planning Services

As outlined in Attachment A, select services within this clinical coverage policy may be provided via telehealth.  See manual for approved codes.

Modifier GT must be appended to the CPT or HCPCS code to indicate that a service has been provided via interactive audio-visual communication. This modifier is not appropriate for virtual patient communications or remote patient monitoring.

Telehealth claims should be filed with the provider’s usual place of service code(s) and not place of service 02 (Telehealth).

Six (6) inter-periodic visits are allowed per 365 calendar days. Each in-person or telehealth encounter will count as one of a beneficiary’s allotted six inter-periodic visits, per 365 days.

SOURCE: NC Div. of Medical Assistance, Family Planning Services, Clinical Coverage Policy, Amended May 1, 2021, pg. 4, 22-24 & 26 (Accessed Nov. 2022).

Home Health Services

The use of telehealth is permitted for home health services. The physician shall provide a written attestation statement that face-to-face contact (including the use of telehealth), was made with the beneficiary within the last 90 days.

SOURCE: NC Div. of Medical Assistance, Clinical Coverage Policies 3A Home Health Services, Amended Oct. 3, 2022, pg. 13, (Accessed Nov. 2022).

Dietary Evaluation and Counseling and Medical Lactation Services 

Telehealth eligible services may be provided to both new and established patients by the eligible providers listed within this policy. See manual for codes.

Modifier GT must be appended to the CPT or HCPCS code to indicate that a service has been provided via interactive audio-visual communication. This modifier is not appropriate for virtual patient communications or remote patient monitoring. Providers who bill for Medical Lactation services with codes 96156, 96158, and 96159 must append the SC modifier to denote Medical Lactation Services.

SOURCE: NC Div. of Medical Assistance, Clinical Coverage Policies Dietary Evaluation and Counseling and Medical Lactation Services Amended Dec. 1, 2020, pg. 18 & 19, (Accessed Nov 2022).

Dialysis Services

Telehealth eligible services may be provided to both new and established patients by the eligible providers listed within this policy. Modifier GT must be appended to the CPT or HCPCS code to indicate that a service has been provided via interactive audio-visual communication. This modifier is not appropriate for virtual communications or remote patient monitoring.

See manual for service codes.

SOURCE:  NC Div. of Medical Assistance, Clinical Coverage Policies Dialysis Services Amended Dec. 1, 2020, pg. 17 (Accessed Nov. 2022).

Diabetes Outpatient Self-Management Education

Telehealth eligible services may be provided to both new and established patients by the eligible providers listed within this policy. Modifier GT must be appended to the CPT or HCPCS code to indicate that a service has been provided via interactive audio-visual communication. This modifier is not appropriate for virtual communications or remote patient monitoring.

See manual for service codes.

SOURCE: NC Div. of Medical Assistance, Clinical Coverage Policies Diabetes Outpatient Self-Management Education Amended Feb. 15, 2021, pg. 14, (Accessed Nov. 2022).

Independent Practitioners Respiratory Therapy Services

Services delivered via telehealth must follow the requirements and guidance set forth in Clinical Coverage Policy 1-H: Telehealth, Virtual Communications, and Remote Patient Monitoring.

A select set of respiratory therapy treatment interventions may be provided to established patients using a telehealth delivery method as described in Clinical Coverage Policy 1-H. After necessary equipment and supplies have been delivered and assembled, delivery of treatment services via telehealth may be medically necessary when a beneficiary’s medical condition is such that exposure to others should be avoided, or if their location is remote or underserved such that access to appropriately qualified providers is limited.

CPT codes that may be billed when service is furnished via telehealth are indicated in Attachment A, Section C: Codes.

See manual for codes.

Respiratory Therapy treatment visits by the IPP must occur in the beneficiary’s primary private residence or via telehealth in accordance with Subsection 3.2.1 c., and focus on legal parent(s), legal guardian(s) or foster care provider(s) education. The IPP may provide two (2) respiratory therapy treatment visits of the allowed 15 treatment visits in either the school or other location (day care) during a six (6) consecutive month time frame to provide staff training.

The beneficiary shall be present and actively participating during each session.

SOURCE: NC Div. of Medical Assistance, Clinical Coverage Policies Independent Practitioners Respiratory Therapy Services Amended Jan. 1, 2021, pg. 7, 12 &14, (Accessed Nov. 2022).

Pregnancy Medical Home

Telehealth eligible services may be provided to new and established patients by the eligible providers listed within this policy. Modifier GT must be appended to the CPT or HCPCS code to indicate that a service has been provided via interactive audio-visual communication. This modifier is not appropriate for virtual patient communications or remote patient monitoring.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1E-6, Telehealth, Pregnancy Medical Home, pg. 14-15, Apr. 1, 2022. (Accessed Nov. 2022).

Enhanced Mental Health and Substance Abuse Services

As outlined in Attachments A and D, select services within this clinical coverage policy may be provided via telehealth. Services delivered via telehealth must follow the requirements and guidance in clinical coverage Policy 1-H, Telehealth, Virtual Communications, and Remote Patient Monitoring, at https://medicaid.ncdhhs.gov/.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Enhanced Mental Health and Substance Abuse Services Amended April 1, 2022, Attachment A pgs 24-27, Attachment D pgs. 31-100 & pg. 4. (Accessed Nov. 2022). 

