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POLICY

The Secretary shall pay for telehealth services that are furnished via a telecommunications system by a physician (as defined in section 1861(r)) or a practitioner (described in section 1842(b)(18)(C)) to an eligible telehealth individual enrolled under this part notwithstanding that the individual physician or practitioner providing the telehealth service is not at the same location as the beneficiary.

SOURCE:  Social Security Act, Sec. 1834(m) (Title 42, Sec. 1395m).  (Accessed Mar. 2024).

We pay for specific Medicare Part B services that a physician or practitioner provides via 2-way, interactive technology (or telehealth).  Telehealth substitutes for an in-person visit, and generally involves 2-way, interactive technology that permits communication between the practitioner and patient.

During the COVID-19 public health emergency (PHE), we used emergency waiver and other regulatory authorities so you could provide more services to your patients via telehealth. Section 4113 of the Consolidated Appropriations Act, 2023 extended many of these flexibilities through December 31, 2024, and made some of them permanent.

Billing and Payment

• Bill covered telehealth to your Medicare Administrative Contractor (MAC). They pay you the appropriate telehealth amount under the Physician Fee Schedule (PFS).
• Submit professional telehealth claims using the appropriate CPT or HCPCS code.
• If you performed telehealth through asynchronous telehealth, add the telehealth GQ modifier with the professional service CPT or HCPCS code. You’re certifying you collected and sent the asynchronous medical file at the distant site from a federal telemedicine demonstration conducted in Alaska or Hawaii.
• Distant site practitioners billing telehealth under the CAH Optional Payment Method II must submit institutional claims using the GT modifier.
• If you’re located in, and you reassigned your billing rights to, a CAH and elected the outpatient Optional Payment Method II, the CAH bills the MAC for telehealth. The payment is 80% of the PFS distant site
  facility amount for the distant site service.

SOURCE: Centers for Medicare and Medicaid Services (CMS), Telehealth Services MLN Fact Sheet, Feb. 2024, (Accessed Mar. 2024).

CY 2024 Physician Fee Schedule notes that section 4113 of Division FF, Title IV, Subtitle A of the Consolidated Appropriations Act, 2023 (CAA, 2023) (Pub. L. 117-328, December 29, 2022) extends the telehealth policies enacted in the Consolidated Appropriations Act, 2022 (CAA, 2022) (Pub. L. 117-103, March 15, 2022) through December 31, 2024, if the PHE ends prior to that date, as discussed in section II.D.c. of this final rule. These provisions included:

• Temporarily removing the geographic and site requirements for the patient location at the time the telehealth interaction takes place
• Temporarily allowing a more expansive list of eligible providers in Medicare to provide services via telehealth such as physical and occupational therapists and federally qualified health centers (FQHCs) and rural health clinics (RHCs)
• Temporarily allowing some services to continue to be provided via audio-only
• Temporarily suspending the in-person service requirement prior to the delivery of mental and behavioral services via telehealth or audio-only in cases where the geographic requirement does not apply, the service takes place in the home and the patient was not being treated for a substance use disorder

SOURCE: Center for Medicare and Medicaid Services, CY 2024 Physician Fee Schedule, Final Rule, CMS 1784-F, (Accessed Mar. 2024).

Requirements for mental health services furnished through telehealth (Delay of In-Person mental health requirement)

Payment may not be made under this paragraph for telehealth services furnished on or after January 1, 2025 (or, if later, the first day after the end of the emergency period described in section 1320b–5(g)(1)(B) of this title) by a physician or practitioner to an eligible telehealth individual for purposes of diagnosis, evaluation, or treatment of a mental health disorder unless such physician or practitioner furnishes an item or service in person, without the use of telehealth, for which payment is made under this subchapter (or would have been made under this subchapter if such individual were entitled to, or enrolled for, benefits under this subchapter at the time such item or service is furnished)—

• within the 6-month period prior to the first time such physician or practitioner furnishes such a telehealth service to the eligible telehealth individual; and
• during subsequent periods in which such physician or practitioner furnishes such telehealth services to the eligible telehealth individual, at such times as the Secretary determines appropriate.

These requirements do not apply to services:

• Under this paragraph (with respect to telehealth services furnished to an eligible telehealth individual with a substance use disorder diagnosis for purposes of treatment of such disorder or co-occurring mental health disorder); or
• under this subsection without application of this paragraph.

SOURCE:  Social Security Act, Sec. 1834(m) (Title 42, Sec. 1395m).  (Accessed Mar. 2024).

When the PHE ends, can individuals continue to see providers virtually using telehealth?

Yes, in most cases. During the PHE, individuals with Medicare had broad access to telehealth services, including in their homes, without the geographic or location limits that usually apply. These waivers were included as provisions of The Consolidated Appropriations Act, 2023, which extended many telehealth flexibilities through December 31, 2024, such as:

• People with Medicare can access telehealth services in any geographic area in the United States, rather than only in rural areas.
• People with Medicare can stay in their homes for telehealth visits that Medicare pays for rather than traveling to a health care facility.
• Certain telehealth visits can be delivered using audio-only technology (such as a telephone) if someone is unable to use both audio and video (such as a smartphone or computer).
• However, if an individual receives routine home care via telehealth under the hospice benefit, this flexibility will end at the end of the PHE.
• MA plans may offer additional telehealth benefits. Individuals in an MA plan should check with their plan about coverage for telehealth services. Additionally, after December 31, 2024, when these flexibilities expire, some ACOs may offer telehealth services that allow primary care doctors to care for patients without an in-person visit, no matter where they live.

SOURCE: Centers for Medicare and Medicaid Services, Frequently Asked Questions: CMS Waivers, Flexibilities and the End of the COVID-19 Public health Emergency, 5/19/23, (Accessed Mar. 2024).

During the PHE, the Secretary has been using the waiver authority under section 1135 of the Act to create flexibilities in the requirements of section 1834(m) of the Act and 42 CFR § 410.78 for use of interactive telecommunications systems to furnish telehealth services. This allows clinicians to furnish more services to beneficiaries via telehealth so that they can take care of their patients while mitigating the risk of the spread of the virus.

During the public health emergency, all beneficiaries across the country have been able to receive Medicare telehealth and other communications technology-based services wherever they are located. Additionally, after the PHE ends, the Consolidated Appropriations Act, 2023 provides for an extension for some of these flexibilities through December 31, 2024.

SOURCE: Centers for Medicare and Medicaid Services, Physicians and Other Clinicians: CMS Flexibilities to Fight COVID-19, 11/6/23, (Accessed Mar. 2024).

In addition to the requirement for the in-person visit mentioned above in statute, CMS will also require there to be an in-person, non-telehealth service within 12 months of each mental health telehealth service.  However, if the patient and practitioner agree that the benefits of an in-person, non-telehealth service within 12 months of the mental health telehealth service are outweighed by risks and burdens associated with an in-person service, and the basis for that decision is documented in the patient’s medical record, the in-person visit requirement will not apply for that particular 12-month period.  CMS will allow a clinician’s colleague in the same subspecialty in the same group to furnish the in-person, non-telehealth service to the beneficiary if the original practitioner is unavailable. [Implementation delayed until January 1, 2025.]

See eligible providers section for additional information for federally qualified health centers (FQHCs) and rural health clinics (RHCs).

SOURCE: CY 2022 Physician Fee Schedule, CMS, p. 63, (Accessed Mar. 2024).

* The US Health and Human Services Administration maintains a website that summarizes Medicare policies.

