Pennsylvania

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: No
  • Audio Only: Yes

PRIVATE PAYER LAW

  • Law Exists: No
  • Payment Parity: No

PROFESSIONAL REQUIREMENTS

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

FQHCs

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

STATE RESOURCES

  1. Medicaid Program: Pennsylvania Medical Assistance Program (MA)
  2. Administrator: Pennsylvania Department of Public Welfare
  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 01/22/2024

Definitions

No Reference Found

Last updated 01/22/2024

Parity

SERVICE PARITY

No Reference Found


PAYMENT PARITY

No Reference Found

Last updated 01/22/2024

Requirements

Will commercial insurers be required to reimburse for telemedicine services and to  reimburse at the same rate as in person services after October 31, 2022?

Coverage for, and reimbursement of, services delivered via telemedicine will be dependent on each commercial insurer’s coverage and operational policies, as well as the terms of any applicable provider contracts.  This includes payment rates, as there are no insurance laws or regulations requiring payment parity.  The Pennsylvania Insurance Department (PID) surveyed the commercial insurers for updated information following the end of the COVID-19 Public Health Emergency (PHE). While the services covered by insurers have not been reduced, insurers across the board have reinstated cost-sharing for telehealth appointments following the end of the PHE. Reimbursement rates vary dependent upon the insurance company’s provider contracts and member’s plan. Insurers noted that they will continue to review their policies in terms of any state/federal guidance moving forward.

I provide school-based physical health and behavioral health services and continue to provide care via telemedicine. Will I be allowed to continue to provide services using telemedicine after October 31, 2022?

Coverage for, and reimbursement of, services delivered via telemedicine will continue to be dependent on each commercial insurer’s coverage and operational policies, as well as the terms of any applicable provider contracts. Insurers may have policy limitations that prohibit coverage for school-based services.  However, state law currently requires all fully insured health plans to cover certain autism services regardless of whether they are provided in a school setting.

SOURCE: PA Dept. of State, Professional Licensing, Telemedicine FAQs. (Accessed Jan. 2024).

Last updated 01/22/2024

Definitions

Historically, “telemedicine” for purposes of Medicaid payment was the use of two-way, real time interactive telecommunication equipment that included, at a minimum, audio and video equipment, as a mode of delivering healthcare services. However, the term “telehealth” has emerged as the umbrella term that encompasses the full range of services furnished remotely. In response to this shift, the Department will now refer to the remote delivery of services as telehealth.

SOURCE: PA Department of Human Services, Medical Assistance Bulletin 99-23-08, p. 2. Aug. 2, 2023.  (Accessed Jan. 2024).

Teledentistry is two-way, real time interactive communication between the patient and dentist. Teledentistry may be provided by any means that allows for two-way, real time interactive audio-video communication, such as through conferencing hosted by a secure mobile application. Audio only technology may be utilized for two procedure codes as described below.

SOURCE: PA Department of Human Services, Medical Assistance Bulletin, Teledentistry Guidelines and Dental Fee Schedule Updates (May 2, 2022). (Accessed Jan. 2024).

Last updated 01/22/2024

Email, Phone & Fax

The Department will continue to allow providers to utilize audio-only telecommunication when the beneficiary does not have access to video capability or for an urgent medical situation. The use of audio-only telecommunication technology is to be consistent with state and federal requirements, including guidance by CMS with respect to Medicaid payment and to compliance with Health Insurance Portability and Accountability Act (HIPAA).

Services rendered via telehealth, including those delivered using audio-only telecommunication technology, must use technology that is two-way, real-time, and interactive between beneficiary and provider.

If the service was rendered using audio-only technology, providers are to document that the services were rendered using audio-only technology and the reason audio/video technology could not be used.

Audio-only telecommunications technology may be used when the beneficiary does not have video capability or for an urgent medical situation, if consistent with state and federal law.

Providers are to indicate in the beneficiary’s medical record when telehealth services are rendered via audio-only.

SOURCE: PA Department of Human Services, Medical Assistance Bulletin 99-23-08 (Aug. 2, 2023), p. 2-4.  (Accessed Jan. 2024).

OMHSAS shall issue a bulletin providing additional detail about the use of audio-only services. Audio-only services can only be provided when clinically appropriate and the individual served does not have access to video capability or for an urgent medical situation. The use of audio-only service delivery must be consistent with Pennsylvania regulations and federal requirements

SOURCE: Mental Health and Substance Abuse Services, Interim Telehealth Guidance, March 30, 2023, (Accessed Jan. 2024).

The Department is opening the PT/Spec/POS combination 31/339 (Psychiatry)/02 to the following procedure codes and modifier combination, as the Department determined it is appropriate for this provider to perform these services. These procedure codes include the modifier FQ (audio only).

Certain services can be performed via audio-only (FQ modifier) and POS 10.

SOURCE: PA Department of Human Services, 2023 Evaluation and Management Fee Adjustments and Code Updates , Medical Assistance Bulletin 99-23-06, June 1, 2023 (Accessed Jan. 2024).

Audio-only refers to the delivery of behavioral health services at a distance using real-time, two-way interactive audio only transmission. Audio-only does not include text messaging, electronic mail messaging or facsimile (fax) transmissions. Providers may utilize audio-only when the individual served does not have access to video capability or for an urgent medical situation, provided that the use of audio-only is consistent with Pennsylvania regulations and federal requirements, including guidance by the Centers for Medicare & Medicaid Services with respect to Medicaid payment and the US Department of Health and Human Services Office of Civil Rights enforcement of HIPAA compliance.

Audio-only and text messages may also continue to be utilized for non-service activities, such as scheduling appointments.

SOURCE: PA Dept. of Human Services, Office of Mental Health and Substance Abuse Services Bulletin OMHSAS-22-02, p. 7, July 1, 2022.  (Accessed Jan. 2024).

In response to CMS’s change in policy, the Department is providing coverage and payment for interprofessional consultation services in the MA Program. Allowing direct payments for interprofessional consultations between providers enrolled in the MA Program improves access to specialty care, supports patient-centered care, and maximizes the capacity of the existing workforce by supporting the focus of medical practice towards managing a beneficiary’s chronic conditions. Services must be directly relevant to the beneficiary’s diagnosis and treatment, and the consulting practitioner must have specialized expertise in the particular health concerns of the beneficiary. Interprofessional consultation services are intended to expand access to specialty care and foster interdisciplinary input on beneficiary care. They are not intended to be a replacement for direct specialty care when such care is clinically indicated.

Technology used for interprofessional consultation services must be real-time interactive telecommunication technology. Asynchronous communication and applications, such as store and forward, may be utilized as a part of the synchronous interprofessional consultation, but by themselves do not meet the requirements for interprofessional consultations. Providers must remain informed on federal and state statutes, regulations, and guidance regarding use of technology to render services.

The MA Program will pay for interprofessional consultation services provided on behalf of a beneficiary between licensed and enrolled MA providers when clinically appropriate.  Interprofessional consultations occur between an initiating treating provider and a consulting provider to benefit the treatment of the beneficiary but without the beneficiary present.  See bulletins for codes eligible for interprofessional consultation services.

The treating provider enrolled in the MA Program who participates in an interprofessional consultation performed at the same time as an office visit is to bill using office visit procedure codes. The treating provider is to bill using procedure code 99452 when participating in a medical consultative discussion outside of an evaluation and management service, which can only be billed once every 14 days.

Consulting providers enrolled in the MA Program are to bill using procedure codes 99446, 99447, 99448, 99449, and 99451 when participating in a medical consultative discussion as the consulting provider. Consulting providers are not to bill for interprofessional consultation services if they have seen the beneficiary in the previous 14 days or if they plan to see the beneficiary in the next 14 days.

Providers who participate in an interprofessional consultation should bill with the POS codes identified in the attachment. Providers should not bill with POS 02 (telehealth provided other than in patient’s home) or POS 10 (telehealth provided in patient’s home) because these POS codes can only be utilized when the MA beneficiary is present.