Facility-Based Crisis Service for Children and Adolescents

As outlined in Attachment A, select services within this clinical coverage policy may be provided via telehealth. Services delivered via telehealth must follow the requirements and guidance in clinical coverage Policy 1-H, Telehealth, Virtual Communications, and Remote Patient Monitoring, at https://medicaid.ncdhhs.gov/.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy  No. 8A-2, Facility-Based Crisis Service for Children and Adolescents pg. 7 & Attachment A pgs. 21-22, Amended May 15, 2022. (Accessed Nov. 2022).

Diagnostic Assessment

A diagnostic assessment is a direct periodic service that can be provided in any location. This service may be provided to the beneficiary in-person or via telehealth.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No. 8A-5, Diagnostic Assessment, Amended April 1, 2021, pg. 5, (Accessed Nov. 2022). 

Children’s Developmental Service Agencies (CDSAs)

As outlined in Attachment A, select services within this clinical coverage policy may be provided via telehealth. Services delivered via telehealth must follow the requirements and guidance in clinical coverage Policy 1-H, Telehealth, Virtual Communications, and Remote Patient Monitoring, at https://medicaid.ncdhhs.gov/.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No. 8-J, Children’s Developmental Service Agencies (CDSAs) Amended Feb. 1, 2022, pg. 8 & Attachment A pgs. 18-20. (Accessed Nov. 2022).

North Carolina Innovations

As outlined in Attachment A, select services within this clinical coverage policy may be provided via telehealth. Services delivered via telehealth must follow the requirements and guidance in clinical coverage Policy 1-H, Telehealth, Virtual Patient Communications, and Remote Patient Monitoring, at https://medicaid.ncdhhs.gov/.

Specialized Consultation Services

Specialized Consultation Services provide expertise, training and technical assistance in a specialty area (psychology, behavior intervention, speech therapy, therapeutic recreation, augmentative communication, assistive technology equipment, occupational therapy, physical therapy, nutrition, nursing, and other licensed professionals who possess experience with individuals with Intellectual / Developmental Disabilities) to assist family members, support staff and other natural supports in assisting the beneficiary with developmental disabilities. Under this model, family members and other paid/unpaid caregivers are trained by a certified, licensed, and/or registered professional, or qualified assistive technology professional to carry out therapeutic interventions, consistent with the Individual Support Plan.

Activities covered include:

  • Tele-consultation through use of two-way, real time-interactive audio and video to provide behavioral and psychological care when distance separates the care from the individual.

See manual for complete list of covered activities.

This service may be used for evaluations for adults when the State Plan limits have been exceeded.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy 8-P, North Carolina Innovations Amended May 1, 2022, pg. 10, Attachment A pgs. 38-43 & pg. 105, (Accessed Nov. 2022).


ELIGIBLE PROVIDERS

To be eligible to bill for procedures, products, and services related to this policy, providers shall

  • Meet Medicaid or NCHC qualifications for participation;
  • Be currently Medicaid or NCHC enrolled; and
  • Bill only for procedures, products, and services that are within the scope of their clinical practice, as defined by the appropriate licensing entity.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, p. 9, Oct. 1, 2022 & NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 8C, Outpatient Behavioral Health Services, p. 13, Sept. 1, 2021. (Accessed Nov. 2022).

The distant site is the location from which the provider furnishes the telehealth, virtual communications, or remote patient monitoring services. There are no restrictions on distant sites. Distant sites may be wherever the provider may be located. Provider(s) shall ensure that beneficiary privacy is protected (such as taking calls from private, secure spaces; using headsets).

Federally Qualified Health Centers (FQHCs), FQHC Look-Alikes and Rural Health Centers (RHCs) are considered eligible distant sites and shall follow the coding and billing guidelines (see Attachment A in the manual).

Eligible providers that can bill for telehealth services:

  • Physicians;
  • Nurse practitioners;
  • Psychiatric Nurse Practitioner
  • Certified nurse midwives;
  • Physician’s assistants; and
  • Clinical pharmacist practitioners

NC Medicaid permits all of the above provider types to bill for the hybrid telehealth with supporting home visits, most virtual communication services and remote patient monitoring, except clinical pharmacist practitioners.  Physicians can only bill interprofessional assessment and management codes.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, p. 2, 13-16, Oct. 1, 2022. (Accessed Nov. 2022).

Early and Periodic Screening, Diagnostic and Treatment (EPSDT)

Medically necessary services will be provided in the most economic mode, as long as the treatment made available is similarly efficacious to the service requested by the beneficiary’s physician, therapist, or other licensed practitioner; the determination process does not delay the delivery of the needed service; and the determination does not limit the beneficiary’s right to a free choice of providers.

EPSDT does not require the state Medicaid agency to provide any service, product or procedure:

  • that is unsafe, ineffective, or experimental or investigational.
  • that is not medical in nature or not generally recognized as an accepted method of medical practice or treatment.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, p. 4, Oct. 1, 2022. (Accessed Nov. 2022).

Federally Qualified Health Centers (FQHCs) and Rural Health Centers (RHCs) may bill for telehealth, virtual communication, and remote patient monitoring services if the service follows core service billing requirements as outlined in clinical coverage policy 1D-4, Core Services Provided in Federally Qualified Health Centers and Rural Health Clinics.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, p. 12, Oct. 1, 2022. (Accessed Nov. 2022).

