Tennessee

Last updated 12/07/2022

Definitions

Telehealth means the use of real-time interactive audio, video telecommunications or electronic technology, or store-and-forward telemedicine services by a healthcare services provider to deliver healthcare services to a patient within the scope of practice of the healthcare services provider when such provider is at a qualified site other than the site where the patient is located; and the patient is at a qualified site at a school clinic staffed by a healthcare services provider and equipped to engage in the telecommunications described in this section or a public elementary or secondary school staffed by a health care services provider and equipped to engage in the telecommunications described in this section and does not include audio only conversation; an electronic mail message or facsimile transmission; and for the provision of behavioral health services when real-time, interactive audio, video telecommunications or electronic technology  or store-and-forward telemedicine are unavailable, telehealth includes audio-only conversation.

SOURCE: TN Code Annotated, Sec. 56-7-1002, as amended by House Bill 620 & Senate Bill 429, (2021 Session), (Accessed Dec. 2022).

 “Provider-based telemedicine”: Means the use of Health Insurance Portability and Accountability Act (HIPAA) (42 U.S.C. § 1320d et seq.) compliant real-time, interactive audio, video telecommunications, or electronic technology, or store-and-forward telemedicine services, used over the course of an interactive visit by a healthcare services provider to deliver healthcare services to a patient within the scope of practice of the healthcare services provider when:

• The healthcare services provider is at a qualified site other than the site where the patient is located and has access to the relevant medical record for that patient;
• The patient is located at a location the patient deems appropriate to receive the healthcare service that is equipped to engage in the telecommunication described in this section; and
• The healthcare services provider makes use of HIPAA compliant real-time, interactive audio, video telecommunications or electronic technology, or store-and-forward telemedicine services to deliver healthcare services to a patient within the scope of practice of the healthcare services provider as long as the healthcare services provider, the healthcare services provider’s practice group, or the healthcare system has established a provider-patient relationship by submitting to a health insurance entity evidence of an in-person encounter between the healthcare service provider, the healthcare services provider’s practice group, or the healthcare system and the patient within sixteen (16) months prior to the interactive visit; and
• The requirement of an in-person encounter between the healthcare services provider, the healthcare services provider’s practice group, or the healthcare system and the patient within sixteen (16) months prior to the interactive visit is tolled for the duration of a state of emergency declared by the governor pursuant to § 58-2-107; provided, that the healthcare services provider or the patient, or both, are located in the geographical area covered by the applicable state of emergency;
• Does not include:
  • An audio-only conversation;
  • An electronic mail message or phone text message;
  • A facsimile transmission;
  • Remote patient monitoring; or
  • Healthcare services provided pursuant to a contractual relationship between a health insurance entity and an entity that facilitates the delivery of provider-based telemedicine as the substantial portion of the entity’s business.

Notwithstanding subdivisions (a)(6)(A) and (B), includes Health Insurance Portability and Accountability Act (HIPAA) (42 U.S.C. § 1320d et seq.) compliant audio-only conversation for the provision of behavioral health services or healthcare services when the means described in subdivision (a)(6)(A) are unavailable.

SOURCE: TN Code Annotated, Sec. 56-7-1003, (Accessed Dec. 2022).

Workers Compensation

“Telehealth” means the distribution of health-related services and information via electronic information and telecommunication technologies.

“Telemedicine” means the use of telehealth by a telehealth provider to provide clinical health care.

SOURCE:  TN Admin Code 0800-02-31.02, (Accessed Dec. 2022).

Last updated 12/07/2022

Parity

SERVICE PARITY

Provider-based Telemedicine

A health insurance entity shall provide coverage under a health insurance policy or contract for covered healthcare services delivered through provider-based telemedicine and shall not exclude from coverage a healthcare service solely because it is provided through provider-based telemedicine and is not provided through an in-person encounter between a healthcare services provider and a patient.  They shall also reimburse healthcare services providers who are out-of-network for provider-based telemedicine care services under the same reimbursement policies applicable to other out-of-network healthcare services providers.