ELIGIBLE SERVICES/SPECIALTIES

Temporary Policy Ending Dec. 31, 2024

CMS has waived the requirements of section 1834(m)(4)(E) of the Act and 42 CFR § 410.78 (b)(2), which specify the types of practitioners who may bill for their services when furnished as Medicare telehealth services from a distant site. The waiver of these requirements expands the types of health care professionals who can furnish distant site telehealth services to include all those who are eligible to bill Medicare for their professional services. As a result, a broader range of practitioners, such as physical therapists, occupational therapists, and speech language pathologists can use telehealth to provide many Medicare services. After the PHE ends, the Consolidated Appropriations Act, 2023 provides for an extension for this flexibility through December 31, 2024.

Additionally, we modified the process to add services to the Medicare Telehealth Services List during the PHE, allowing us to consider adding appropriate services on a sub-regulatory basis, as they were requested, as practitioners were actively learning how to use telehealth. A complete list of all Medicare telehealth services can be found here: https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes

After the PHE ends, we will resume consideration of changes to the Medicare Telehealth Services List exclusively through notice and comment rulemaking.

See factsheet for Medicare telehealth service list.

These services will remain on the Medicare Telehealth Services List and will be available through the end of CY 2023, and we anticipate addressing updates to the Medicare Telehealth Services List for CY 2024 and beyond through our established processes as part of the CY 2024 Physician Fee Schedule proposed and final rules.

Using section 1135 waiver authority, on an interim basis during the PHE, we removed the frequency restrictions for the following listed codes furnished via Medicare telehealth. These restrictions were established through rulemaking and implemented through systems edits:

• A subsequent inpatient visit could be furnished via Medicare telehealth, without the limitation that the telehealth visit is once every three days (CPT codes 99231-99233).
• A subsequent skilled nursing facility visit could be furnished via Medicare telehealth, without the limitation that the telehealth visit is once every 14 days (CPT codes 99307- 99310).
• Critical care consult codes could be furnished to a Medicare beneficiary by telehealth, without the limitation that the telehealth visit is once per day (HCPCS codes G0508- G0509).

We have received a number of inquiries from interested parties regarding temporarily continuing our suspension of these frequency limitations beyond the end of the PHE, specifically our requirement that CPT codes 99231-99233 may only be furnished via Medicare telehealth once every 3 days, and our requirement that CPT codes 99307-99309 may only be furnished via Medicare telehealth once every 14 days. We are exercising enforcement discretion and will not consider these frequency limitations through December 31, 2023, as we anticipate considering our policy further through our rulemaking process.

Medicare patients with end-stage renal disease (ESRD) who are on home dialysis must receive a face-to-face visit, without the use of telehealth, at least monthly in the case of the initial three months of home dialysis and at least once every three consecutive months after the initial three months. We used section 1135 waiver authority during the PHE to allow these visits to be furnished as telehealth services. This will expire at the end of the COVID-19 public health emergency.

To the extent that a National Coverage Determination (NCD) or Local Coverage Determination (LCD) would otherwise require an in-person, face-to-face visit for evaluations and assessments, we used section 1135 waiver authority to remove those requirements so that these services can be furnished via telehealth during the public health emergency. This will expire at the end of the COVID-19 public health emergency.

Opioid Treatment Programs (OTPs): During the PHE, patient counseling and therapy services have been provided by telephone in cases where two-way interactive audio-video communication technology is not available to the beneficiary, and all other applicable requirements are met. This flexibility has been made permanent for OTPs in the CY 2022 PFS final rule. During the PHE, periodic assessments have been conducted via two-way interactive audio-video communication technology and may have been provided by telephone, only in cases where the beneficiary has not had access to two-way interactive audio-video communication technology and all other applicable requirements have been met.

SOURCE: Centers for Medicare and Medicaid Services, Physicians and Other Clinicians: CMS Flexibilities to Fight COVID-19, 11/6/23, (Accessed Mar. 2024).

After the end of the PHE, how often will Medicare provide payment for a subsequent nursing facility or subsequent inpatient visit when furnished via Medicare telehealth?

We have received a number of inquiries from interested parties regarding temporarily continuing our suspension of these frequency limitations beyond the end of the PHE, specifically our requirement that CPT codes 99231-99233 may only be furnished via Medicare telehealth once every 3 days, and our requirement that CPT codes 99307-99309 may only be furnished via Medicare telehealth once every 14 days. We are exercising enforcement discretion and will not consider these frequency limitations through December 31, 2023, as we anticipate considering our policy further through our rulemaking process.

SOURCE: Centers for Medicare and Medicaid Services, Frequently Asked Questions: CMS Waivers, Flexibilities and the End of the COVID-19 Public health Emergency, 5/19/23, (Accessed Mar. 2024).

Section 3706 of The CARES Act allowed for face-to-face encounters for purposes of patient recertification for the Medicare hospice benefit can now be conducted via telehealth (i.e., two-way audio-video telecommunications technology that allows for real-time interaction between the hospice physician/hospice nurse practitioner and the patient). This statutory change will expire on December 31, 2024.

SOURCE: Centers for Medicare and Medicaid Services, Hospice: CMS Flexibilities to Fight COVID-19, 5/10/23, (Accessed Mar. 2024).

Subject to paragraph (8), the term “telehealth service” means professional consultations, office visits, and office psychiatry services (identified as of July 1, 2000, by HCPCS codes 99241–99275, 99201–99215, 90804–90809, and 90862 (and as subsequently modified by the Secretary)), and any additional service specified by the Secretary. The Secretary shall establish a process that provides, on an annual basis, for the addition or deletion of services (and HCPCS codes), as appropriate.

SOURCE:  Social Security Act, Sec. 1834(m) (Title 42, Sec. 1395m).  (Accessed Mar. 2024).

ESRD Treatment

§494.90(b)(4): CMS has modified the requirement that the ESRD dialysis facility ensure that all dialysis patients are seen by a physician, nurse practitioner, clinical nurse specialist, or physician’s assistant providing ESRD care at least monthly, and periodically while the hemodialysis patient is receiving in-facility dialysis. CMS has been waiving the requirement for a monthly in-person visit if the patient is considered stable and also recommends exercising telehealth flexibilities; e.g., phone calls, to ensure patient safety. After the PHE ends, the Consolidated Appropriations Act, 2023 provides for an extension of telehealth flexibility through December 31, 2024.

SOURCE: Centers for Medicare and Medicaid Services, End Stage Renal Disease (ESRD) Facilities: CMS Flexibilities to Fight COVID-19, 5/10/23, (Accessed Mar. 2024).

Medicare Part B pays for covered telehealth services included on the telehealth list when furnished by an interactive telecommunications system if the following conditions are met, except that for the duration of the Public Health Emergency as defined in § 400.200 of this chapter, Medicare Part B pays for office and other outpatient visits, professional consultation, psychiatric diagnostic interview examination, individual psychotherapy, pharmacologic management and end stage renal disease related services included in the monthly capitation payment furnished by an interactive telecommunications system if certain conditions are met.

A clinical psychologist and a clinical social worker, a marriage and family therapist (MFT), and a mental health counselor (MHC) may bill and receive payment for individual psychotherapy via a telecommunications system, but may not seek payment for medical evaluation and management services.

The physician visits required under § 483.40(c) of this title may not be furnished as telehealth services.

The distant site practitioner who reports the DSMT services may bill and receive payment when a professional furnishes injection training for an insulin-dependent patient using interactive telecommunications technology when such training is included as part of the DSMT plan of care referenced at § 410.141(b)(2).

SOURCE: 42 CFR Sec. 410.78 (Accessed Mar. 2024).

Except as otherwise provided in this paragraph (f), changes to the list of Medicare telehealth services are made through the annual physician fee schedule rulemaking process. During the Public Health Emergency, as defined in § 400.200 of this chapter, we will use a subregulatory process to modify the services included on the Medicare telehealth list during the Public Health Emergency, taking into consideration infection control, patient safety, and other public health concerns resulting from the emergency. CMS maintains the list of services that are Medicare telehealth services under this section, including the current HCPCS codes that describe the services on the CMS website.