FQHCs/RHCs

Eligible providers include all core service providers as defined in Section 3.2.1 of the FQHC/RHC clinical policy, which includes physicians, physician assistants, nurse practitioners, nurse midwives, clinical psychologists, clinical social workers, licensed psychological associates, licensed clinical mental health counselors, licensed marriage and family therapists, advance practice nurse specialists, clinical nurse specialists, and licensed clinical addiction specialists.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1D-4, Core Services Provided in Federally Qualified Health Centers and Rural Health Clinics, p. 19, Dec. 1, 2020. (Accessed Nov. 2022).


ELIGIBLE SITES

The Originating Site is the location in which the beneficiary is located, which may be health care facilities, schools, community sites, the home, or wherever the beneficiary may be at the time they receive services via telehealth, virtual communications, or remote patient monitoring. There are no restrictions on originating sites.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, p. 2, Oct. 1, 2022 (Accessed Nov. 2022).

When the originating site is a hospital, the originating site facility fee must be billed with RC780 and Q3014.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, p. 17, Oct. 1, 2022. (Accessed Nov. 2022).

Dietary Evaluation

Dietary evaluation and counseling is provided in hospital outpatient clinics; public agencies such as health departments, federally qualified health centers, and rural health clinics; private agencies; physician or medical diagnostic clinics; and physician offices.

Telehealth claims should be filed with the provider’s usual place of service code(s).

SOURCE:  NC Div. of Medical Assistance, Clinical Coverage Policies Dietary Evaluation and Counseling and Medical Lactation Services Amended Dec. 1, 2020, pg.  19, (Accessed Nov. 2022).

Lactation Consultation Services

Services must be provided in hospital outpatient clinics; public agencies such as health departments, federally qualified health centers, and rural health clinics; private agencies; physician or medical diagnostic clinics; and physician offices.

Telehealth claims should be filed with the provider’s usual place of service code(s).

SOURCE:  NC Div. of Medical Assistance, Clinical Coverage Policies Dietary Evaluation and Counseling and Medical Lactation Services Amended Dec. 1, 2020, pg.  19, (Accessed Nov. 2022).

Dialysis Services

Telehealth claims should be filed with the provider’s usual place of services code(s).

SOURCE:  NC Div. of Medical Assistance, Clinical Coverage Policies Dialysis Services Amended Dec. 1, 2020, pg. 18, (Accessed Nov. 2022).

Diabetes Outpatient Self-Management Education

Physician’s office, outpatient hospital department, physician diagnostic clinic, local health department, rural health clinic, federally qualified health center.

Telehealth claims should be filed with the provider’s usual place of service code(s).

SOURCE: NC Div. of Medical Assistance, Clinical Coverage Policies Diabetes Outpatient Self-Management Education Amended Feb. 15, 2021, pg. 14, (Accessed Nov. 2022).

Independent Practitioners

Office, Home, School, through the Head Start program, and childcare (regular and developmental day care) settings.

Telehealth claims should be filed with the provider’s usual place of service code(s).

SOURCE: NC Div. of Medical Assistance, Independent Practitioners, Clinical Coverage Policy, Amended Oct. 1, 2022, pg. 45 (Accessed Nov. 2022).

FQHCs/RHCs

Core Services

Core visit services delivered via telehealth are billed under the FQHC and RHC provider number using the HCPCS code T1015 (clinic visit/encounter, all-inclusive), T1015-HI (for behavioral health services), or T1015-SC (subsequent sick visit) and appended with the GT modifier. Eligible providers include all core service providers as defined in Section 3.2.1 of this policy, which includes physicians, physician assistants, nurse practitioners, nurse midwives, clinical psychologists, clinical social workers, licensed psychological associates, licensed clinical mental health counselors, licensed marriage and family therapists, advance practice nurse specialists, clinical nurse specialists, and licensed clinical addiction specialists.

Hybrid Telehealth with Supporting Home Visit

In addition, FQHC and RHC core service providers may conduct telehealth visits with a supporting home visit by a delegated staff member (“hybrid model”) with new or established patients and bill using HCPCS code T1015 (or T1015-HI, T1015-SC), for a range of scenarios including (but not limited to) chronic disease management and perinatal visits.

See manual for additional guidance.

Telehealth claims, except for hybrid telehealth with supporting home visits, should be filed with the provider’s usual place of service code(s).

Hybrid telehealth with supporting home visits should be filed with Place of Service (POS) 12 (home).

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1D-4, Core Services Provided in Federally Qualified Health Centers and Rural Health Clinics, pgs 19 & 20, Dec. 1, 2020. (Accessed Nov. 2022).

Pregnancy Medical Home

Telehealth claims should be filed with the provider’s usual place of service code(s).

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1E-6, Telehealth, Pregnancy Medical Home, pg. 15, April 1, 2022. (Accessed Nov. 2022).


GEOGRAPHIC LIMITS

There are no restrictions on the originating or distant sites.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, p. 2, Oct. 1, 2022. (Accessed Nov. 2022).