SOURCE: PA Department of Human Services, Medical Assistance Bulletin Interprofessional Consultation Services, (Dec. 27, 2023) (Accessed Jan. 2024).

Outpatient Drug and Alcohol Clinic Services
Payment will not be made for the following types of services regardless of where or to whom they are provided:
  • Clinic visits, psychotherapy, diagnostic psychological evaluations, psychiatric evaluations and comprehensive medical evaluations conducted over the telephone, that is, any clinic service conducted over the telephone.

SOURCE:  PA 55 Code 1223.14 (Accessed Jan. 2024).

Payment will not be made for the following types of services regardless of where or to whom they are provided:
  • A covered psychiatric outpatient clinic, MMHT or partial hospitalization outpatient service conducted over the telephone.

SOURCE: PA 55 Code 1153.14. (Accessed Jan. 2024).

School-Based ACCESS Program Provider Handbook Mid-Year Update

The provider services log must indicate whether the service type is Direct: Telemedicine or Direct: In Person when documenting the service and how it was provided. The “Description of Service” section of the provider service paper log should be used to record details about the service provided, including verification consent was obtained prior to the start of any telemedicine session, whether any service disruptions or connectivity issues occurred during the service delivery and whether the service was delivered using telephone-only.

SOURCE:  PA Department of Human Services, School-Based ACCESS Program Provider Handbook Mid-Year Update, May 2, 2022, (Accessed Jan. 2024).

Last updated 01/22/2024

Live Video

POLICY

Services rendered via telehealth, including those delivered using audio-only telecommunication technology, must use technology that is two-way, real-time, and interactive between beneficiary and provider.

SOURCE: PA Department of Human Services, Medical Assistance Bulletin 99-23-08 (Aug. 2, 2023), p. 3.  (Accessed Jan. 2024).

Behavioral Health

Services delivered in the MA FFS delivery system through telehealth will be paid the same rate as if the services were delivered in-person.

MA providers in the MA FFS delivery system that provide services via telehealth should bill for services with a Place of Service (POS) 02 for telehealth provided in a location other than the home of the individual being served and (POS) 10 for telehealth provided in the home of the individual being served, unless instructed otherwise for specific services. Please consult the MA Fee Schedule for procedure codes that have the POS 02 or 10. For services delivered through audio-only, informational modifier code FQ should be used. Providers in the MA HC program must follow the billing instructions of the BH-MCO.

SOURCE: PA Department of Human Services, Office of Mental Health and Substance Abuse Services Bulletin OMHSAS-22-02, p. 8, July 1, 2022, (Accessed Jan. 2024).

In response to CMS’s change in policy, the Department is providing coverage and payment for interprofessional consultation services in the MA Program. Allowing direct payments for interprofessional consultations between providers enrolled in the MA Program improves access to specialty care, supports patient-centered care, and maximizes the capacity of the existing workforce by supporting the focus of medical practice towards managing a beneficiary’s chronic conditions. Services must be directly relevant to the beneficiary’s diagnosis and treatment, and the consulting practitioner must have specialized expertise in the particular health concerns of the beneficiary. Interprofessional consultation services are intended to expand access to specialty care and foster interdisciplinary input on beneficiary care. They are not intended to be a replacement for direct specialty care when such care is clinically indicated.

Technology used for interprofessional consultation services must be real-time interactive telecommunication technology. Asynchronous communication and applications, such as store and forward, may be utilized as a part of the synchronous interprofessional consultation, but by themselves do not meet the requirements for interprofessional consultations. Providers must remain informed on federal and state statutes, regulations, and guidance regarding use of technology to render services.

SOURCE: PA Department of Human Services, Medical Assistance Bulletin Interprofessional Consultation Services, (Dec. 27, 2023) (Accessed Jan. 2024).


ELIGIBLE SERVICES/SPECIALTIES

MA services in the FFS delivery system rendered via telehealth will be paid the same rate as if the services were rendered in person. MA managed care organizations (MCO) may, but are not required to, allow for the use of telehealth. MA MCOs may negotiate payment for services rendered via telehealth.  The MA Program will continue to pay for MA covered services rendered to beneficiaries via telehealth when clinically appropriate. Services rendered via telehealth must be provided according to the same standard of care as if delivered in-person.

SOURCE: PA Department of Human Services, Medical Assistance Bulletin 99-23-08 (Aug. 2, 2023), p. 3.  (Accessed Jan. 2024).

The Department is adding POS 10 (Telehealth Provided in a Patient’s Home) for the following procedure codes and procedure code and modifier combinations for all PT/Spec combinations as the Department determined telehealth is appropriate for the performance of these services. These procedure codes may include modifiers FP, GN (speech pathology), HD (pregnant/parenting women’s program), HQ (group therapy), TC, TJ (Childhood Nutrition Weight Management Services), TM (School-Based ACCESS Program), UA (audiology), UB (pricing), U3 (pricing), U4 (pricing), U5 (pricing), U6 (pricing), U7, U8 (pricing), U9 (pricing), 24 (unrelated E&M service by the same physician or other qualified health care professional during a postoperative period), 25 (significant, separate identifiable E&M service by the same physician or other qualified health care professional on the same day of the procedure or other service), 26, 27(multiple outpatient hospital E&M encounters on the same date), 57 (decision for surgery).

SOURCE: PA Department of Human Services, Medical Assistance Bulletin 99-23-09, 2023 Healthcare Common Procedure Coding System (HCPCS) Updates, Fee Adjustments, and Other Procedure Code Changes (Aug. 31, 2023), (Accessed Jan. 2024).

The Department added POS 10 (Telehealth Provided in a Patient’s Home) to procedure 96160 with the FP modifier for the following PT/Spec combinations as the Department determined telehealth is appropriate for the performance of these services

SOURCE: PA Department of Human Services, Medical Assistance Bulletin, Updates to the Family Planning Services Program Fee Schedule (Sept. 1, 2023), (Accessed Jan. 2024).

The Department added Place of Service (POS) 10 (Telehealth Provided in a Patient’s Home) to the following procedure codes (see bulletin) as the Department determined telehealth was appropriate for the performance of services.

SOURCE: PA Department of Human Services, 2023 Medical Assistance Program Dental Fee Schedule Update and Dental Provider Handbook Update (Sept. 5, 2023), (Accessed Jan. 2024).

Additionally, the MA Program now utilizes two Place of Service (POS) codes to identify when services are rendered via telehealth – POS 02 (Telehealth Provided Other than in a Patient’s Home) and POS 10 (Telehealth Provided in a Patient’s Home). As a result of revisions announced in the 2023 HCPCS Update bulletin, the Department added POS 10 to all CNWMS-related procedure codes on the MA Program Fee Schedule. In conjunction with these updates, the GT Modifier was removed from procedure code T1015. Therefore, the chart attached to this bulletin has been updated to reflect the POS code changes for CNWMS rendered via telehealth.

SOURCE: PA Department of Human Services, 2023 Updates to Childhood Nutrition and Weight Management Services (Sept. 5, 2023), (Accessed Jan. 2024).

For FQHCs & RHCs

Telepsychiatry Services – Only applicable to Behavioral Health Managed Care delivery system claims and not fee-for-service delivery. Mental health services are provided through the use of approved electronic communication and information technologies to provide or support clinical psychiatric care at a distance. Qualifying telepsych services utilize real-time, two-way interactive audio-video transmission, and do not include a telephone conversation, electronic mail message, or facsimile transmission between a health care practitioner and a service recipient, or a consultation between two healthcare practitioners, although these activities may support the delivery of telepsych services. Telepsych services require service providers to have a service description approved by the Office of Mental Health and Substance Abuse Services (OMHSAS) and deliverable through the managed care option.

SOURCE: PA PROMISe, 837 Professional/CMS-1500 Claim Form, Provider Handbook, Appendix E – FQHC/RHC. p. 10 (Apr. 22, 2014). (Accessed Jan. 2024).