Process for adding or deleting services. Except as otherwise provided in this paragraph (f), changes to the list of Medicare telehealth services are made through the annual physician fee schedule rulemaking process. During the Public Health Emergency, as defined in § 400.200 of this chapter, we will use a subregulatory process to modify the services included on the Medicare telehealth list during the Public Health Emergency, taking into consideration infection control, patient safety, and other public health concerns resulting from the emergency. CMS maintains the list of services that are Medicare telehealth services under this section, including the current HCPCS codes that describe the services on the CMS website.

SOURCE: 42 CFR Sec. 410.78 (Accessed Mar. 2024).

List of services payable under the Medicare Physician Fee Schedule when furnished via telehealth is available on the CMS website. Find the complete List of Telehealth Services by downloading the ZIP and opening the Excel or text files.

SOURCE:  CMS Telehealth List Year, Updated 11/13/2023.  (Accessed Mar. 2024).

Also see Table 11 for list of eligible codes in CY 2024 Physician Fee Schedule.

SOURCE: Center for Medicare and Medicaid Services, CY 2024 Physician Fee Schedule, Final Rule, CMS 1784-F, (Accessed Mar. 2024).

Through December 31, 2024:

• You may use telehealth to conduct hospice care eligibility recertification
• For behavioral or mental telehealth, you don’t have to conduct an in-person visit within 6 months of the initial telehealth visit or annually thereafter
• We’ve extended the Acute Hospital Care at Home Program, which heavily relies on telehealth for hospitals to provide inpatient services, including routine services, outside the hospital

CY 2024, we’re adding new codes to the list of Medicare telehealth services, including:

• CPT codes 0591T – 0593T for health and well-being coaching services, which we’re adding on a temporary basis
• HCPCS code G0136 for Social Determinants of Health Risk Assessment, which we’re adding on a permanent basis

Based on several telehealth-related provisions of the Consolidated Appropriations Act (CAA), 2023 and the CY 2024 PFS final rule, we’re: …

• Removing frequency limitations in 2024 for:
  • Subsequent inpatient visits
  • Subsequent nursing facility visits
  • Critical care consultation

Starting January 1, 2023, you may voluntarily report the use of telehealth technology in providing home health (HH) services on HH payment claims. See MLN Matters Article MM12805 for more information.

Starting July 1, 2023, you must include on HH claims:

• G0320: Home health services you furnish using synchronous telehealth you render via real-time audio video telehealth
• G0321: Home health services you furnish using synchronous telehealth you render via telephone or another real-time, interactive, audio-only telehealth
• G0322: The collection of physiologic data the patient digitally stores or transmits to the HH agency

See fact sheet for additional details.

SOURCE: Centers for Medicare and Medicaid Services (CMS), Telehealth Services MLN Fact Sheet, Feb. 2024, (Accessed Mar. 2024).

Communication Technology-Based Services (CTBS)

CMS makes separate payment for brief communication technology-based services. This includes ‘brief communication technology-based service, e.g. virtual check-in’ by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5–10 minutes of medical discussion). The code (G2012) allows real-time audio-only telephone interactions in addition to synchronous, two-way audio interactions that are enhanced with video or other kinds of data transmission. The service is limited to established patients.

Interprofessional consultations are reimbursable by CMS as part of their CTBS services (CPT codes include 99451, 99452, 99446, 99447, 99448, and 99449). Cost sharing will apply. These interprofessional services may be billed only by practitioners that can bill Medicare independently for evaluation and management services.  Includes telephone and internet assessments.

CTBS services are not regarded by CMS as telehealth.

SOURCE: CY 2019 Final Physician Fee Schedule. CMS, p. 31-40, (Accessed Mar. 2024).

CMS has finalized a process for which services will be added to the permanently eligible telehealth services list. In the new process, a suggested code would either be made permanent, provisional or rejected.  See CY 2024 Physician Fee Schedule or the CMS webpage that describes the process for more details.

CMS is finalizing its proposal that would allow practitioners who can “appropriately report DSMT services furnished in person by the DSMT entity…to report DSMT services via telehealth by the DSMT entity, including when the services are performed by others as part of the DSMT entity.”

Additionally, flexibilities for the Medicare Diabetes Prevention Program (MDPP) will be extended for an additional four years. Among the flexibilities is the ability to provide distance learning virtually.

Frequency limitations on subsequent in-patient visits, subsequent skilled nursing facility visits and critical care consultations are removed for CY 2024.

Telehealth Injection Training for Insulin-Dependent – Providers can use telehealth to provide the full initial 10 hours or annual 2 hours of insulin injection-training that is required for insulin dependent beneficiaries to take place via telehealth. CMS clarified that only physicians and those nonphysician practitioners listed in section 1842(b)(18)(C) may bill and hospitals and pharmacies are not included.

Periodic Assessments for Opioid Use Disorder (OUD) by Opioid Treatment Provider (OTP) – CMS will extend periodic assessments by OTPs to the end of 2024. The audio-only option will only be available if video is not and to the extent audio-only is permitted by SAMHSA and Drug Enforcement Administration (DEA) and all other relevant requirements.

SOURCE: Center for Medicare and Medicaid Services, CY 2024 Physician Fee Schedule, Final Rule, CMS 1784-F, (Accessed Mar. 2024).

We may cover these behavioral health and wellness services:

• Interactive telecommunications, including 2-way, interactive audio-only technology to diagnose, evaluate, or treat certain mental health or SUDs using telehealth services if the patient is in their home
  • Hospital clinical staff must have the capability to provide 2-way, interactive, audio-video technology services but may use audio-only technology given an individual patient’s technological limitations, abilities, or preferences
  • You can provide telehealth using 2-way, interactive, audio-only technology through December 31, 2024
  • Telehealth services provided to people in their homes will be paid at the non-facility PFS rate through December 31, 2024
• Marriage and family therapist (MFT) services (also available through telehealth)
• Mental health counselor (MHC) services (also available through an acceptable telehealth mental health disorder service site)
  • Addiction counselors or alcohol and drug counselors who meet the applicable MHC requirements can enroll in Medicare as MHCs
• SUD treatment in a patient’s home (an acceptable telehealth substance use treatment or a
  co-occurring mental health disorder service site)

Beginning in 2025, in-person visit requirements will apply for mental health services provided by telehealth.

This includes a required in-person visit within the 6 months before the initial telehealth treatment as well as the required subsequent in-person visits at least every 12 months.

We’ll continue to define direct supervision to permit the immediate availability of the supervising practitioner through real-time audio and visual interactive telecommunications through December 31, 2024.

The regulations at 42 CFR 410.78(b)(3)(xiv) describe 2 exceptions to the in-person requirements that take effect on January 1, 2025:

1. Patients who already get telehealth behavioral health services and have circumstances where in-person care may not be appropriate
2. Groups with limited availability for in-person behavioral health visits have the flexibility to arrange for practitioners to provide in-person and telehealth visits with different practitioners, based on availability The telehealth policies described above also apply to Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs).

Beginning January 1, 2024, MHCs and MFTs can provide and bill Medicare telehealth services. Exceptions to the in-person visit requirement require a clear justification documented in the patient’s medical record. Hospitals must also document that patients have a regular source of general medical care and can get any needed point-of-care testing, including vital sign monitoring and lab studies.

We created 3 Outpatient Prospective Payment System (OPPS)-specific HCPCS codes to describe that the patient must be in their home and that no associated professional service is billed under the PFS. Hospital staff must be licensed to provide these services consistent with all applicable state scope of practice laws. We exempt these services from having staff physically located in the hospital or outpatient department when providing services remotely using communication technology.  See booklet for list of codes.

SOURCE: Centers for Medicare and Medicaid Services, Medicare Learning Network Booklet 1986542, Medicare & Mental Health Coverage, Jan. 2024, (Accessed Mar. 2024).