FACILITY/TRANSMISSION FEE

Any Medicaid enrolled provider who provides a beneficiary with access to audio and visual equipment in order to complete a telehealth encounter may bill for a facility fee when their office or facility is the site at which the beneficiary is located when the service is provided and the distant site provider is at a different physical location. Skilled nursing facilities (SNF) shall not bill an originating site facility fee when the SNF Medical Director or a beneficiary’s attending physician is conducting a telehealth visit.

Providers must bill Q3014 for the originating site facility fee.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, p. 9 & 17, Oct. 1, 2022. (Accessed Nov. 2022).

FQHCs, FQHC-Lookalikes and RHCs may bill their core service code (T1015) and an originating site facility fee (Q3014) for hybrid model visits to reflect the additional cost of the delegated staff person attending the beneficiary’s home. To be reimbursed for the originating site facility fee, all of the following requirements must be met for each home visit:

  • The assistance delivered in the home must be given by an appropriately trained delegated staff person.
  • The fee must be billed for the same day that the home visit is conducted.
  • HCPCS code Q3014 must be appended with the GT modifier and billed with a place of service ‘12’ to designate that the originating site was the home.
  • The core service code (T1015) must be billed separately from the originating site facility fee code (Q3014).

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, p. 14, Oct. 1, 2022, (Accessed Nov. 2022).

Last updated 11/04/2022

Miscellaneous

Providers shall comply with the following in effect at the time the service was rendered:

  • All applicable agreements, federal, state and local laws and regulations including HIPAA and medical retention requirements.
  • All Medicaid’s clinical (medical) coverage policies, guidelines, policies, provider manuals, implementation updates and bulletins published by CMS, DHHS, its divisions or its fiscal contractor(s).

Since telehealth services are considered professional services, a beneficiary and provider relationship may be established via telehealth.

Provider(s) are expected to send documentation of any telehealth services rendered to a beneficiary’s identified primary care provider or medical home within 48 hours of the encounter for medical services (including behavioral health medication management), obtaining required consent when necessary (as per 42 CFR Part 2 for relevant substance use disorder related disclosures). Documentation can be sent by any HIPAA-compliant secure means.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, p. 3 & 9-10, Oct. 1, 2022. (Accessed Nov. 2022).

Last updated 11/04/2022

Out of State Providers

No Reference Found

Last updated 11/04/2022

Overview

NC Medicaid reimburses for medically necessary telehealth services via live video, remote patient monitoring, audio-only and other virtual communications modalities outlined in its updated telehealth clinical coverage policies.

Last updated 11/04/2022

Remote Patient Monitoring

POLICY

Remote Patient Monitoring is the use of digital devices to measure and transmit personal health information from a beneficiary in one location to a provider in a different location. Remote patient monitoring enables providers to collect and analyze information such as vital signs (blood pressure, heart rate, weight, blood oxygen levels) in order to make treatment recommendations. There are two types of remote patient monitoring addressed within this policy:

  • Self-Measured and Reported Monitoring: When a beneficiary uses a digital device to measure and record their own vital signs, then transmits the data to a provider for evaluation.
  • Remote Physiologic Monitoring: When a beneficiary’s physiologic data is wirelessly synced from a beneficiary’s digital device where it can be evaluated immediately or at a later time by a provider.

Remote patient monitoring requires use of a device that is defined by the FDA as a medical device and is in real-time and transmittable. Some forms of remote patient monitoring, such as remote physiologic monitoring (detailed below), require a device that is wirelessly synced where the provider can evaluate the data in real or near-real time. All remote patient monitoring must be conducted in a HIPAA compliant manner, particularly with respect to protecting transmission of patient health data.

NC Medicaid reimburses for remote patient monitoring for self-measured blood pressure monitoring and remote physiologic monitoring. See manual for coverage criteria. See Appendix A of manual for covered remote monitoring codes.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, p. 2, & 8 Oct. 1, 2022. (Accessed Nov. 2022).

SMBPM is a beneficiary’s regular use of a personal blood pressure monitoring device to assess and record blood pressure across different points in time outside of a clinical setting, typically at home. This service is available for new or established patients.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, p. 16, Oct. 1, 2022. (Accessed Nov. 2022).

A special COVID-19 Medicaid bulletin lists remote physiologic monitoring and blood pressure monitoring codes that have been made permanently eligible for reimbursement that have not yet been incorporated into the 1H Telehealth, Virtual Communication and Remote Patient Monitoring provider manual.

SOURCE: NC Medicaid Special Bulletin COVID-19 #237, Oct. 2022, (Accessed Nov. 2022).


CONDITIONS

No Reference Found


PROVIDER LIMITATIONS

Providers that may bill NC Medicaid for remote patient monitoring include physicians, nurse practitioners; psychiatric nurse practitioner; certified nurse midwives; and physician’s assistants.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, p. 15, Nov. 15, 2020. (Accessed Aug. 2022).


OTHER RESTRICTIONS

Remote patient monitoring requires use of a device that is defined by the FDA as a medical device. Some forms of remote patient monitoring, such as remote physiologic monitoring (detailed below), require a device that is wirelessly synced where the provider can evaluate the data in real or near-real time. All remote patient monitoring must be conducted in a HIPAA compliant manner, particularly with respect to protecting transmission of patient health data.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, p. 8, Nov. 15, 2020. (Accessed Aug. 2022).