Limited English Proficiency

All recipients of federal funding, including the MA Program, must offer and make available interpretation services to beneficiaries with limited English proficiency, visual limitations, and/or auditory limitations. Providers who elect to render services through telehealth (telemedicine) must have policies in place to make language assistance services, such as oral interpretation, including sign language interpretation, and written translation, available to beneficiaries being served via telemedicine.

SOURCE: PA Department of Human Services, Medical Assistance Bulletin 99-23-08 (Aug. 2, 2023), p. 3-4.   & PA Department of Human Services, Office of Mental Health and Substance Abuse Services Bulletin OMHSAS-22-02, p. 6, July 1, 2022, (Accessed Jan. 2024).

Some behavioral health services may be appropriate to be provided primarily through telehealth, while other services will require ongoing in-person delivery for a significant portion of or all of the services. Providers and practitioners should carefully consider the clinical appropriateness of telehealth delivery for such services, including, but not limited to: Partial Hospitalization, Intensive Behavioral Health Services (IBHS), Family Based Mental Health, Assertive Community Treatment (ACT), or for beneficiaries in a residential facility or inpatient setting.

Providers in the MA HC program must follow the billing instructions of the BH-MCO.

SOURCE: PA Department of Human Services, Office of Mental Health and Substance Abuse Services Bulletin OMHSAS-22-02, p. 5, & 8, July 1, 2022, (Accessed Jan. 2024).

Teledentistry may be used by dentists, FQHCs, and RHCs to provide dental services to MA beneficiaries. The provider must be licensed in Pennsylvania and enrolled in the MA Program.

FQHCs and RHCs are to continue billing procedure code T1015 with the U9 modifier to indicate dental visits/encounters rendered via teledentistry to patients. FQHCs and RHCs should no longer use the GT modifier, as previously directed in Provider Quick Tip # 237, “Teledentistry Guidelines Related to COVID-19 for Dentists, Federally Qualified Health Centers and Rural Health Clinics” (https://www.dhs.pa.gov/providers/Quick­ Tips/Documents/PROMISeQuickTip237.pdf), and must begin using POS 02 as of May 2, 2022.

Teledentistry visits must be provided according to the same standard of care as if delivered in-person.

SOURCE: PA Department of Human Services, Medical Assistance Bulletin, Teledentistry Guidelines and Dental Fee Schedule Updates (May 2, 2022), p. 2-3. (Accessed Jan. 2024).

Additionally, vaccine counseling only visits may be provided via telemedicine with the use of Place of Service 02. For further information on MA Program guidelines for telemedicine see MA Bulletin 99-21-06, titled, “Guidelines for the Delivery of Physical Health Services via Telemedicine”

SOURCE: PA Department of Human Services, Medical Assistance Bulletin, Vaccine Counseling Only Visits for Beneficiaries Under 21 (May 30, 2023). (Accessed Jan. 2024).

I am a licensed Medical Assistance enrolled provider – will I continue to be reimbursed for physical health and behavioral health services delivered via telemedicine after October 31, 2022, when the suspended regulations expire?

The MA program will continue to reimburse both physical health and behavioral services delivered via telemedicine after October 31, 2022

Act 98 of 2022 permanently abrogated the two DHS regulations that prohibited payment specifically for audio-only telehealth service delivery—outpatient psychiatric clinics (which includes Mobile Mental Health Treatment and Partial Hospitalization Outpatient Services) under 55 Pa. Code § 1153.14(1), and Outpatient Drug & Alcohol Clinic Services under 55 Pa. Code § 1223.14(2).

Will there be a change in MA reimbursements for physical health or behavioral health services provided via telemedicine after May 11, 2023, or will I continue to be reimbursed at the same level for services provided regardless of how they are delivered?

DHS will continue to reimburse services delivered via telemedicine at the same rates as in-person delivered services for the MA Fee-for-Service (FFS) Program.

MA MCOs may negotiate payment for services rendered via telemedicine in the MA HealthChoices managed care program. To date, all MCOs are reimbursing for services delivered via telemedicine.  DHS cannot require the MCOs to have payment parity for services delivered via telemedicine without a CMS approved directed payment, as MCOs are allowed to negotiate rates.

SOURCE: PA Dept. of State, Professional Licensing, Telemedicine FAQs. (Accessed Jan. 2024).

School-Based ACCESS Program Provider Handbook Mid-Year Update

Delivery Method: While DHS has historically expressed its intent for MA services to be rendered to MA beneficiaries in person, some services may be delivered using telemedicine. Telemedicine is the use of telecommunications technologies to deliver services when the provider and the student are not in the same place at the same time. As outlined within this section by provider type, services rendered via telemedicine must be provided according to the same standard of care as if delivered in person. MA coverage and payment for services provided via telemedicine is separate and apart from authorization to engage in telemedicine from a licensing standpoint. All providers using telemedicine are advised to remain informed on all federal and state statutes, regulations and guidance regarding telemedicine.

SOURCE:  PA Department of Human Services, School-Based ACCESS Program Provider Handbook Mid-Year Update, May 2, 2022, (Accessed Jan. 2024).

The MA Program will pay for interprofessional consultation services provided on behalf of a beneficiary between licensed and enrolled MA providers when clinically appropriate.  Interprofessional consultations occur between an initiating treating provider and a consulting provider to benefit the treatment of the beneficiary but without the beneficiary present.  See bulletins for codes eligible for interprofessional consultation services.

The treating provider enrolled in the MA Program who participates in an interprofessional consultation performed at the same time as an office visit is to bill using office visit procedure codes. The treating provider is to bill using procedure code 99452 when participating in a medical consultative discussion outside of an evaluation and management service, which can only be billed once every 14 days.

Consulting providers enrolled in the MA Program are to bill using procedure codes 99446, 99447, 99448, 99449, and 99451 when participating in a medical consultative discussion as the consulting provider. Consulting providers are not to bill for interprofessional consultation services if they have seen the beneficiary in the previous 14 days or if they plan to see the beneficiary in the next 14 days.

Providers who participate in an interprofessional consultation should bill with the POS codes identified in the attachment. Providers should not bill with POS 02 (telehealth provided other than in patient’s home) or POS 10 (telehealth provided in patient’s home) because these POS codes can only be utilized when the MA beneficiary is present.

SOURCE: PA Department of Human Services, Medical Assistance Bulletin Interprofessional Consultation Services, (Dec. 27, 2023) (Accessed Jan. 2024).


ELIGIBLE PROVIDERS

Does the Department of Human Services allow Medical Assistance enrolled providers to bill for services delivered using telemedicine?

Yes. The Department of Human Services (DHS) has allowed services to be provided via telemedicine since 2007 and has allowed MA-enrolled providers to bill MA for these services. MA-enrolled providers should consult the Office of Medical Assistance Programs (OMAP) and Office of Mental Health and Substance Abuse Services (OMHSAS) telemedicine bulletins for more information on service delivery and billing (see question 7 below). DHS will continue allowing physical health and behavioral health services to be provided via telemedicine delivery and will continue to reimburse at the same rate as services delivered in person in the fee-for-service program. Managed Care Organizations (MCOs) may, but are not required to, allow for the use of telemedicine. MA MCOs may negotiate payment for services rendered via telemedicine.

SOURCE: PA Dept. of State, Professional Licensing, Telemedicine FAQs. (Accessed Jan. 2024).

Licensed Practitioners

Licensed practitioners may provide behavioral health services through telehealth that are within their scope of practice. Practitioners should exercise sound clinical judgement and should not provide services through telehealth when it is clinically not appropriate to do so. Services delivered using telehealth must comply with all service specific and payment requirements for the service.