ELIGIBLE PROVIDERS

Temporary Policy – Ends Dec. 31, 2024

The term “practitioner” has the meaning given that term in section 1395u(b)(18)(C) of this title and, in the case that the emergency period described in section 1320b–5(g)(1)(B) of this title ends before December 31, 2024, for the period beginning on the first day after the end of such emergency period and ending on December 31, 2024, shall include a qualified occupational therapist (as such term is used in section 1395x(g) of this title), a qualified physical therapist (as such term is used in section 1395x(p) of this title), a qualified speech-language pathologist (as defined in section 1395x(ll)(4)(A) of this title), and a qualified audiologist (as defined in section 1395x(ll)(4)(B)).

…

In the case that such emergency period ends before December 31, 2024, during the period beginning on the first day after the end of such emergency period and ending on December 31, 2024—

• the Secretary shall pay for telehealth services that are furnished via a telecommunications system by a Federally qualified health center or a rural health clinic to an eligible telehealth individual enrolled under this part notwithstanding that the Federally qualified health center or rural clinic providing the telehealth service is not at the same location as the beneficiary;
• the amount of payment to a Federally qualified health center or rural health clinic that serves as a distant site for such a telehealth service shall be determined under subparagraph (B); and
• for purposes of this subsection—
  • the term “distant site” includes a Federally qualified health center or rural health clinic that furnishes a telehealth service to an eligible telehealth individual; and
  • the term “telehealth services” includes a rural health clinic service or Federally qualified health center service that is furnished using telehealth to the extent that payment codes corresponding to services identified by the Secretary under clause (i) or (ii) of paragraph (4)(F) are listed on the corresponding claim for such rural health clinic service or Federally qualified health center service.

SOURCE:  Social Security Act, Sec. 1834(m) (Title 42, Sec. 1395m).  (Accessed Mar. 2024).

CMS has waived the requirements of section 1834(m)(4)(E) of the Act and 42 CFR § 410.78 (b)(2), which specify the types of practitioners who may bill for their services when furnished as Medicare telehealth services from a distant site. The waiver of these requirements expands the types of health care professionals who can furnish distant site telehealth services to include all those who are eligible to bill Medicare for their professional services. As a result, a broader range of practitioners, such as physical therapists, occupational therapists, and speech language pathologists can use telehealth to provide many Medicare services. After the PHE ends, the Consolidated Appropriations Act, 2023 provides for an extension for this flexibility through December 31, 2024.

Reporting Home Address: During the PHE, CMS allowed practitioners to render telehealth services from their home without reporting their home address on their Medicare enrollment while continuing to bill from their currently enrolled location.  Even though the PHE is anticipated to end on May 11, 2023, the waiver will continue through December 31, 2024.

[Also listed in Teaching Hospital COVID Factsheet]

SOURCE: Centers for Medicare and Medicaid Services, Physicians and Other Clinicians: CMS Flexibilities to Fight COVID-19, 11/6/23, (Accessed Mar. 2024).

Through the end of CY 2023, hospital and other providers of physical therapy, occupational therapy, speech-language pathology, diabetes self-management training and medical nutrition therapy services that remain on the telehealth list, can continue to bill for these services when furnished remotely in the same way they have been during the PHE, except that beneficiaries’ homes will no longer need to be registered as provider-based departments of the hospital to allow for hospitals to bill for these services. We note that we are exercising enforcement discretion in reviewing the telehealth practitioner status of the clinical staff personally providing any part of a remotely furnished DSMT service, so long as the practitioner is otherwise qualified to provide the service.

SOURCE: Centers for Medicare and Medicaid Services, Hospitals and CAHs (including Swing Beds, DPUs), ASCs and CMHCs: CMS Flexibilities to Fight COVID-19, 6/26/23, (Accessed Mar. 2024).

Application of Teaching Physician Regulations: Under current rules, Medicare payment is made for services furnished by a teaching physician involving residents only if the physician is physically present for the key portion of the service or procedure, and immediately available to furnish services during the entire procedure, where applicable. During the COVID-19 PHE, teaching physicians may use audio/video real time communications technology to interact with the resident through virtual means, which would meet the requirement that they be present for the key portion of the service, including when the teaching physician involves the resident in furnishing Medicare Telehealth services. After the PHE, CMS is exercising enforcement discretion to allow teaching physicians in all teaching settings to be present virtually, through audio/video real-time communications technology, for purposes of billing under the PFS for services they furnish involving resident physicians. We are exercising this enforcement discretion through December 31, 2023, as we anticipate considering our policy for services involving teaching physicians and residents further through our rulemaking process. These flexibilities do not apply in the case of surgical, high risk, interventional, or other complex procedures, services performed through an endoscope, and anesthesia services. This allows teaching hospitals to maximize their workforce to safely take care of patients.

SOURCE: Centers for Medicare and Medicaid Services, Teaching Hospitals, Teaching Physicians and Medical Residents, 11/6/23, (Accessed Mar. 2024).

Home Health Agencies (HHAs) can provide more services to beneficiaries using telecommunications technology within the 30-day period of care, as long as it’s part of the patient’s plan of care and does not replace needed in-person visits as ordered on the plan of care. We acknowledge that the use of such technology may result in changes to the frequency or types of in-person visits outlined on existing or new plans of care. Telecommunications technology can include, for example: remote patient monitoring; telephone calls (audio only and TTY); and two-way audio-video technology that allows for real-time interaction between the clinician and patient. This provision is permanent beyond the COVID-19 PHE. Home health services furnished using telecommunication systems are required to be included on the home health claim beginning July 1, 2023.

The required face-to-face encounter for home health can be conducted via telehealth (i.e., 2-way audio-video telecommunications technology that allows for real-time interaction between the physician/allowed practitioner and the patient) when the patient is at home. After the PHE ends, the Consolidated Appropriations Act, 2023 provides for an extension for the flexibility to allow the home to be an originating site through December 31, 2024.

SOURCE: Centers for Medicare and Medicaid Services, Home Health Agencies, CMS Flexibilities to Fight COVID-19, 5/10/23, (Accessed Mar. 2024).

At the end of the PHE, when can hospitals bill for:

• The originating site facility fee (HCPCS code Q3014)?
• The clinic visit (HCPCS code G0463)?
• Remote mental health services (HCPCS codes C7900 – C7902)?

Following the anticipated end of the PHE (May 11, 2023):

• Hospitals cannot bill for this code after the PHE unless the beneficiary is located within a hospital and the beneficiary receives a Medicare telehealth service from an eligible distant site practitioner. Only in these cases can the hospital would bill for the originating site facility fee (HCPCS code Q3014). See question 17 for additional details.
• If the beneficiary is within a hospital and receives a hospital outpatient clinic visit (including a mental/behavioral health visit) from a practitioner in the same physical location, then the hospital would bill for the clinic visit (HCPCS code G0463).
• If the beneficiary is in their home and receives a mental/behavioral health service from hospital staff through the use of telecommunications technology and no separate professional service can be billed, then the hospital would bill for the applicable HCPCS C-code describing this service (HCPCS codes C7900 – C7902).

Following the end of the PHE, can hospitals bill for outpatient physical therapy (PT), occupational therapy (OT), speech language pathology (SLP) services, Diabetes Self-Management Training (DSMT), or Medical Nutrition Therapy (MNT) provided to beneficiaries in their homes through telecommunication technology by hospital-employed staff?

In context of the end of the PHE, we have received a number of inquiries from interested parties regarding the expiration of this policy. We have reviewed all of the relevant guidance, including applicable billing instructions and external feedback, and recognize the confusion around these policies. We also recognize that the therapists and many of the other practitioners who provide these services remain on the list of distant site practitioners for Medicare telehealth services.