Last updated 11/04/2022

Store and Forward

POLICY

Virtual communications is the use of technologies other than video to enable remote evaluation and consultation support between a provider and a beneficiary or a provider and another provider. As outlined in Attachment A and program- specific clinical coverage policies, covered virtual communication services include: telephone conversations (audio only); virtual portal communications (secure messaging); and store and forward (transfer of data from beneficiary using a camera or similar device that records (stores) an image that is sent by telecommunication to another site for consultation).

Virtual communication, including:

  • online digital evaluation and management codes;
  • telephonic evaluation and management;
  • telephonic evaluation and management and virtual communication codes; and
  • interprofessional assessment and management codes.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, p. 2 & 6, Oct. 1, 2022. (Accessed Nov. 2022).

A special COVID-19 Medicaid bulletin lists codes that include an element of store-and-forward (such as online digital evaluation and management) have been made permanently eligible for reimbursement that have not yet been incorporated into the 1H Telehealth, Virtual Communication and Remote Patient Monitoring provider manual.

SOURCE: NC Medicaid Special Bulletin COVID-19 #237, Oct 2022, (Accessed Nov. 2022).


ELIGIBLE SERVICES/SPECIALTIES

Virtual patient communications must be transmitted between a patient and provider, or between two providers, in a manner that is consistent with the CPT code definition for those services. Provider(s) shall follow all applicable HIPAA rules.

Covered virtual communication services include: telephone conversations (audio only); virtual portal communications (secure messaging); and store and forward (transfer of data from beneficiary using a camera or similar device that records (stores) an image that is sent by telecommunication to another site for consultation).

Virtual communications include online digital evaluation and management codes and interprofessional assessment and management codes. See manual for covered codes.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, p. 2, 8 & 14, Oct. 1, 2022. (Accessed Nov. 2022).


GEOGRAPHIC LIMITS

There are no site restrictions on the use of virtual communications for originating or distant sites.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, p. 2, Oct. 1, 2022. (Accessed Nov. 2022).


TRANSMISSION FEE

Any Medicaid enrolled provider who provides a beneficiary with access to audio and visual equipment in order to complete a telehealth encounter may bill for a facility fee when their office or facility is the site at which the beneficiary is located when the service is provided and the distant site provider is at a different physical location. 

Skilled nursing facilities (SNF) shall not bill an originating site facility fee when the SNF Medical Director or a beneficiary’s attending physician is conducting a telehealth visit. 

SOURCE:  NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, p. 9, Oct. 1, 2022. (Accessed Nov. 2022).

Last updated 11/04/2022

Cross State Licensing

The Board may approve a dental hygienist licensed in this State or any other state or territory to provide local anesthesia upon the dental hygienist meeting all of the following criteria:

  • Produces satisfactory evidence of the required education, training, and clinical qualifications to provide local anesthesia.
  • Has been practicing dental hygiene, as defined in G.S. 90-221, under the supervision of a licensed dentist for a minimum of two years immediately preceding the date of the application.
  • Has successfully completed a course of study on local anesthetics offered through a school or college approved by the United States Department of Education or a Board-approved continuing education provider that includes all of the following:
      • A minimum of 16 lecture hours on pharmacology, physiology, equipment, block and infiltration techniques, legal issues, and medical emergencies, including systemic complications.
      • A minimum of eight clinical hours of instruction and experience in administering local anesthesia injections.
      • Completion of at least 12 block and 12 infiltration injections under the direct supervision of a licensed dentist who must certify the applicant’s competency.

SOURCE: NC General Statutes Sec. 90-225.3. (Accessed Nov. 2022).

A person providing applied behavior analytic services via telehealth to a person physically located in North Carolina while services are provided shall be licensed by the board.

A person providing applied behavior analytic services via telehealth from a physical location in North Carolina shall be licensed by the board and may be subject to licensure requirements in other states where the services are received by the client.

SOURCE: 21 NCAC 05 .0403. (Accessed Nov. 2022).

Last updated 11/04/2022

Definitions

Maternal and Child Health and Women’s Health

Telemedicine is the use of audio and video between places of lesser and greater medical capability or expertise to provide and support health care when distance separates participants who are in different geographical locations.

SOURCE: NC General Statute 130A-125(b2)(1). (Accessed Nov. 2022).

Involuntary Commitments

“Telehealth” means the use of two-way, real-time interactive audio and video where the respondent and commitment examiner can hear and see each other.

SOURCE: NC General Statute Sec. 122C-263, (Accessed Nov. 2022).

Practice of teledentistry

The provision of dental services by use of any electronic or other digital means, as authorized in G.S. 90-29(b)(11) and provided for in subsection (b) of this section.

A person shall be deemed to be practicing dentistry in this State who does, undertakes or attempts to do, or claims the ability to do any one or more of the following acts or things which, for the purposes of this Article, constitute the practice of dentistry:

  • Administers an anesthetic of any kind in the treatment of dental or oral diseases or physical conditions, or in preparation for or incident to any operation within the oral cavity; provided, however, that this subsection shall not apply to a lawfully qualified nurse anesthetist who administers such anesthetic under the supervision and direction of a licensed dentist or physician;physician, or to a registered dental hygienist qualified to administer local anesthetics.
  • Owns, manages, supervises, controls or conducts, either himself or himself, by and through another person or other persons, or by use of any electronic or other digital means, any enterprise wherein any one or more of the acts or practices set forth in subdivisions (1) through (10) above are done, attempted to be done, or represented to be done.