Provider Agencies

Provider agencies using behavioral health staff who are unlicensed, including, but not limited to, unlicensed master’s level therapists, mental health targeted case managers, mental health certified peer support specialists, certified recovery specialists, and drug and alcohol counselors (as defined in 28 Pa. Code §704.7(b)), and licensed practitioners may provide services using telehealth. Provider agencies should establish and enforce policies for assessing when it is clinically appropriate to deliver services through telehealth. Services delivered using telehealth must comply with all service specific and payment requirements for the service.

SOURCE: PA Department of Human Services, Office of Mental Health and Substance Abuse Services Bulletin OMHSAS-22-02, p. 3, July 1, 2022, (Accessed Jan. 2024).

The Department is opening Provider Type (PT)/Specialty (Spec) combination 08 (Clinic)/110 (Psychiatric Outpatient Clinic) in Place of Service (POS) 02 (Telemedicine), 10 (Telehealth provided in the home of the individual being served) and 49 (Independent Clinic) and PT/Spec combination 08/184 (Outpatient Drug and Alcohol Clinic) in POS 02, 10, 12 (Home) and 57 (Non-Residential Substance Abuse Treatment Facility) for the following outpatient and other office evaluation and management procedure codes as a result of clinical review.

SOURCE: PA Department of Human Services, Medical Assistance Bulletin, Addition of Behavioral Health Providers to Certain Procedure Codes and other Procedure Code Changes (Aug. 2, 2022). (Accessed Jan. 2024).

Telepsych services delivered in FQHCs and RHCs require providers to have a service description approved by the Office of Mental Health and Substance Abuse Services and the service must be deliverable through the managed care option. Telepsych services are limited to psychologists and psychiatrists.

SOURCE:  PA PROMISe, 837 Professional/CMS-1500 Claim Form, Provider Handbook, Appendix E – FQHC/RHC. p. 10 (Apr. 22, 2014). (Accessed Jan. 2024).

Teledentistry may be used by dentists, FQHCs, and RHCs to provide dental services to MA beneficiaries. The provider must be licensed in Pennsylvania and enrolled in the MA Program.

FQHCs and RHCs are to continue billing procedure code T1015 with the U9 modifier to indicate dental visits/encounters rendered via teledentistry to patients. FQHCs and RHCs should no longer use the GT modifier, as previously directed in Provider Quick Tip # 237, “Teledentistry Guidelines Related to COVID-19 for Dentists, Federally Qualified Health Centers and Rural Health Clinics” (https://www.dhs.pa.gov/providers/Quick­ Tips/Documents/PROMISeQuickTip237.pdf), and must begin using POS 02 as of May 2, 2022.

Teledentistry visits must be provided according to the same standard of care as if delivered in-person.

SOURCE: PA Department of Human Services, Medical Assistance Bulletin, Teledentistry Guidelines and Dental Fee Schedule Updates (May 2, 2022). (Accessed Jan. 2024).

School-Based ACCESS Program Provider Handbook Mid-Year Update

The provider services log must indicate whether the service type is Direct: Telemedicine or Direct: In Person when documenting the service and how it was provided. The “Description of Service” section of the provider service paper log should be used to record details about the service provided, including verification consent was obtained prior to the start of any telemedicine session, whether any service disruptions or connectivity issues occurred during the service delivery and whether the service was delivered using telephone-only.

SOURCE:  PA Department of Human Services, School-Based ACCESS Program Provider Handbook Mid-Year Update, May 2, 2022, (Accessed Jan. 2024).


ELIGIBLE SITES

The originating site is where the beneficiary is located at the time the MA covered service is rendered to them via telehealth. The originating site can be, but is not limited to, the beneficiary’s home, a provider’s office, clinic, nursing facility, or other medical facility site. When the originating site is a provider’s office, clinic, nursing facility or other medical facility, staff at the originating site should be trained to assist beneficiaries with the use of the telehealth equipment and available to provide in-person clinical intervention, if needed. Providers should obtain the location of the beneficiary at the time each service is rendered via telehealth should there be a need for emergency medical services.

Providers are to use POS 02 when billing for services provided via telehealth technology to beneficiaries located in a location other than their home. Providers are to use POS 10 to identify when services via telehealth technology are provided in the home of the individual being served.

SOURCE: PA Department of Human Services, Medical Assistance Bulletin 99-23-08 (Aug. 2, 2023), p. 4-5.  (Accessed Jan. 2024).

The originating site is the setting at which an individual receives behavioral health services using telehealth delivery. When telehealth is being used to deliver services to an individual who is at a clinic, residential treatment setting, or facility setting, the originating site must have staff trained in telehealth equipment and protocols to provide operating support. In addition, the clinic or facility must have staff trained and available to provide clinical intervention in-person, if a need arises.

Services delivered through telehealth may also be provided outside of a clinic, residential treatment setting or facility setting. With the consent of the individual served and when clinically appropriate, licensed practitioners and provider agencies may deliver services through telehealth to individuals in community settings, such as to an individual located in their home. The licensed practitioner or provider agency must have policies in place to address emergency situations, such as a risk of harm to self or others.

Prior to delivering services through telehealth, providers or practitioners should provide information to the individual receiving services that supports the delivery of quality services. At a minimum, information should address the importance of the individual being in a private location, preventing interruptions and distractions such as from children or other family members, visitors in the household and from other communication or bandwidth reducing devices. When services are being provided to a child, youth or young adult, consideration should also be given to how much caregiver involvement will be needed during the appointment.

SOURCE: PA Department of Human Services, Office of Mental Health and Substance Abuse Services Bulletin OMHSAS-22-02, p. 4, & 7, July 1, 2022, (Accessed Jan. 2024).

The Department is opening Provider Type (PT)/Specialty (Spec) combination 08 (Clinic)/110 (Psychiatric Outpatient Clinic) in Place of Service (POS) 02 (Telemedicine), 10 (Telehealth provided in the home of the individual being served) and 49 (Independent Clinic) and PT/Spec combination 08/184 (Outpatient Drug and Alcohol Clinic) in POS 02, 10, 12 (Home) and 57 (Non-Residential Substance Abuse Treatment Facility) for the following outpatient and other office evaluation and management procedure codes as a result of clinical review.

SOURCE: PA Department of Human Services, Medical Assistance Bulletin, Addition of Behavioral Health Providers to Certain Procedure Codes and other Procedure Code Changes (Aug. 2, 2022). (Accessed Jan. 2024).

Additionally, vaccine counseling only visits may be provided via telemedicine with the use of Place of Service 02. For further information on MA Program guidelines for telemedicine see MA Bulletin 99-21-06, titled, “Guidelines for the Delivery of Physical Health Services via Telemedicine”

SOURCE: PA Department of Human Services, Medical Assistance Bulletin, Vaccine Counseling Only Visits for Beneficiaries Under 21 (May 30, 2023). (Accessed Jan. 2024).

Teledentistry may be used by dentists, FQHCs, and RHCs to provide dental services to MA beneficiaries. The provider must be licensed in Pennsylvania and enrolled in the MA Program.

FQHCs and RHCs are to continue billing procedure code T1015 with the U9 modifier to indicate dental visits/encounters rendered via teledentistry to patients. FQHCs and RHCs should no longer use the GT modifier, as previously directed in Provider Quick Tip # 237, “Teledentistry Guidelines Related to COVID-19 for Dentists, Federally Qualified Health Centers and Rural Health Clinics” (https://www.dhs.pa.gov/providers/Quick­ Tips/Documents/PROMISeQuickTip237.pdf), and must begin using POS 02 as of May 2, 2022.

Teledentistry visits must be provided according to the same standard of care as if delivered in-person.

SOURCE: PA Department of Human Services, Medical Assistance Bulletin, Teledentistry Guidelines and Dental Fee Schedule Updates (May 2, 2022). (Accessed Jan. 2024).

POS Code 02 (Telemedicine) and 10 (telehealth at home) is listed as reimbursable for specific CPT/HCPCS codes in several bulletins, including a bulletin for behavioral health providers,

School-Based ACCESS Program Provider Handbook Mid-Year Update

POS 02 is to be used when services are rendered via telemedicine for certain services (see bulletin).