However, for DSMT services, we understand that some other types of hospital clinical staff, beyond those identified as eligible distant site practitioners for Medicare telehealth, can provide these services in some cases. To allow these services to continue to be furnished to patients in their home through telecommunication technology through the end of CY 2023, we are exercising enforcement discretion in reviewing the telehealth practitioner status of the clinical staff personally providing any part of a remotely furnished DSMT service, so long as the practitioner is otherwise qualified to provide the service. Through the end of CY 2023, PT, OT, SLP, DSMT, MNT providers should continue to bill for these services when furnished remotely in the same way they have been during the PHE.

Following the end of the PHE, can other facilities bill for outpatient physical therapy (PT), occupational therapy (OT), speech language pathology (SLP) services, Diabetes Self-Management Training (DSMT), or Medical Nutrition Therapy (MNT) provided to beneficiaries in their homes through telecommunication technology by their staff?

Similar to the questions we received regarding billing for outpatient therapy, DSMT, and MNT services in hospitals, in context of the end of the PHE, we have also received a number of inquiries from interested parties regarding the expiration of this policy as it relates to other facilities. We recognize that therapists and many of the other practitioners who provide these services remain on the list of distant site practitioners for Medicare telehealth services. PT, OT, SLP, DSMT, MNT providers should continue to bill for these telehealth services under the Medicare Physician Fee Schedule when furnished remotely in the same way they have been during the PHE.

Accordingly, outpatient therapy, DSMT, and MNT services furnished remotely by institutional providers of therapy services such as rehabilitation agencies and comprehensive outpatient rehabilitation facilities, not including those that are receiving payment under any

• Part A payment systems (home health agencies (HHAs) and skilled nursing facilities (SNFs)), should continue to be furnished and billed the same way they have been during the PHE, which can include the use of telecommunications technology and when billed on institutional claims forms.

For HHAs, all services within a 30-day period of care are part of a bundled prospective payment. As was the case during the PHE, while CMS allows services to be furnished via a telecommunications system so long as the services are included in a beneficiary’s plan of care, these services cannot be considered a “visit” for purposes of patient eligibility or payment per Medicare law, nor can they substitute for a home visit as ordered on the plan of care. Medicare is requiring HHAs to report the use of telecommunications technology in providing home health services on home health payment claims on July 1, 2023, and HHAs may voluntarily report this information until that time.

For SNFs and inpatient rehabilitation facilities (IRFs), under Part A, CMS pays through a bundled payment for all covered Part A services. To the extent that therapy services furnished via telehealth or telecommunications technology are covered Part A services, then these services would be considered part of the bundled prospective payment system payment under Part A and such services would not be separately billable for those patients in a Part A covered SNF or IRF stay. Again, Part B outpatient therapy, DSMT, and MNT services furnished remotely by institutional providers of therapy, should continue to be furnished and billed the same way they have been during the PHE, which can include the use of telecommunications technology.

SOURCE: Centers for Medicare and Medicaid Services, Frequently Asked Questions: CMS Waivers, Flexibilities and the End of the COVID-19 Public health Emergency, 5/19/23, (Accessed Mar. 2024).

Permanent Policy

Subject to paragraph (8), the Secretary shall pay to a physician or practitioner located at a distant site that furnishes a telehealth service to an eligible telehealth individual an amount equal to the amount that such physician or practitioner would have been paid under this subchapter had such service been furnished without the use of a telecommunications system.

SOURCE:  Social Security Act, Sec. 1834(m) (Title 42, Sec. 1395m).  (Accessed Mar. 2024).

The physician or practitioner at the distant site must be licensed to furnish the service under State law. The physician or practitioner at the distant site who is licensed under State law to furnish a covered telehealth service described in this section may bill, and receive payment for, the service when it is delivered via a telecommunications system.

The practitioner at the distant site is one of the following:

• A physician
• A nurse practitioner
• Physician Assistant
• A clinical nurse specialist
• A nurse-midwife
• A clinical psychologist
• A clinical social worker
• A registered dietitian or nutrition professional
• A certified registered nurse anesthetist
• Any distant site practitioner who can appropriately bill for diabetes self-management training services may do so on behalf of others who personally furnish the services as part of the DSMT entity.
• A marriage and family therapist
• A mental health counselor

Clinical psychologist and a clinical social worker, a marriage and family therapist (MFT), and a mental health counselor (MHC) may bill and receive payment for individual psychotherapy via a telecommunications system, but may not seek payment for medical evaluation and management services.

The physician visits required under § 483.40(c) of this title may not be furnished as telehealth services.

The distant site practitioner who reports the DSMT services may bill and receive payment when a professional furnishes injection training for an insulin-dependent patient using interactive telecommunications technology when such training is included as part of the DSMT plan of care referenced at § 410.141(b)(2).

SOURCE: 42 CFR Sec. 410.78, (Accessed Mar. 2024).

A distant site is the location where a physician or practitioner provides telehealth. Before the COVID-19 PHE, only certain types of distant site providers could provide and get paid for telehealth. Through December 31, 2024, all providers who are eligible to bill Medicare for professional services can provide distant site telehealth

Based on several telehealth-related provisions of the Consolidated Appropriations Act (CAA), 2023 and the CY 2024 PFS final rule, we’re:

• Expanding the scope of telehealth originating sites for services provided via telehealth to include any site in the U.S. where the patient is at the time of the telehealth service, including a person’s home
• Expanding the definition of telehealth practitioners to include qualified occupational therapists (OTs), physical therapists (PTs), speech-language pathologists (SLPs), and audiologists
• Adding mental health counselors and marriage and family therapists as distant site practitioners for purposes of providing telehealth services
• Continuing payment for telehealth services rural health clinics (RHCs) and federally qualified health centers (FQHCs) provided using the methodology established for those telehealth services during the PHE
• Delaying the requirement for an in-person visit with the physician or practitioner within 6 months before initiating mental health telehealth services, and, again, at subsequent intervals as the Secretary determines appropriate, as well as similar requirements for RHCs and FQHCs
• Allowing teaching physicians to use audio or video real-time communications technology when the resident provides Medicare telehealth services in all residency training locations through the end of CY 2024
• Removing frequency limitations in 2024 for:
  • Subsequent inpatient visits
  • Subsequent nursing facility visits
  • Critical care consultation
• Allowing hospitals and other providers of PT, OT, SLP, diabetes self-management training (DSMT) and medical nutrition therapy (MNT) services that remain on the Medicare Telehealth Services List to continue to bill for these services when provided remotely in the same way they’ve been during the PHE and the remainder of CY 2023, except that:
  • For outpatient hospitals, patients’ homes no longer need to be registered as provider-based entities to allow for hospitals to bill for these services
  • The 95 modifier is required on claims from all providers, except for Critical Access Hospitals (CAHs) electing Method II, as soon as hospitals needing to do so can update their systems

Place of Service (POS) Codes:

• For 2023, continue billing telehealth claims with the POS indicator you’d bill for an in-person visit
• Use modifier 95 when the clinician is in the hospital and the patient is in the home, as well as for outpatient therapy services provided via telehealth by qualified PTs, OTs, or SLPs through December 31, 2024
• Starting January 1, 2024, use:
  • POS 02-Telehealth to indicate you provided the billed service as a professional telehealth service when the originating site is other than the patient’s home
  • POS 10-Telehealth for services when the patient is in their home

SOURCE: Centers for Medicare and Medicaid Services (CMS), Telehealth Services MLN Fact Sheet, Feb. 2024, (Accessed Mar. 2024).

Beginning January 1, 2024, MHCs and MFTs can provide and bill Medicare telehealth services. Exceptions to the in-person visit requirement require a clear justification documented in the patient’s medical record. Hospitals must also document that patients have a regular source of general medical care and can get any needed point-of-care testing, including vital sign monitoring and lab studies.