SOURCE: NC General Statutes Sec. 90-29 & 90-30.2 (Accessed Nov. 2022).

Veterinary Telemedicine

“Veterinary Telemedicine” or “telemedicine” means the use of electronic or telecommunication technologies to remotely provide medical information regarding a patient’s clinical health status and to deliver veterinary medical services to a patient that resides in or is located in the State. The delivery of veterinary medical services through telemedicine is the practice of veterinary medicine.

SOURCE:  21 NCAC 66 .0211  & NC Veterinary Board of Medicine. (Accessed Nov. 2022).

Occupational Therapy Compact

Telehealth – The application of telecommunication technology to deliver occupational therapy services for assessment, intervention, or consultation.

SOURCE: NC General Statute Sec. 90-270.181, (Accessed Nov. 2022).

Interstate Compact For Audiology And Speech Pathology

Telehealth – The application of telecommunication technology to deliver audiology or speech-language pathology services at a distance for assessment, intervention, and/or consultation.

SOURCE: NC General Statute Sec. 90-312.2. (Accessed Nov. 2022).

Last updated 11/03/2022

Licensure Compacts

Member of the Physical Therapy Compact.

SOURCE: PT Compact. Compact Map, (Accessed Nov. 2022).

Member of the Nurses Licensure Compact.

SOURCE:  Current NLC States & Status.  Nurse Licensure Compact.  (Accessed Nov. 2022).

Member of Psychology Interjurisdictional Compact.

SOURCE: PSYPACT. Compact Map, (Accessed Nov. 2022).

Member of the Audiology and Speech-Language Pathology Interstate Compact

SOURCE: Audiology and Speech-Language Pathology Interstate Compact. Compact Map, (Accessed Nov. 2022).

Member of Occupational Therapy Interstate Compact

SOURCE: OT Compact Map. (Accessed Nov. 2022).

Member of the Counseling Compact.

SOURCE: Counseling Compact Map. (Accessed Nov. 2022).

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

Last updated 11/04/2022

Miscellaneous

Telemedicine may be utilized for neonatal or infant echocardiograms.

SOURCE: 10A N.C.A.C. 43K.0102(c)(3). (Accessed Nov. 2022).

Telehealth may be used to perform the initial examination for purposes of involuntary commitment.

SOURCE: N.C. Gen. Stat. § 122C-263(c), (Accessed Nov. 2022).

The Commission is required to address follow-up protocols to ensure early treatment for newborn infants diagnosed with congenital heart defects, including by means of telemedicine (live video).

SOURCE: NC General Statute 130A-125(b2)(1). (Accessed Nov. 2022).

Audiology Assistants may utilize telehealth to extend access to clinical care.

SOURCE: 21 NCAC 64 .1104(a)(7). (Accessed Nov. 2022).

Teledentistry

The licensee shall ensure that any electronic and digital communication used in the practice of teledentistry is secure to maintain confidentiality of the patient’s medical information as required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and all other applicable laws and administrative regulations. Patients receiving services through teledentistry under this section are entitled to protection of their medical information no less stringent than the requirements that apply to patients receiving in-person services.

SOURCE: NC General Statutes Sec. 90-30.2. (Accessed Nov. 2022).

Involuntary Commitment

For an involuntary commitment, the respondent may either be in the physical face-to-face presence of the person conducting the screen or may be examined utilizing telehealth equipment and procedures. See statute for additional information.

SOURCE: NC General Statutes 122C-263 & 122C-266, (Accessed Nov. 2022).

Last updated 11/04/2022

Online Prescribing

Teledentistry

The indication, appropriateness, and safety considerations for each prescription for medication, laboratory services, or dental laboratory services provided through the use of teledentistry shall be evaluated by the licensed dentist in accordance with applicable law and current standards of care, including those for appropriate documentation. A licensed dentist’s use of teledentistry carries the same professional accountability as a prescription issued in connection with an in-person encounter. A licensed dentist who prescribes any type of analgesic or pain medication as part of the provision of teledentistry services shall comply with all applicable North Carolina Controlled Substance Reporting System requirements.”

SOURCE: NC Statute Sec. 90-30.2. (Accessed Nov. 2022).

 

Last updated 11/04/2022

Professional Board Standards

Veterinary Medical Board

SOURCE: NC Admin Code, Title 21, Sec. 66 .0211 35:20, (Accessed Nov. 2022).

See statute for ‘practice of teledentistry’ requirements.

SOURCE: NC Statute Sec. 90-30.2. (Accessed Nov. 2022).

An audiology assistant may engage in the following direct patient services: … Providing services previously mentioned through telehealth to extend access to clinical care.

SOURCE: NC Admin Code, Title 21, Sec. 64.1104, (Accessed Nov. 2022).

Applied Behavior Analytic Services

SOURCE: 21 NCAC 05 .0403. (Accessed Nov. 2022).