Nursing Services/Personal Care Services: Services delivered through telemedicine are NOT compensable.

SOURCE:  PA Department of Human Services, School-Based ACCESS Program Provider Handbook Mid-Year Update, May 2, 2022, (Accessed Jan. 2024).


GEOGRAPHIC LIMITS

Services may be provided using telehealth to Pennsylvania residents who are temporarily out of the state as long as the individual continues to meet eligibility for the Pennsylvania MA Program, and the provider or licensed practitioner has received authorization to practice in the state or territory where the individual will be temporarily located.

SOURCE: PA Department of Human Services, Medical Assistance Bulletin 99-23-08 (Aug. 2, 2023), p. 5.  (Accessed Jan. 2024).

Access to Services Delivered In-Person

In the managed care delivery system, the HealthChoices Primary Contractor must ensure that provider agencies and licensed practitioners who deliver services through telehealth within their service area can arrange for services to be delivered in-person as clinically appropriate or requested by the individual served. HealthChoices Primary Contractors must ensure that each contracted provider agency and licensed practitioner meets one of the two following criteria:

  • The provider agency or licensed practitioner maintains a physical location in Pennsylvania within 60 minutes or 45 miles (whichever is greater) of the area served with appropriate licensure for all services provided through telehealth; or
  • The provider agency or licensed practitioner maintains a physical location in a state bordering Pennsylvania, located within 60 minutes or 45 miles (whichever is greater) of the area served in Pennsylvania, maintains licensure in the state where they are physically located for all services provided through telehealth and is enrolled with the Pennsylvania MA program.

The HealthChoices Primary Contractor may apply for an exception to allow licensed practitioners and/or provider agencies beyond the 60 minute/45 mile restriction to deliver services through telehealth in their service area when supporting additional access to services or in circumstances when the licensed practitioner and/or provider agency is needed to meet the cultural, racial/ethnic, sexual/affectional or linguistic needs of individual(s) served or in instances when the licensed practitioner serves less than 5 individuals. An exception request can be submitted to the OMHSAS Telehealth Resource Account using the form in Attachment B.

SOURCE: PA Department of Human Services, Office of Mental Health and Substance Abuse Services Bulletin OMHSAS-22-02, July 1, 2022, (Accessed Jan. 2024).


FACILITY/TRANSMISSION FEE

When the beneficiary accesses services at an enrolled originating site, the provider serving as the originating site may bill for the technology service using the telehealth originating site procedure code Q3014 only. The MA fee for Q3014 is $15.72. MA Providers may not bill procedure code Q3014 if another MA covered service is provided at the originating site. Providers may access the online version of the MA Program Fee Schedule at the Department’s website at: https://www.dhs.pa.gov/providers/Providers/Pages/Health%20Care%20for%20Providers/MAFee-Schedule.aspx.

SOURCE: PA Department of Human Services, Office of Mental Health and Substance Abuse Services Bulletin OMHSAS-22-02, July 1, 2022, (Accessed Jan. 2024).

Last updated 01/22/2024

Miscellaneous

Technology Requirements:

Technology used for telehealth, whether fixed or mobile, should be capable of presenting sound and image in real-time and without delay. Telehealth equipment should clearly display the practitioners’ and participants’ faces to facilitate clinical interactions. The telehealth equipment must meet all state and federal requirements for the transmission or security of health information and comply with the Health Insurance Portability and Accountability Act (HIPAA).

Delivery of Services:

The medical record for the individual served must indicate each time a service is provided using telehealth including the receipt of informed consent prior to the start of the session, start time of service and end time of service. Additionally, if the individual served or their legal guardian, as applicable, consents to the recording of a telehealth service, documentation of consent must be included in the medical record.

Provider Policies:

  • Providers using telehealth must maintain written policies for the operation and use of telehealth equipment. Policies must include the provision of periodic staff training to ensure telehealth is provided in accordance with the guidance in this bulletin as well as the provider’s established patient care standards.
  • Providers must maintain a written policy detailing a contingency plan for transmission failure or other technical difficulties that render the behavioral health service undeliverable. Contingency plans should describe how the plan will be communicated to individuals receiving services.
  • Prior to delivering services through telehealth, providers or practitioners should provide information to the individual receiving services that supports the delivery of quality services. At a minimum, information should address the importance of the individual being in a private location, preventing interruptions and distractions such as from children or other family members, visitors in the household and from other communication or bandwidth reducing devices. When services are being provided to a child, youth or young adult, consideration should also be given to how much caregiver involvement will be needed during the appointment.

Determining Appropriateness for Telehealth Delivery of Services

Licensed practitioners and provider agencies delivering services through telehealth must have policies that ensure that services are delivered using telehealth only when it is clinically appropriate to do so and that licensed practitioners are complying with standards of practice set by their licensing board for telehealth where applicable.

Factors to consider include, but are not limited to:

  • The preference of the individual served and/or the preference of parents/guardians
  • Whether there is an established relationship with the service provider and the length of time the individual has been in treatment
  • Level of acuity needed for care
  • Risk of harm to self or others
  • Age of a minor child
  • Ability of the individual served to communicate, either independently or with accommodation such as an interpreter or electronic communication device
  • Any barriers to in-person service delivery for the individual
  • Access to technology of the individual served
  • Whether privacy for the individual served could be maintained if services are delivered using telehealth
  • Whether the service relies on social cueing and fluency

The preference of the individual served and their legal guardian(s), as applicable, should be given high priority when making determinations of the appropriateness of the telehealth delivery. However, no service should be provided through telehealth when, in the best clinical judgement of the licensed practitioner, it is not clinically appropriate. When the use of telehealth is not clinically appropriate, the licensed practitioner or provider agency must offer the services in-person. If the individual disagrees with the clinical determination, the licensed practitioner or provider agency may refer the individual to other in-network providers or the managed care organization.

Guidance specific to delivering children’s services through telehealth is included in Attachment A.

SOURCE:  PA Department of Human Services, Office of Mental Health and Substance Abuse Services Bulletin OMHSAS-22-02, pgs. 4-5 & 7-8, July 1, 2022, (Accessed Jan. 2024).

Pennsylvania Residents Temporarily Out-of-State

Behavioral Health Services may be provided using telehealth to meet the behavioral healthcare needs of Pennsylvania residents who are temporarily out of the state as long as the delivery of services out-of-state is consistent with the authorization for services and treatment plan, the individual continues to meet eligibility for the Pennsylvania MA Program, and the Pennsylvania provider agency or licensed practitioner has received authorization to practice in the state or territory where the individual will be temporarily located.

SOURCE:  PA Department of Human Services, Office of Mental Health and Substance Abuse Services Bulletin OMHSAS-22-02, July 1, 2022, (Accessed Jan. 2024).

Technology Requirements

Providers should fully document the services rendered and the telecommunication technology used to render the service in the MA beneficiary’s medical record. If the service was rendered using audio-only technology, providers are to document that the services were rendered using audio-only technology and the reason audio/video technology could not be used.

Technology used for telehealth, whether fixed or mobile, should be capable of presenting sound and image in real-time and without delay. The telehealth equipment should clearly display the rendering practitioner’s and participant’s face to facilitate clinical interactions and must meet all state and federal requirements for the transmission and security of health information, including HIPAA.

Audio-only telecommunications technology may be used when the beneficiary does not have video capability or for an urgent medical situation, if consistent with state and federal law. Providers must assure the privacy of the beneficiary receiving services and comply with HIPAA and all other federal and state laws governing confidentiality, privacy, and consent. Public facing video communication applications should not be used to render services via telehealth.

Telehealth does not include asynchronous or “store and forward” technology such as facsimile machines, electronic mail systems, or remote patient monitoring devices. While asynchronous applications are not considered telemedicine in the MA Program, they may be utilized as part of a MA covered service, such as a laboratory service, x-ray service or physician service. Telehealth also does not include text messages, although text messages and telephone may continue to be utilized for non-service activities, such as scheduling appointments.