SOURCE: TN Code Annotated, Sec. 56-7-1003 (Accessed Dec. 2022)

Telehealth Services

Health insurance entities (including managed care organizations) participating in the medical assistance program are required to provide coverage for telehealth (which includes live video) delivered services in a manner that is consistent with the health insurance policy or contract provided for in-person for the same service, and shall reimburse for healthcare services provided during a telehealth encounter without distinction or consideration of the geographic location, or any federal, state, or local designation or classification of the geographic area where the patient is located.

SOURCE: TN Code Annotated, Title 56, Ch. 7, Part 1002.  (Accessed Dec. 2022).

Remote patient monitoring

A health insurance entity may consider any remote patient monitoring service a covered medical service if the same service is covered by Medicare. The appropriate parties may negotiate the rate for these services in the manner in which is deemed appropriate by the parties.

Reimbursement of expenses for covered remote patient monitoring services must be established through negotiations conducted by the health insurance entity with the healthcare services provider, healthcare system, or practice group in the same manner as the health insurance entity establishes reimbursement of expenses for covered healthcare services that are delivered by in-person means.

SOURCE: TN Code Annotated, Sec. 56-7-1011, (Accessed Dec. 2022). 

Worker’s Compensation

Except when a medical fee waiver in accordance with Rule 0800-02-17-.18 is obtained from the bureau, nothing in this Chapter 0800-02-31 shall require an employer to pay a total reimbursement for a telehealth encounter for workers’ compensation, including the use of telehealth equipment, in an amount exceeding the amount that would be paid for the same service provided by a healthcare services provider during an in-person encounter under the medical fee schedule set forth in Chapters 0800-02-17, 18, and 19. The medical fee schedule, including but not limited to Tennessee specific conversion percentages, shall apply to the providers of telehealth services rendered pursuant to the workers’ compensation law.

Billing for telehealth services shall be by standard HCFA-1500 using modifier -95 and the appropriate place of service code as specified by CMS for the date of service or their successors as used by CMS. The provider shall append modifier -95 to the CPT® code with the place of service code -02 (telehealth) or -11 (office) as specified by CMS for the date of service. All other modifiers should also be added to the CPT® code as applicable.

When a procedure is provided using telemedicine, reimbursement shall be as follows:The procedure code is reimbursed at the non-facility Medicare maximum allowable payment or the billed charge, whichever is less, regardless of the practitioner’s physical location at the time of service.

Coding and billing regulations shall follow the Medicare guidelines in effect for the date of service with no geographic qualifier.

SOURCE:  TN Admin Code 0800-02-31.05, (Accessed Dec. 2022).

PAYMENT PARITY

Provider-based Telemedicine

This section does not require a health insurance entity to pay total reimbursement for a provider-based telemedicine encounter in an amount that exceeds the amount that would be paid for the same service provided by a healthcare services provider for an in-person encounter.

This section does not require a health insurance entity to provide coverage for healthcare services that are not medically necessary, unless the terms and conditions of an applicable health insurance policy provide that coverage.

This section does not require a health insurance entity to provide coverage or reimbursement for healthcare services delivered by means of provider-based telemedicine if the applicable health insurance policy would not provide coverage or reimbursement for the same healthcare services if delivered by in-person means.

This section does not require a health insurance entity to pay total reimbursement for a provider-based telemedicine encounter in an amount that exceeds the amount that would be paid for the same service provided by a healthcare services provider for an in-person encounter.

Insurers shall reimburse healthcare services providers who are out-of-network for provider-based telemedicine care services under the same reimbursement policies applicable to other out-of-network healthcare services providers.

SOURCE: TN Code Annotated, Sec. 56-7-1003 (Accessed Dec. 2022)

Telehealth Services

Health Insurance entities are required to reimburse for the diagnosis, consultation, and treatment of an insured patient for a healthcare service covered under a health insurance policy or contract provided through telehealth without distinction of the geographic location or any federal, state, or local designation, or classification of the geographic area where the patient is located.

Out-of-network providers providing healthcare services through telehealth must be reimbursed under the same policies applicable to other out-of-network healthcare service providers.

SOURCE: TN Code Annotated, Title 56, Ch. 7, Part 1002. (Accessed Dec. 2022).