Last updated 11/03/2022

Definition of Visit

A core visit shall be a professional service that is rendered during a face-to-face encounter by a physician or other health professional listed in this policy. If the only services rendered during a visit are “incident to” services ordinarily performed by a nurse, technician, or office assistant (such as taking blood pressure and temperature, giving injections, or changing dressings), the visit does not constitute a core visit.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1D-4, Core Services Provided in Federally Qualified Health Centers and Rural Health Clinics, p. 8-9, Dec. 1, 2020. (Accessed Nov. 2022).

Last updated 11/03/2022

Eligible Distant Site

The distant site is the location from which the provider furnishes the telehealth, virtual communications, or remote patient monitoring services. There are no restrictions on distant sites. Distant sites may be wherever the provider may be located. Provider(s) shall ensure that beneficiary privacy is protected (such as taking calls from private, secure spaces; using headsets).

Telehealth is the use of two-way real-time interactive audio and video to provide and support health care services when participants are in different physical locations. Federally Qualified Health Centers (FQHCs), FQHC Look-Alikes and Rural Health Centers (RHCs) are considered eligible distant sites and shall follow the coding and billing guidelines in Attachment A below.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, pg. 2, Oct. 1, 2022. (Accessed Nov. 2022).

See: NC Medicaid Live Video Eligible Providers

Last updated 11/03/2022

Eligible Originating Site

Hybrid Telehealth with Supporting Home Visit

FQHCs and RHCs may bill their core service code (T1015, T1015-HI, or T1015-SC) and an originating site facility fee (Q3014) for hybrid model visits to reflect the additional cost of the delegated staff person attending the patient’s home.  HCPCS code Q3014 must be appended with the GT modifier and billed with a place of service ‘12’ to designate that the originating site was the home. See manual for additional requirements.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, pg. 14 Oct. 1, 2022NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1D-4, Core Services Provided in Federally Qualified Health Centers and Rural Health Clinics, p. 19, Dec. 1, 2020. (Accessed Nov. 2022).

Medicaid Telehealth manual indicates there are no restrictions on originating sites.

See: NC Medicaid Live Video Eligible Sites

Last updated 11/03/2022

Facility Fee

FQHCs and RHCs may bill their core service code (T1015, T1015-HI, or T1015- SC) and an originating site facility fee (Q3014) for hybrid model visits to reflect the additional cost of the delegated staff person attending the patient’s home. To be reimbursed for the originating site facility fee, all of the following requirements must be met for each home visit:

  • The assistance delivered in the home must be given by an appropriately trained delegated staff person.
  • The fee must be billed for the same day that the home visit is conducted.
  • HCPCS code Q3014 must be appended with the GT modifier and billed with a place of service ‘12’ to designate that the originating site was the home.
  • The core service code (T1015, T1015-HI or T1015-SC) must be billed as a separate claim from the originating site facility fee code (Q3014).

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1D-4, Core Services Provided in Federally Qualified Health Centers and Rural Health Clinics, pg. 19 Dec. 1, 2020. (Accessed Nov. 2022).

Any Medicaid enrolled provider who provides a beneficiary with access to audio and visual equipment in order to complete a telehealth encounter may bill for a facility fee when their office or facility is the site at which the beneficiary is located when the service is provided and the distant site provider is at a different physical location.

See: NC Medicaid Live Video Facility/Transmission Fee

Last updated 11/03/2022

Home Eligible

FQHC and RHC core service providers may conduct telehealth visits with a supporting home visit by a delegated staff member (“hybrid model”) with new or established patients and bill using HCPCS code T1015 (or T1015-HI, T1015-SC), for a range of scenarios including (but not limited to) chronic disease management and perinatal visits.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1D-4, Core Services Provided in Federally Qualified Health Centers and Rural Health Clinics, pg. 19 Dec. 1, 2020. (Accessed Nov. 2022).

FQHCs, FQHC-Lookalikes, and RHCs may utilize this hybrid model but shall not bill the home visit codes in table C.1.; FQHCs, FQHC-Lookalikes and RHCs may bill their core service code (T1015) and an originating site facility fee (Q3014) for hybrid model visits to reflect the additional cost of the delegated staff person attending the beneficiary’s home. To be reimbursed for the originating site facility fee, all of the following requirements must be met for each home visit:

  • The assistance delivered in the home must be given by an appropriately trained delegated staff person.
  • The fee must be billed for the same day that the home visit is conducted.
  • HCPCS code Q3014 must be appended with the GT modifier and billed with a place of service ‘12’ to designate that the originating site was the home.
  • The core service code (T1015) must be billed separately from the originating site facility fee code (Q3014).

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1D-4, Core Services Provided in Federally Qualified Health Centers and Rural Health Clinics, pg. 19 Dec. 1, 2020. (Accessed Nov. 2022).

Last updated 11/03/2022

Modalities Allowed

Live Video

Select services may be provided via telehealth, virtual patient communications, and remote patient monitoring. Services delivered via telehealth, virtual patient communications, and remote patient monitoring must follow the requirements and guidance set forth in Clinical Coverage Policy 1-H: Telehealth, Virtual Patient Communications, and Remote Patient Monitoring.

Federally Qualified Health Center (FQHC) and Rural Health Clinic (RHC) core service providers may deliver core services via telehealth if the service is: a. Defined as a core visit service in Section 5.3 of Clinical Coverage Policy 1D-4: Core Services Provided in Federally Qualified Health Centers and Rural Health Clinics; and, b. Covered as a telehealth-eligible core visit service in Attachment A, Section C.1 of this policy.