SOURCE: PA Department of Human Services, Medical Assistance Bulletin 99-23-08, Aug. 2, 2023, p. 3-4, (Accessed Jan. 2024).

Guidelines for Telehealth Service Delivery for Children and Youth

The following guidelines are recommended best practices. When delivering services through telehealth, licensed practitioners and provider agencies should ensure that, regardless of age, each child or youth has sufficient caregiver support to engage effectively in services.

  • When services are being delivered through telehealth to children 3 to 5 years old, each child should have a caregiver participate during the provision of services.
  • When services are being delivered through telehealth to children 6 to 9 years old, a caregiver should observe each child during provision of services.
  • When services are being delivered through telehealth to children ages 10 to 13 years old, any child that may need a caregiver during the provision of services should have a caregiver available.
  • When services are being delivered through telehealth to youth 14 years old to 18 years old, any youth that may need a caregiver during the provision of services should have a caregiver available.
  • All children or youth that participate in services through telehealth delivery should have the ability to communicate, either independently or with accommodation such as an interpreter or electronic communication device.

SOURCE: PA Department of Human Services, Office of Mental Health and Substance Abuse Bulletin, OMHSAS 22-02, Attachment A Guidelines for Telehealth Service Delivery for Children and Youth. (Accessed Jan. 2024).

Last updated 09/11/2023

Out of State Providers

Out-of-state licensed practitioners who provide treatment through telehealth to individuals in Pennsylvania through the MA program must meet the licensing requirements established by the Pennsylvania Department of State. In order to receive payment for services to beneficiaries in the FFS delivery system, practitioners must be enrolled in the MA Program. Practitioners seeking to provide services to beneficiaries in the managed care delivery system should contact the appropriate Managed Care Organization for its enrollment processes. Practitioners are also advised to consult with their professional liability insurance carrier regarding provision of services in other jurisdictions.

SOURCE: PA Department of Human Services, Office of Mental Health and Substance Abuse Services Bulletin OMHSAS-22-02, p. 3, July 1, 2022, (Accessed Sept. 2023).

Out-of-state licensed practitioners who render services via telehealth to individuals in Pennsylvania through the MA Program must meet the licensing requirements established by the Pennsylvania Department of State. In order to receive payment for services to beneficiaries in the FFS delivery system, practitioners must be enrolled in the MA Program.

SOURCE: PA Department of Human Services, Medical Assistance Bulletin 99-23-08, p. 5, (Aug. 2, 2023) (Accessed Sept. 2023).

Out-of-state licensed practitioners who participate in an interprofessional consultation service for a beneficiary must meet the licensing requirements established by the Pennsylvania Department of State. Providers must be enrolled in the MA Program to receive payment for services to beneficiaries in the FFS delivery system.

SOURCE: PA Department of Human Services, Medical Assistance Bulletin Interprofessional Consultation Services, (Dec. 27, 2023) (Accessed Jan. 2024).

See Miscellaneous section for residence temporarily out-of-state.

Last updated 01/22/2024

Overview

Under bulletins from the Office of Mental Health and Substance Abuse Services and PA Medical Assistance, they now offer live video reimbursement to a wide range of licensed providers, and patient locations, and audio-only in situations when the beneficiary does not have video capability or an urgent medical situation.   PA Medicaid does not consider store-and-forward or remote patient monitoring to fall under the definition of telemedicine.  Reimbursement for interprofessional consultation services were also recently added though store-and-forward may only be utilized as part of the synchronous consultation.

Last updated 01/22/2024

Remote Patient Monitoring

POLICY

Telehealth, for purposes of MA Program payment, does not include asynchronous or store and forward technology or facsimile machines, electronic mail systems or remote patient monitoring devices. However, these technologies may be utilized as a part of the provision of a MA covered service.

SOURCE: PA Department of Human Services, Medical Assistance Bulletin 99-23-08, p. 2-3, Aug. 2, 2023 (Accessed Jan. 2024).


CONDITIONS

PA Medicaid pays for some continuous glucose monitoring products with prior authorization.

SOURCE:  PA Department of Human Services, Medical Assistance Bulletin Prior Authorization of Continuous Glucose Monitoring Products – Pharmacy Services, Jan. 8, 2024, (Accessed Jan. 2024).


PROVIDER LIMITATIONS

No Reference Found


OTHER RESTRICTIONS

No Reference Found

Last updated 01/22/2024

Store and Forward

POLICY

Telehealth does not include asynchronous or store and forward technology such as facsimile machines, electronic mail systems, or remote patient monitoring devices. While asynchronous applications are not considered telehealth in the MA Program, they may be utilized as part of a MA covered service, such as a laboratory service, x-ray service or physician service. Telehealth also does not include text messages, although text messages and telephone may continue to be utilized for non-service activities, such as scheduling appointments.

SOURCE: PA Department of Human Services, Medical Assistance Bulletin 99-23-08, p. 4, Aug. 2, 2023 (Accessed Jan. 2024).

In response to CMS’s change in policy, the Department is providing coverage and payment for interprofessional consultation services in the MA Program. Allowing direct payments for interprofessional consultations between providers enrolled in the MA Program improves access to specialty care, supports patient-centered care, and maximizes the capacity of the existing workforce by supporting the focus of medical practice towards managing a beneficiary’s chronic conditions. Services must be directly relevant to the beneficiary’s diagnosis and treatment, and the consulting practitioner must have specialized expertise in the particular health concerns of the beneficiary. Interprofessional consultation services are intended to expand access to specialty care and foster interdisciplinary input on beneficiary care. They are not intended to be a replacement for direct specialty care when such care is clinically indicated.

Technology used for interprofessional consultation services must be real-time interactive telecommunication technology. Asynchronous communication and applications, such as store and forward, may be utilized as a part of the synchronous interprofessional consultation, but by themselves do not meet the requirements for interprofessional consultations. Providers must remain informed on federal and state statutes, regulations, and guidance regarding use of technology to render services.

SOURCE: PA Department of Human Services, Medical Assistance Bulletin Interprofessional Consultation Services, (Dec. 27, 2023) (Accessed Jan. 2024).


ELIGIBLE SERVICES/SPECIALTIES

The MA Program will pay for interprofessional consultation services provided on behalf of a beneficiary between licensed and enrolled MA providers when clinically appropriate.  Interprofessional consultations occur between an initiating treating provider and a consulting provider to benefit the treatment of the beneficiary but without the beneficiary present.  See bulletins for codes eligible for interprofessional consultation services.

The treating provider enrolled in the MA Program who participates in an interprofessional consultation performed at the same time as an office visit is to bill using office visit procedure codes. The treating provider is to bill using procedure code 99452 when participating in a medical consultative discussion outside of an evaluation and management service, which can only be billed once every 14 days.

Consulting providers enrolled in the MA Program are to bill using procedure codes 99446, 99447, 99448, 99449, and 99451 when participating in a medical consultative discussion as the consulting provider. Consulting providers are not to bill for interprofessional consultation services if they have seen the beneficiary in the previous 14 days or if they plan to see the beneficiary in the next 14 days.

Providers who participate in an interprofessional consultation should bill with the POS codes identified in the attachment. Providers should not bill with POS 02 (telehealth provided other than in patient’s home) or POS 10 (telehealth provided in patient’s home) because these POS codes can only be utilized when the MA beneficiary is present.

SOURCE: PA Department of Human Services, Medical Assistance Bulletin Interprofessional Consultation Services, (Dec. 27, 2023) (Accessed Jan. 2024).


GEOGRAPHIC LIMITS

No Reference Found


TRANSMISSION FEE

No Reference Found

Last updated 01/22/2024

Cross State Licensing

Pennsylvania issues extraterritorial licenses that allow practice in Pennsylvania to physicians residing or practicing with unrestricted licenses in an adjoining state, near the Pennsylvania boundary, and whose practice extends into Pennsylvania.