Reimbursement of expenses for covered remote patient monitoring services must be established through negotiations conducted by the health insurance entity with the healthcare services provider, healthcare system, or practice group in the same manner as the health insurance entity establishes reimbursement of expenses for covered healthcare services that are delivered by in-person means.

SOURCE: TN Code Annotated, Sec. 56-7-1011 (Accessed Dec. 2022).

Last updated 12/07/2022

Requirements

Telehealth Services

A health insurance entity shall provide coverage for healthcare services provided during a telehealth encounter in a manner that is consistent with what the health insurance policy or contract provides for in-person encounters for the same service, and shall reimburse for healthcare services provided during a telehealth encounter without distinction or consideration of the geographic location, or any federal, state, or local designation or classification of the geographic area where the patient is located.

SOURCE: TN Code Annotated, Title 56, Ch. 7, Part 1002, (Accessed Dec. 2022). 

A provider must be at a qualified site other than the site where the patient is located; and the patient is at a qualified site, at a school clinic staffed by a healthcare services provider and equipped to engage in the telecommunications described in this section, or at a public elementary or secondary school staffed by a healthcare services provider and equipped to engage in the telecommunications described in this section.

A health insurance entity cannot exclude from coverage, a healthcare service solely because it is provided through telehealth and is not provided through an in-person encounter.

“Qualified site” means the office of a healthcare services provider, a hospital licensed under title 68, a facility recognized as a rural health clinic under federal Medicare regulations, a federally qualified health center, a facility licensed under title 33, or another location deemed acceptable by the health insurance entity; and Includes, for the provision of behavioral health services provided via telehealth, the patient’s home or a remote location chosen by the patient.

SOURCE: TN Code Annotated, Sec. 56-7-1002, as amended by House Bill 620 & Senate Bill 429, (2021 Session), (Accessed Dec. 2022).

A health insurance entity shall reimburse an originating site hosting a patient as part of a telehealth encounter an originating site fee in accordance with the federal centers for Medicare and Medicaid services telehealth services rule 42 C.F.R. § 410.78 and at an amount established prior to the effective date of this act by the federal centers for Medicare and Medicaid services.

This section does not require a health insurance entity to provide coverage for healthcare services that are not medically necessary, unless the terms and conditions of an applicable health insurance policy provide that coverage.

For a healthcare service for which coverage or reimbursement is provided under the Medical Assistance Act of 1968, compiled in title 71, chapter 5, part 1, or provided under title 71, chapter 3, part 11, “medically necessary” means a healthcare service that is determined by the bureau of TennCare to satisfy the medical necessity standard set forth in 71-5-144; and

For all other healthcare services, “medically necessary” means healthcare services that a healthcare services provider, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing, or treating an illness, injury, or disease or the symptoms of an illness, injury, or disease, and that are:

• • In accordance with generally accepted standards of medical practice;
  • Clinically appropriate, in terms of type, frequency, extent, site and duration; and considered effective for the patient’s illness, injury or disease; and
  • Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury, or disease excluding any costs paid pursuant to subsection (j).

SOURCE: TN Code Annotated, Sec. 56-7-1002 (Accessed Dec. 2022).

Provider-Based Telemedicine

A health insurance entity shall provide coverage for healthcare services provided during a provider-based telemedicine encounter in a manner that is consistent with what the health insurance policy or contract provides for in-person encounters for the same service, and shall reimburse for healthcare services provided during a provider-based telemedicine encounter without distinction or consideration of the geographic location, or any federal, state, or local designation or classification of the geographic area where the patient is located.

This section does not require a health insurance entity to provide coverage for healthcare services that are not medically necessary, unless the terms and conditions of an applicable health insurance policy provide that coverage.

The healthcare services provider makes use of HIPAA compliant real-time, interactive audio, video telecommunications or electronic technology, or store-and-forward telemedicine services to deliver healthcare services to a patient within the scope of practice of the healthcare services provider as long as the healthcare services provider, the healthcare services provider’s practice group, or the healthcare system has established a provider-patient relationship by submitting to a health insurance entity evidence of an in-person encounter between the healthcare service provider, the healthcare services provider’s practice group, or the healthcare system and the patient within sixteen (16) months prior to the interactive visit.