SOURCE: Centers for Medicare and Medicaid Services, Medicare Learning Network Booklet 1986542, Medicare & Mental Health Coverage, Jan. 2024, (Accessed Mar. 2024).

After consideration of public comments, we are finalizing our proposal to add MFTs and MHCs as distant site practitioners for purposes of furnishing telehealth services. We are finalizing our proposed amendments to add MFTs and MHCs to the list of distant site  practitioners in the telehealth regulation at § 410.78(b)(2)(xi),(xii).

SOURCE: Center for Medicare and Medicaid Services, CY 2024 Physician Fee Schedule, Final Rule, CMS 1784-F, (Accessed Mar. 2024.

CMS allows Opioid Treatment Programs (OTPs) to use two-way interactive audio-video communication technology, as clinically appropriate, in furnishing substance use counseling and individual and group therapy services.  An intake add-on code by live video for the initiation of treatment with buprenorphine, when clinically appropriate and in compliance with other requirement was also added.

SOURCE:  CY 2020 Final Physician Fee Schedule. CMS, p. 249, & CY 2023 Final Physician Fee Schedule, CMS, p. 1055, (Accessed Mar. 2024).

After consideration of public comments, we are finalizing as proposed that beginning in CY 2024, claims for telehealth services billed with POS 10 will be paid at the non-facility PFS rate. Claims billed with POS 02 will continue to be paid at the facility rate. In addition, we are clarifying that modifier ’95’ should be used when the clinician is in the hospital and the patient is in the home, as well as for outpatient therapy services furnished via telehealth by PT, OT, or SLP.

SOURCE: Center for Medicare and Medicaid Services, CY 2024 Physician Fee Schedule, Final Rule, CMS 1784-F, (Accessed Mar. 2024).

Through CY 2024, we will continue to permit the distant site practitioner to use their currently enrolled practice location instead of their home address when providing telehealth services from their home. We will also consider this issue further for future rulemaking and request that interested parties provide clear examples of how the enrollment process shows material privacy risks to inform future enrollment and payment policy development. We request further information from interested parties to better understand the scope of considerations involved with including a practitioner’s home address as an enrolled practice location when that address is the distant site location where they furnish Medicare telehealth services.

SOURCE: Center for Medicare and Medicaid Services, CY 2024 Physician Fee Schedule, Final Rule, CMS 1784-F, (Accessed Mar. 2024).

Communication Technology-Based Services

Payment for communication technology-based and remote evaluation services. or communication technology-based and remote evaluation services furnished on or after January 1, 2019, payment to RHCs and FQHCs is at the rate set for each of the RHC and FQHC payment codes for communication technology-based and remote evaluation services.

SOURCE:  42 CFR 405.2464 (Accessed Mar. 2024).

RHCs and FQHCs are not eligible for reimbursement of interprofessional consultation services, as only practitioners that can bill Medicare independently for evaluation and management services are eligible.

SOURCE: CY 2019 Final Physician Fee Schedule. CMS, p. 31-40, (Accessed Mar. 2024).

Medicare waives the RHC and FQHC face-to-face requirements when an RHC or FQHC furnishes communication technology-based services (Includes the Brief Communication Technology-Based Service, Remote Evaluation of Pre-Recorded Patient Information) to an RHC or FQHC patient. RHCs and FQHCs receive payment for communication technology-based services or remote evaluation services when an RHC or FQHC practitioner provides at least 5 minutes of communications-based technology or remote evaluation services to a patient who has been seen in the RHC or FQHC within the previous year.

G0071 should be billed for both services.

SOURCE:  Medicare Learning Network Matters Factsheet, MM10843, Aug. 10, 2018, & Virtual Communication Services RHCs and FQHCs FAQs, December 2018, (Accessed Mar. 2024).

Mental Health for FQHCs and RHCs

Revised definition of a ‘mental health visit’ to include encounters furnished through interactive, real-time telecommunications technology, but only when furnishing services for purposes of diagnosis, evaluation or treatment of a mental health disorder.

FQHCs and RHCs will be able to furnish mental health visits to include visits furnished using interactive, real-time telecommunications technology and RHCs and FQHCs can report and be paid for furnishing those visits in the same way they currently do when these services are furnished in-person.  RHCs and FQHCs will be paid for mental health visits furnished via telecommunications technology at the same rate they are paid for in-person mental health visits (that is, the AIR or FQHC PPS).

There must be an in-person mental health service furnished within 6 months prior to the furnishing of the telecommunications service and that in general, there must be an in-person mental health service (without the use of telecommunications technology) must be provided at least every 12 months while the beneficiary is receiving services furnished via telecommunications technology for diagnosis, evaluation, or treatment of mental health disorders.  This applies only to patients receiving services at home.  If the patient and practitioner consider the risks and burdens of an in-person service and agree that, on balance, these outweigh the benefits, and the practitioner documents the basis for that decision in the patient’s medical record, then the in-person visit requirement is not applicable for that 12-month period.

In person requirement delayed under Medicare until on or after January 1, 2025.

SOURCE: CY 2022 Physician Fee Schedule, CMS, p. 214-215 & delay in implementation in HR 2617 (2022 Session).  (Accessed Mar. 2024).

RHCs and FQHCs can provide telecommunications for mental health visits using audio-video technology and audio-only technology. You may use audio-only technology in situations when your patient can’t access or doesn’t consent to use audio-video technology. You can report and get paid in the same way as in-person visits.

• Audio-video visits: Use modifier 95 (Synchronous Telemedicine Service Rendered via Real-Time Interactive Audio and Video Telecommunications System).
• Audio-only visits: Use new service-level modifier FQ or 93.

These in-person visit requirements apply only to a patient getting mental health visits via telecommunications at home:

• There must be an in-person mental health visit 6 months before the telecommunications visit
• In general, there must be an in-person mental health visit at least every 12 months while the patient is getting services from you via telecommunications to diagnose, evaluate, or treat mental health disorders

NOTE: Section 4113 of the Consolidated Appropriations Act (CAA), 2023, delayed the in-person visit requirements under Medicare for mental health visits that RHCs and FQHCs provide via telecommunications technology. For RHCs and FQHCs, we won’t require in-person visits until January 1, 2025.

CMS will allow for limited exceptions to the requirement for an in-person visit every 12 months based on patient circumstances in which the risks and burdens of an in-person visit may outweigh the benefit. These include, but aren’t limited to, when:

• An in-person visit is likely to cause disruption in service delivery or has the potential to worsen the patient’s condition
• The patient getting services is in partial or full remission and only needs maintenance level care
• The clinician’s professional judgment says that the patient is clinically stable and that an in-person visit has the risk of worsening the patient’s condition, creating undue hardship on self or family
• The patient is at risk of withdrawing from care that’s been effective in managing the illness

With proper documentation, the in-person visit requirement isn’t applicable for that 12-month period. You must document the circumstance in the patient’s medical record.

SOURCE: Mental Health Visits via Telecommunications for Rural Health Clinics and Federally Qualified Health Centers, MLN Matters SE22001, (May 23, 2023), (Accessed Mar. 2024).

A mental health visit is a medically-necessary face-to-face encounter between an RHC or FQHC patient and an RHC or FQHC practitioner during which time one or more RHC or FQHC mental health services are rendered. Effective January 1, 2022, a mental health visit is a face-to-face encounter or an encounter furnished using interactive, real-time, audio and video telecommunications technology or audio-only interactions in cases where the patient is not capable of, or does not consent to, the use of video technology for the purposes of diagnosis, evaluation or treatment of a mental health disorder.