Pennsylvania bases the granting of this license on the availability of medical care in the area involved, and whether the adjoining state extends similar privileges to Pennsylvania physicians.

SOURCE: PA Statutes Annotated, Title 63 Sec. 422.34(a) and (c)(2). (Accessed Jan. 2024).

How will the use of telemedicine by out-of-state practitioners be impact?

As was the case prior to the pandemic, practitioners wishing to provide services to individuals in Pennsylvania need to be licensed in Pennsylvania in order to practice in Pennsylvania. This holds true whether the provision of services occurs in person or via an electronic interaction such as a telehealth consultation. Practitioners who are not licensed in Pennsylvania and wish to provide services to individuals in Pennsylvania via telemedicine or otherwise may apply for licensure here:  https://www.pals.pa.gov

SOURCE: PA Dept. of State, Professional Licensing, Telemedicine FAQ.  (Accessed Jan. 2024).

Last updated 01/22/2024

Definitions

Telemedicine is a way to provide health services virtually, such as through video conferencing or over the phone. In Pennsylvania, Medical Assistance (MA) enrolled providers have been permitted to provide certain physical health and behavioral health services virtually since 2007 and 2011, respectively, but the option was not widely used until many providers shifted to deliver services via telemedicine during the COVID-19 pandemic. Similarly, commercial health insurance plans may have had individual policies allowing for reimbursement for services provided via telemedicine but there is no statute in Pennsylvania that explicitly authorizes or prohibits the use or disallowance of telemedicine in Pennsylvania.

SOURCE: PA Dept. of State, Professional Licensing, Telemedicine FAQs. (Accessed Jan. 2024).

Last updated 01/22/2024

Licensure Compacts

Member of the Interstate Medical Licensure Compact.

SOURCE: The IMLC. Interstate Medical Licensure Compact. (Accessed Jan. 2024).

Member of Interjurisdictional Psychology Compact.

SOURCE: PSYPACT, Map, (Accessed Jan. 2024).

Member of Nurses Licensure Compact.

SOURCE:  NCSBN, Nurse Licensure Compact, (Accessed Jan. 2024).

Member of Physical Therapy Compact.

SOURCE:  PT Compact, Compact Map, (Accessed Jan. 2024).

Member of the Emergency Medical Services Compact.

SOURCE: EMS Compact. (Accessed Jan. 2024).

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

Last updated 01/22/2024

Miscellaneous

No Reference Found

Last updated 01/22/2024

Online Prescribing

Medical Marijuana

Except as provided in subsection (b), a dispensary shall ensure that a physician or a pharmacist is available, either in person or by synchronous interaction, to verify patient certifications and to consult with patients and caregivers at all times during the hours the facility is open to dispense or to offer to dispense medical marijuana products to patients and caregivers.

If a dispensary is authorized to operate more than one facility under its permit, a physician assistant or a certified registered nurse practitioner may be available, either in person or by synchronous interaction, to verify patient certifications and to consult with patients and caregivers at each of the other locations instead of a physician or pharmacist. The physician, pharmacist, physician assistant or certified registered nurse practitioner may rotate coverage of the facilities, provided that a physician or pharmacist is always available, either in person or by synchronous interaction, at one of the facilities. Furthermore, no less than one dedicated medical professional must be present either, physically or by synchronous interaction, for each distinct dispensary facility location and shall not cover more than one dispensary facility location regardless of whether in-person coverage or synchronous interaction is used.

SOURCE: Rules and Regulations, Title 28, 1161a.25, (Accessed Jan. 2024).

See FAQ Number 13 on federal requirements for substance use disorder treatment and Medication Assisted Treatment.

SOURCE: PA Dept. of State, Professional Licensing, Telemedicine FAQs. (Accessed Jan. 2024).

Last updated 01/22/2024

Professional Board Standards

Does the Department of State allow licensed professionals to practice telemedicine in Pennsylvania?

Regarding licensed healthcare practitioners and the use of telemedicine, there is currently no statute in Pennsylvania that explicitly authorizes its use, nor one that explicitly prohibits it. This was true even before the pandemic. The purpose of the telemedicine waiver issued by the Department of State at the beginning of the COVID-19 disaster declaration was to address significant confusion and make it clear that licensees under the Department’s Bureau of Professional and Occupational Affairs (BPOA) health-licensing boards can provide services within their existing scopes of practice via telemedicine when appropriate, provided it is done according to accepted standards of care.

While providing telemedicine is permissible from a professional licensing standpoint, it is important to note that there may be additional issues to consider − such as the type of insurance coverage, insurance reimbursement policies, medical appropriateness, and the intersection of telemedicine services with existing facility licensing requirements that must be met by hospitals or other licensed health care facilities.

These additional considerations are not within the purview of the Department of State.  Rather, such issues fall within the jurisdiction of other federal and state agencies, such as the United States Department of Health and Human Services (HHS), the Centers for Medicare and Medicaid Services (CMS), the Pennsylvania Department of Human Services (DHS), the Pennsylvania Insurance Department, the Pennsylvania Department of Drug and Alcohol Programs (DDAP), and the Pennsylvania Department of Health (DOH).

SOURCE: PA Dept. of State, Professional Licensing, Telemedicine FAQs. (Accessed Jan. 2024).

Last updated 01/22/2024

Definition of Visit

An encounter is a face-to-face contact between a patient and the physician, dentist or mid-level practitioner who exercises independent judgment in the provision of health care services. Claims for encounters are prepared and submitted for payment according to the billing instructions outlined in the PA PROMISeTM Provider Handbook for the 837 Professional/CMS-1500 Claim Form. For a health service to be defined as an encounter, the provision of the health services must be recorded in the patient’s record.

See Appendix for complete list of qualifying encounters.

SOURCE: PA PROMISe Provider Handbook, Appendix E, FQHC/RHC (Accessed Jan. 2024).

Last updated 01/22/2024

Eligible Distant Site

Teledentistry may be used by dentists, FQHCs, and RHCs to provide dental services to MA beneficiaries. The provider must be licensed in Pennsylvania and enrolled in the MA Program.

FQHCs and RHCs are to continue billing procedure code T1015 with the U9 modifier to indicate dental visits/encounters rendered via teledentistry to patients. FQHCs and RHCs should no longer use the GT modifier, as previously directed in Provider Quick Tip # 237, “Teledentistry Guidelines Related to COVID-19 for Dentists, Federally Qualified Health Centers and Rural Health  Clinics”(https://www.dhs.pa.gov/providers/QuickTips/Documents/PROMISeQuickTip237.pdf), and must begin using POS 02 as of May 2, 2022.

Teledentistry visits must be provided according to the same standard of care as if delivered in-person.

SOURCE: PA Department of Human Services, Medical Assistance Bulletin, Teledentistry Guidelines and Dental Fee Schedule Updates (May 2, 2022). (Accessed Jan. 2024).

Telepsychiatry Services – Only applicable to Behavioral Health Managed Care delivery system claims and not fee-for-service delivery. Mental health services are provided through the use of approved electronic communication and information technologies to provide or support clinical psychiatric care at a distance. Qualifying telepsych services utilize real-time, two-way interactive audio-video transmission, and do not include a telephone conversation, electronic mail message, or facsimile transmission between a health care practitioner and a service recipient, or a consultation between two healthcare practitioners, although these activities may support the delivery of telepsych services. Telepsych services require service providers to have a service description approved by the Office of Mental Health and Substance Abuse Services (OMHSAS) and deliverable through the managed care option.

SOURCE: PA PROMISe, 837 Professional/CMS-1500 Claim Form, Provider Handbook, Appendix E – FQHC/RHC. p. 10 (Apr. 22, 2014). (Accessed Jan. 2024).

I work as a licensed professional at a Federally Qualified Health Center (FQHC). Will I be able to bill for services delivered via telemedicine after October 31, 2022?