The requirement of an in-person encounter between the healthcare services provider, the healthcare services provider’s practice group, or the healthcare system and the patient within sixteen (16) months prior to the interactive visit is tolled for the duration of a state of emergency declared by the governor pursuant to § 58-2-107; provided, that the healthcare services provider or the patient, or both, are located in the geographical area covered by the applicable state of emergency.

Notwithstanding § 56-7-1002(e), a health insurance entity shall provide reimbursement for healthcare services provided during a telehealth encounter in a manner that is consistent with what the health insurance policy or contract provides for in-person encounters for the same service, and shall reimburse for healthcare services provided during a telehealth encounter without distinction or consideration of the geographic location, or any federal, state, or local designation or classification of the geographic area where the patient is located.

Notwithstanding § 56-7-1003(e), a health insurance entity shall provide reimbursement for healthcare services provided during a provider-based telemedicine encounter in a manner that is consistent with what the health insurance policy or contract provides for in-person encounters for the same service, and shall reimburse for healthcare services provided during a provider-based telemedicine encounter without distinction or consideration of the geographic location, or any federal, state, or local designation or classification of the geographic area where the patient is located.

SOURCE: TN Code Annotated, Sec. 56-7-1003 & Sec. 56-7-1012, (Accessed Dec. 2022).

“Qualified site” means the primary or satellite office of a healthcare services provider, a hospital licensed under title 68, a facility recognized as a rural health clinic under federal medicare regulations, a federally qualified health center, a facility licensed under title 33, or any other location deemed acceptable by the health insurance entity.

A provider-based telemedicine provider who seeks to contract with or who has contracted with a health insurance entity to participate in the health insurance entity’s network is subject to the same requirements and contractual terms as any other healthcare services provider in the health insurance entity’s network.

SOURCE: TN Code Annotated, Sec. 56-7-1003, (Accessed Dec. 2022).

A health insurance entity may consider any remote patient monitoring service a covered medical service if the same service is covered by Medicare. The appropriate parties may negotiate the rate for these services in the manner in which is deemed appropriate by the parties.

SOURCE: TN Code Annotated, Sec. 56-7-1011, (Accessed Dec. 2022).

Workers Compensation

Telehealth for workers’ compensation is an available option for medically appropriate healthcare services to be provided with the voluntary consent and agreement of the injured worker and the willingness of the healthcare services provider as provided in these rules.  Medically appropriate healthcare services do not include treatment where an in-person physical examination is necessary (see rule for examples).

Telehealth providers shall be held to the same standard of care as healthcare services providers providing the same healthcare services through in-person encounters.

An employer shall provide coverage for workers’ compensation medical services provided during a telehealth encounter in a manner that is consistent with what the workers’ compensation law requires for in-person encounters for the same healthcare service(s). Payment shall be in accordance with the Tennessee workers’ compensation medical fee schedule in Rule 0800-02-18 and corresponding rules for medical payments in Rule 0800-02- 17 in effect on the date of service.

Records/recordings requirements for telehealth services shall be the same as if the visit with the provider were in person and face-to-face. A telehealth provider shall be compliant with all federal and state of Tennessee laws for records/recordings. A recording shall not substitute for a written record.

Telehealth services are subject to any and all appropriate utilization review protocols or other protocols for healthcare treatment adopted by the bureau, shall be based on evidence-based guidelines, and shall be in accordance with the Tennessee standards of medical practice.

All services shall be delivered to the eligible employee at no cost to the employee in accordance with the provisions of section 50-6-204.

The provision of medical services via telehealth does not change or in any way affect the requirements for causation, date of maximum medical improvement, or permanent impairment ratings required of an authorized treating physician pursuant to the workers’ compensation law. In all workers’ compensation claims, statements of causation, date of maximum medical improvement, permanent restrictions, and permanent impairment rating(s) must be provided by a medical doctor, doctor of osteopathy, or doctor of chiropractic in accordance with the workers’ compensation law.

SOURCE:  TN Admin Code 0800-02-31.03, (Accessed Dec. 2022).