Non-Core Visit Services: FQHCs and RHCs may also deliver a select set of services via telehealth, virtual patient communications, and remote patient monitoring that are not defined as a core visit service in Section 5.3 of Clinical Coverage Policy 1D-4: Core Services Provided in Federally Qualified Health Centers and Rural Health Clinics. FQHCs and RHCs would be reimbursed on a fee-for-service basis for delivering non-core visit services via telehealth, virtual patient communications, or remote patient monitoring. See Attachment A, Section C.1 of this policy for further guidance for billing virtual patient communications and remote patient monitoring codes.

See: NC Medicaid Live Video


Store and Forward

As outlined in Section 5.7 and Attachment A, select services may be provided via telehealth, virtual patient communications, and remote patient monitoring. Services delivered via telehealth, virtual patient communications, and remote patient monitoring must follow the requirements and guidance set forth in Clinical Coverage Policy 1-H: Telehealth, Virtual Patient Communications, and Remote Patient Monitoring.

FQHCs and RHCs may also deliver a select set of services via telehealth, virtual patient communications, and remote patient monitoring that are not defined as a core visit service in Section 5.3 of Clinical Coverage Policy 1D-4: Core Services Provided in Federally Qualified Health Centers and Rural Health Clinics. FQHCs and RHCs would be reimbursed on a fee-for-service basis for delivering non-core visit services via telehealth, virtual patient communications, or remote patient monitoring. See Attachment A, Section C.1 of this policy for further guidance for billing virtual patient communications and remote patient monitoring codes.

 See: NC Medicaid Store and Forward


Remote Patient Monitoring

As outlined in Section 5.7 and Attachment A, select services may be provided via telehealth, virtual patient communications, and remote patient monitoring. Services delivered via telehealth, virtual patient communications, and remote patient monitoring must follow the requirements and guidance set forth in Clinical Coverage Policy 1-H: Telehealth, Virtual Patient Communications, and Remote Patient Monitoring.

FQHCs and RHCs may also deliver a select set of services via telehealth, virtual patient communications, and remote patient monitoring that are not defined as a core visit service in Section 5.3 of Clinical Coverage Policy 1D-4: Core Services Provided in Federally Qualified Health Centers and Rural Health Clinics. FQHCs and RHCs would be reimbursed on a fee-for-service basis for delivering non-core visit services via telehealth, virtual patient communications, or remote patient monitoring. See Attachment A, Section C.1 of this policy for further guidance for billing virtual patient communications and remote patient monitoring codes.

See: NC Medicaid Remote Patient Monitoring


Audio-Only

FQHCs and RHCs may conduct telephonic evaluation and management services using HCPCS code G0071. Eligible providers include physicians, nurse practitioners, psychiatric nurse practitioners, physician assistants, and certified nurse midwives.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1D-4, Core Services Provided in Federally Qualified Health Centers and Rural Health Clinics, p. 19, Dec. 1, 2020. (Accessed Nov. 2022).

See: NC Medicaid Audio-Only

Last updated 11/03/2022

Patient-Provider Relationship

No reference found.

Last updated 11/03/2022

PPS Rate

Federally Qualified Health Center (FQHC) and Rural Health Clinic (RHC) core service providers may deliver core services via telehealth.

FQHCs and RHCs would be reimbursed on a fee-for-service basis for delivering non-core visit services via telehealth, virtual patient communications, or remote patient monitoring.

Core visit services delivered via telehealth are billed under the FQHC and RHC provider number using the HCPCS code T1015 (clinic visit/encounter, all-inclusive), T1015-HI (for behavioral health services), or T1015-SC (subsequent sick visit) and appended with the GT modifier. Eligible providers include all core service providers as defined in Section 3.2.1 of this policy, which includes physicians, physician assistants, nurse practitioners, nurse midwives, clinical psychologists, clinical social workers, licensed psychological associates, licensed clinical mental health counselors, licensed marriage and family therapists, advance practice nurse specialists, clinical nurse specialists, and licensed clinical addiction specialists.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1D-4, Core Services Provided in Federally Qualified Health Centers and Rural Health Clinics, pgs.8-9 & 19 Dec. 1, 2020. (Accessed Nov. 2022).

Last updated 11/03/2022

Same Day Encounters

Core service encounters with more than one health professional, and multiple encounters with the same health professional, that take place on the same date of service and at a single location, constitute a single visit and are limited to one encounter per day, except when one of the following conditions exists:

  • After the first encounter, the beneficiary appears or presents with or suffers illness or injury requiring additional diagnosis or treatment; or
  • The beneficiary has a medical visit and an “other health” visit, such as a behavioral health visit. Core service visits for behavioral health are subject to the requirements and limitations specified in 42 CFR 405.2450 and 405.2452.

Note: Service is limited to a maximum of three encounters per day when the conditions of the above paragraphs are met. Written documentation shall be provided to justify more than three core visits billed on the same date of service.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1D-4, Core Services Provided in Federally Qualified Health Centers and Rural Health Clinics, p. 8, Dec. 1, 2020. (Accessed Nov. 2022).