The CAA, 2023 extends the telehealth policies of the CAA, 2022 through December 31, 2024 if the PHE ends prior to that date. The in-person visit requirements for mental health telehealth services and mental health visits furnished by RHCs and FQHCs begin on January 1, 2025 if the PHE ends prior to that date. There must be an in-person mental health service furnished within 6 months prior to the furnishing of the mental health service furnished via telecommunications and that an in-person mental health service (without the use of telecommunications technology) must be provided at least every 12 months while the beneficiary is receiving services furnished via telecommunications technology for diagnosis, evaluation, or treatment of mental health disorders, unless, for a particular 12-month period, the physician or practitioner and patient agree that the risks and burdens outweigh the benefits associated with furnishing the in-person item or service, and the practitioner documents the reasons for this decision in the patient’s medical record.

RHCs and FQHCs are instructed to append modifier 95 (Synchronous Telemedicine Service Rendered via Real-Time Interactive Audio and Video Telecommunications System) in instances where the mental health visit was furnished using audio-video communication technology and to append modifier 93 (Synchronous Telemedicine Service Rendered Via Telephone or Other Real-Time Interactive Audio-Only Telecommunications System) in cases where the service was furnished using audio-only communication.

Mental health services that qualify as stand-alone billable visits in an FQHC are listed on the FQHC center website, http://www.cms.gov/Center/Provider-Type/FederallyQualified-Health-Centers-FQHC- Center.html. Services furnished must be within the practitioner’s state scope of practice.

Medicare-covered mental health services furnished incident to an RHC or FQHC visit are included in the payment for a medically necessary mental health visit when an RHC or FQHC practitioner furnishes a mental health visit. Group mental health services do not meet the criteria for a one-one-one, face-to-face encounter in an FQHC or RHC.

SOURCE:  CMS, Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) Medicare Benefit Policy Manual Chapter 13 Update, Jan. 26, 2023, pg. 20 (Accessed Mar. 2024).

Home Health (HH) Agencies

Starting on or after January 1, 2023, they may voluntarily report the use of telecommunications technology in providing HH services on HH payment claims. CMS will require this information on HH claims starting on July 1, 2023. Home Health Agencies will submit the use of telecommunications technology on the HH claim using the following 3 G-codes:

• G0320: Home health services furnished using synchronous telemedicine rendered via a real-time two-way audio and video telecommunications system
• G0321: Home health services furnished using synchronous telemedicine rendered via telephone or other real-time interactive audio-only telecommunications system
• G0322: The collection of physiologic data digitally stored and/or transmitted by the patient to the home health agency (for example, remote patient monitoring)

SOURCE: Telehealth Home Health Services: G-Codes, MLN Matters MM12805, (Effective Date: Jan. 1, 2023), (Accessed Mar. 2024).

Can MFTs and MHCs perform telehealth services?

Yes. MFTs and MHCs have been added to the list of practitioners who can furnish Medicare telehealth services.

During the COVID-19 public health emergency (PHE), CMS used emergency waiver and other regulatory authorities so you could provide more services to your patients via telehealth. Section 4113 of the CAA, 2023 extended many of these flexibilities through December 31, 2024, and made some of them permanent. For more information refer to Telehealth Services Fact Sheet.

SOURCE: Centers for Medicare and Medicaid Services, Marriage and Family Therapists and Mental Health Counselors, Provider Enrollment Frequently Asked Questions, March 2024, (Accessed Mar. 2024).

ELIGIBLE SITES

Temporary Policy – Ends Dec. 31, 2024

In the case that the emergency period described in section 1320b–5(g)(1)(B) of this title ends before December 31, 2024, with respect to telehealth services identified in subparagraph (F)(i) as of March 15, 2022, that are furnished during the period beginning on the first day after the end of such emergency period and ending on December 31, 2024, the term “originating site” means any site in the United States at which the eligible telehealth individual is located at the time the service is furnished via a telecommunications system, including the home of an individual.

SOURCE:  Social Security Act, Sec. 1834(m) (Title 42, Sec. 1395m) as amended by HR 2617 (2022 Session).  (Accessed Mar. 2024).

Permanent Policy

Eligible Sites:

• The office of a physician or practitioner.
• A critical access hospital
• A rural health clinic
• A Federally qualified health center
• A hospital
• A hospital-based or critical access hospital- based renal dialysis center (including satellites).
• A skilled nursing facility
• Rural emergency hospital
• A community mental health center
• A renal dialysis facility for purposes of individuals with end-stage renal disease getting home dialysis.
• The home of an individual, but only for purposes of individuals with end-stage renal disease getting home dialysis or telehealth services to treat substance use disorder or individuals with co-occurring mental health disorders, or mental health disorders under certain circumstances.
• Mobile Stroke Unit
• The home of a beneficiary for the purposes of diagnosis, evaluation, and/or treatment of a mental health disorder for services furnished on or after the first day after the end of the PHE as defined in our regulation at § 400.200 except as otherwise provided in this paragraph. Payment will not be made for a telehealth service furnished under this paragraph unless the following conditions are met:
  • The physician or practitioner has furnished an item or service in-person, without the use of telehealth, for which Medicare payment was made (or would have been made if the patient were entitled to, or enrolled for, Medicare benefits at the time the item or service is furnished) within 6 months prior to the initial telehealth service;
  • The physician or practitioner has furnished an item or service in-person, without the use of telehealth, at least once within 12 months of each subsequent telehealth service described in this paragraph, unless, for a particular 12-month period, the physician or practitioner and patient agree that the risks and burdens associated with an in-person service outweigh the benefits associated with furnishing the in-person item or service, and the practitioner documents the reason(s) for this decision in the patient’s medical record.
  • The requirements of paragraphs (b)(3)(xiv)(A) and (B) may be met by another physician or practitioner of the same specialty and subspecialty in the same group as the physician or practitioner who furnishes the telehealth service, if the physician or practitioner who furnishes the telehealth service described under this paragraph is not available.

Note:

• The Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act removed originating site geographic conditions and added an individual’s home as a permissible originating telehealth services substance use disorder or co-occurring mental health treatment site.
• Medicare doesn’t apply originating site geographic conditions to hospital-based and CAH based renal dialysis centers, renal dialysis facilities, and patient homes when practitioners provide monthly ESRD-related medical evaluations in patient homes. Independent Renal Dialysis Facilities aren’t eligible originating sites.

SOURCE:  Social Security Act, Sec. 1834(m) (US Code Title 42, Sec. 1395m) & 42 CFR Sec. 410.78.  (Accessed Mar. 2024).

Requirements for mental health services furnished through telehealth (Delay of In-Person mental health requirement)

Payment may not be made under this paragraph for telehealth services furnished on or after January 1, 2025 (or, if later, the first day after the end of the emergency period described in section 1320b–5(g)(1)(B) of this title) by a physician or practitioner to an eligible telehealth individual for purposes of diagnosis, evaluation, or treatment of a mental health disorder unless such physician or practitioner furnishes an item or service in person, without the use of telehealth, for which payment is made under this subchapter (or would have been made under this subchapter if such individual were entitled to, or enrolled for, benefits under this subchapter at the time such item or service is furnished)—

• within the 6-month period prior to the first time such physician or practitioner furnishes such a telehealth service to the eligible telehealth individual; and
• during subsequent periods in which such physician or practitioner furnishes such telehealth services to the eligible telehealth individual, at such times as the Secretary determines appropriate.

These requirements do not apply to services:

• Under this paragraph (with respect to telehealth services furnished to an eligible telehealth individual with a substance use disorder diagnosis for purposes of treatment of such disorder or co-occurring mental health disorder); or
• under this subsection without application of this paragraph.

SOURCE:  Social Security Act, Sec. 1834(m) (Title 42, Sec. 1395m).  (Accessed Mar. 2024).

An originating site is the location where a patient gets physician or practitioner medical services through telehealth. Before the COVID-19 PHE, patients needed to get telehealth at an originating site located in a certain geographic location.

Through December 31, 2024, all patients can get telehealth wherever they’re located. They don’t need to be at an originating site, and there aren’t any geographic restrictions.