Yes, as clarified in MA Bulletin 99-22-02 (NOTE: Bulletin 99-22-02 has been replaced by 99-23-08) telemedicine remains a mode of service delivery that providers can utilize.  Providers that are licensed by the Office of Mental Health and Substance Abuse Services should refer to bulletin OMHSAS-22-02 – Revised Guidelines for Delivery of BH Services Through Telehealth 7.1.22.pdf (pa.gov) when rendering the behavioral health services for which they are licensed.  In addition, DHS recently issued MA Bulletin 08-22-13, 27-22-07 related to tele dentistry services that is also relevant to FQHC providers that offer dental services.

SOURCE: PA Department of State, Frequently asked Questions About Telemedicine in Pennsylvania, (Accessed Jan. 2024).

See: PA Medicaid Live Video Distant Site

Last updated 01/22/2024

Eligible Originating Site

Not explicitly listed as originating site, however there is no restriction on eligible originating site, according to PA Dept. of Human Services Bulletin  99-23-08.

The originating site is where the beneficiary is located at the time the MA covered service is rendered to them via telehealth. The originating site can be, but is not limited to, the beneficiary’s home, a provider’s office, clinic, nursing facility, or other medical facility site. When the originating site is a provider’s office, clinic, nursing facility or other medical facility, staff at the originating site should be trained to assist beneficiaries with the use of the telehealth equipment and available to provide in-person clinical intervention, if needed. Providers should obtain the location of the beneficiary at the time each service is rendered via telehealth should there be a need for emergency medical services.

SOURCE: PA Department of Human Services, Medical Assistance  Bulletin 99-23-08 (Aug. 2, 2023), p. 4, (Accessed Jan. 2024).

Telepsych services delivered in FQHCs and RHCs require providers to have a service description approved by the Office of Mental Health and Substance Abuse Services and the service must be deliverable through the managed care option. Telepsych services are limited to psychologists and psychiatrists.

SOURCE:  PA PROMISe, 837 Professional/CMS-1500 Claim Form, Provider Handbook, Appendix E – FQHC/RHC. p. 10 (Apr. 22, 2014). (Accessed Jan. 2024).

See: PA Medicaid Live Video Eligible Sites.

Last updated 01/22/2024

Facility Fee

PA Medicaid reimburses a facility fee, however there isn’t an explicit indication of whether or not FQHCs are eligible for the fee.

See: PA Medicaid Live Video Facility/Transmission Fee

Last updated 01/22/2024

Home Eligible

An encounter may take place in the FQHC/RHC or at any other location in which project-supported activities are carried out. Examples of other locations include mobile vans, shelters, hospitals, patients’ homes, and schools.

SOURCE: PA PROMISe Provider Handbook pg. 11, Appendix E, FQHC/RHC   (Accessed Sept. 2023).

Last updated 01/22/2024

Modalities Allowed

Live Video

Telepsychiatry Services – Only applicable to Behavioral Health Managed Care delivery system claims and not fee-for-service delivery. Mental health services are provided through the use of approved electronic communication and information technologies to provide or support clinical psychiatric care at a distance. Qualifying telepsych services utilize real-time, two-way interactive audio-video transmission, and do not include a telephone conversation, electronic mail message, or facsimile transmission between a health care practitioner and a service recipient, or a consultation between two healthcare practitioners, although these activities may support the delivery of telepsych services. Telepsych services require service providers to have a service description approved by the Office of Mental Health and Substance Abuse Services (OMHSAS) and deliverable through the managed care option.

SOURCE: PA PROMISe Provider Handbook, Appendix E, FQHC/RHC (Accessed Jan. 2024).

Teledentistry may be used by dentists, FQHCs, and RHCs to provide dental services to MA beneficiaries. The provider must be licensed in Pennsylvania and enrolled in the MA Program.

FQHCs and RHCs are to continue billing procedure code T1015 with the U9 modifier to indicate dental visits/encounters rendered via teledentistry to patients. FQHCs and RHCs should no longer use the GT modifier, as previously directed in Provider Quick Tip # 237, “Teledentistry Guidelines Related to COVID-19 for Dentists, Federally Qualified Health Centers and Rural Health  Clinics”(https://www.dhs.pa.gov/providers/QuickTips/Documents/PROMISeQuickTip237.pdf), and must begin using POS 02 as of May 2, 2022.

Teledentistry visits must be provided according to the same standard of care as if delivered in-person.

SOURCE: PA Department of Human Services, Medical Assistance Bulletin, Teledentistry Guidelines and Dental Fee Schedule Updates (May 2, 2022). (Accessed Jan. 2024).

See: PA Medicaid Live Video.


Store and Forward

 Telehealth, for purposes of MA Program payment, does not include asynchronous or store and forward technology or facsimile machines, electronic mail systems or remote patient monitoring devices. However, these technologies may be utilized as a part of the provision of a MA-covered service.

SOURCE: PA Department of Human Services, Medical Assistance Bulletin 99-23-08, p. 2-3, Aug. 2, 2023, (Accessed Jan. 2024).

There is no explicit reference to whether or not FQHCs  can be reimbursed for Store and Forward.

See:  PA Medicaid Store and Forward.


Remote Patient Monitoring

 Telehealth, for purposes of MA Program payment, does not include asynchronous or store and forward technology or facsimile machines, electronic mail systems or remote patient monitoring devices. However, these technologies may be utilized as a part of the provision of a MA-covered service.

SOURCE: PA Department of Human Services, Medical Assistance Bulletin 99-23-08, p. 2-3, Aug. 2, 2023, (Accessed Jan. 2024).

There is no explicit reference to whether or not FQHCs can be reimbursed for remote patient monitoring.

See: PA Medicaid Remote Patient Monitoring.


Audio-Only

PA Medicaid allows audio-only telecommunication technology to be used when the beneficiary does not have video capability or for an urgent medical situation.

SOURCE: PA Department of Human Services, Medical Assistance Bulletin 99-23-08, p. 2, Aug. 2, 2023, (Accessed Jan. 2024).

There is no explicit reference to whether or not FQHCs can be reimbursed for audio-only delivery.

See:  PA Medicaid Email, Phone and Fax.

Last updated 09/11/2023

Patient-Provider Relationship

No reference found

Last updated 01/22/2024

PPS Rate

MA MCOs may also cover teledentistry visits and encounters. MA MCOs may negotiate payment for services rendered via telemedicine. FQHCs and RHCs that have opted into the Alternative Payment Methodology (APM) will receive at least their provider-specific MA FFS Prospective Payment System (PPS) rate for a dental encounter from the MA MCO. If the FQHC or RHC has not opted into this APM, then the Department will make supplemental payments to the provider that equal the difference between the payment under the PPS rate and the payment provided by the MA MCO.

SOURCE: PA Department of Human Services, Medical Assistance Bulletin, Teledentistry Guidelines and Dental Fee Schedule Updates (May 2, 2022). (Accessed Jan. 2024).

Last updated 01/22/2024

Same Day Encounters

FQHCs/RHCs may bill for more than one encounter (such as a medical encounter, and a dental encounter) for the same patient on the same day. Additional other health encounters may be billed with the applicable type of service; however, medical necessity for the billing of such multiple encounters on the same day must be fully documented (including the time individually spent with the patient during each encounter) and justified in the patient’s record. Medical necessity for multiple daily encounters is verified by periodic site audit, and must meet the federal standard mandated at 42 CFR §405.2463.

The allowance of billing for multiple types of encounters in a single day must not interfere with the recipient’s freedom in choosing a provider. A recipient may obtain medical, dental or other health services from any institution, agency, pharmacy, person, or organization that is approved by the Department to provide them. Therefore, the FQHC/RHC shall not make any direct or indirect referral arrangements between practitioners and other providers of medical services or supplies but may suggest the services of another clinic provider or practitioner; automatic referrals between providers continue to be prohibited (Chapter 1101.51).

SOURCE: PA PROMISe Provider Handbook pg. 11, Appendix E, FQHC/RHC (Accessed Jan. 2024).