After December 31, 2024:

• For non-behavioral or mental telehealth, there may be originating site requirements and geographic location restrictions
• For behavioral or mental telehealth, all patients can continue to get telehealth wherever they’re located, with no originating site requirements or geographic location restrictions

SOURCE: Centers for Medicare and Medicaid Services (CMS), Telehealth Services MLN Fact Sheet, Feb. 2024, (Accessed Mar. 2024).

Exceptions to the in-person visit requirement require a clear justification documented in the patient’s medical record. Hospitals must also document that patients have a regular source of general medical care and can get any needed point-of-care testing, including vital sign monitoring and lab studies.

We created 3 Outpatient Prospective Payment System (OPPS)-specific HCPCS codes to describe that the patient must be in their home and that no associated professional service is billed under the PFS. Hospital staff must be licensed to provide these services consistent with all applicable state scope of practice laws. We exempt these services from having staff physically located in the hospital or outpatient department when providing services remotely using communication technology.  See booklet for list of codes.

SOURCE: Centers for Medicare and Medicaid Services, Medicare Learning Network Booklet 1986542, Medicare & Mental Health Coverage, Jan. 2024, (Accessed Mar. 2024).

CMS has directed place of service (POS) code 02 to be used for telehealth provided in places other than the patient’s home.  POS code 10 should be used when telehealth is provided in the patient’s home.

SOURCE: Medicare Learning Network, MLN # MM12427, New/Modifications to the Place of Service POS Codes for Telehealth, Jan. 1, 2022 (implementation Apr. 4, 2022), (Accessed Mar. 2024).

In addition to the requirement for the in-person visit mentioned above in statute, CMS will also require there to be a an in-person, non-telehealth service within 12 months of each mental health telehealth service.  However, if the patient and practitioner agree that the benefits of an in-person, non-telehealth service within 12 months of the mental health telehealth service are outweighed by risks and burdens associated with an in-person service, and the basis for that decision is documented in the patient’s medical record, the in-person visit requirement will not apply for that particular 12-month period.  This applies only to patients receiving services at home.  CMS will allow a clinician’s colleague in the same subspecialty in the same group to furnish the in-person, non-telehealth service to the beneficiary if the original practitioner is unavailable.

The home (for purposes of mental health reimbursement), can include temporary lodging, such as hotels and homeless shelters.  CMS clarifies that for circumstances where the patient, for privacy or other personal reasons, chooses to travel a short distance from the exact home location during a telehealth services, the services is still considered to be furnished “in the home of an individual”.

In person requirement delayed under Medicare until on or after January 1, 2025.

SOURCE: CY 2022 Physician Fee Schedule, CMS, p. 63 & 64, & delay in implementation in HR 2617 (2022 Session).  (Accessed Mar. 2024).

Treatment of stroke telehealth services

The requirements described in paragraph (4)(C) shall not apply with respect to telehealth services furnished on or after January 1, 2019, for purposes of diagnosis, evaluation, or treatment of symptoms of an acute stroke, as determined by the Secretary.

With respect to telehealth services for acute stroke, the term “originating site” shall include any or critical access hospital, any mobile stroke unit, or any other site determined appropriate by the Secretary, at which the eligible telehealth individual is located at the time the service is furnished via a telecommunications system.

SOURCE:  Social Security Act, Sec. 1834(m) (Title 42, Sec. 1395m).  (Accessed Mar. 2024).

After consideration of public comments, we are finalizing as proposed that beginning in CY 2024, claims for telehealth services billed with POS 10 will be paid at the non-facility PFS rate. Claims billed with POS 02 will continue to be paid at the facility rate. In addition, we are clarifying that modifier ’95’ should be used when the clinician is in the hospital and the patient is in the home, as well as for outpatient therapy services furnished via telehealth by PT, OT, or SLP.

SOURCE: Center for Medicare and Medicaid Services, CY 2024 Physician Fee Schedule, Final Rule, CMS 1784-F, (Accessed Mar. 2024).

Accountable Care Organizations (two-sided model tested or expanded under 1115A of the Social Security Act)

In the case of telehealth services for which payment would otherwise be made under this title furnished on or after January 1, 2020, the home of a beneficiary shall be treated as an originating site.  In the case of telehealth services where the home of a Medicare fee-for-service beneficiary is the originating site, the following shall apply:

• There shall be no facility fee paid to the originating site.
• No payment may be made for such services that are inappropriate to furnish in the home setting such as services that are typically furnished in inpatient settings such as a hospital.

SOURCE:  Social Security Act Sec. 1899 (Accessed Mar. 2024).

Hospital Expansion Site

Hospitals Able to Provide Care in Temporary Expansion Sites: As part of the CMS Hospital Without Walls initiative during the PHE, hospitals could provide hospital services in other hospitals and sites that otherwise would not have been considered part of a healthcare facility, or could set up temporary expansion sites to help address the urgent need to increase capacity to care for patients. During the PHE, CMS provided additional flexibilities for hospitals to create surge capacity by allowing them to provide room and board, nursing, and other hospital services at remote locations, such as hotels or community facilities. During the PHE, hospitals are expected to control and oversee the services provided at an alternative location. When the PHE ends, hospitals and CAHs will be required to provide services to patients within their hospital departments, pursuant to Hospital and CAH conditions of participation at 42 CFR part 482 and part 485, Subpart F, respectively.

Hospital Without Walls

CMS permitted ambulatory surgical centers (ASCs) to temporarily reenroll as hospitals and to provide hospital services to help address the urgent need to increase hospital capacity to take care of patients. Other interested entities, such as independent, freestanding, emergency departments (IFEDs), could pursue temporarily enrolling as a hospital during the PHE. (As of December 1, 2021, no new ASC or new IFED requests to temporarily enroll as hospitals were being accepted.) See https://www.cms.gov/files/document/provider-enrollment-relief-faqscovid-19.pdf for additional information. When the PHE ends, ASCs must decide either to meet the certification standards for hospitals at 42 CFR part 482, or return to ASC status. If they choose to return to ASC status, they can only be paid under the ASC payment system for services on the ASC Covered Procedures List. When the PHE ends, IFEDs cannot bill Medicare for services as their temporary Medicare certification would end.

SOURCE: Centers for Medicare and Medicaid Services, Hospitals and CAHs (including Swing Beds, DPUs), ASCs and CMHCs: CMS Flexibilities to Fight COVID-19, 6/26/23, (Accessed Mar. 2024).

If the Hospitals Without Walls Initiative expires at the end of the day on May 11, 2023, why are beneficiaries able to receive mental/behavioral health services in their home from hospital staff through the use of telecommunications technology after that date?

The flexibilities currently in place under the Hospital Without Walls Initiative during the COVID-19 PHE allowed hospitals to bill for services furnished by hospital clinical staff to beneficiaries in their homes using telecommunications technology, because the home was considered a provider-based department of the hospital. The services included a subset of hospital outpatient therapy, counseling, and educational services, beyond just mental/behavioral health services.

After the PHE ends, in some circumstances, hospitals will continue to be able to bill for mental/behavioral health services furnished to beneficiaries in their homes by hospital staff using telecommunications technology permanently. This policy only applies when no separate professional service is billable, as finalized in the calendar year 2023 Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems final rule (87 FR 71748). These services are considered “remote mental health services.” However, once the beneficiary’s home is no longer considered a provider-based department of the hospital after the end of the PHE, the hospital staff will no longer be able to bill for other outpatient services furnished to beneficiaries in the home.

Notably, in accordance with the Consolidated Appropriations Act, 2023, eligible distant site physicians and practitioners may still be able to bill as a Medicare telehealth service under the Medicare physician fee schedule for professional services furnished via telehealth to individuals in their homes through December 31, 2024.

SOURCE: Centers for Medicare and Medicaid Services, Frequently Asked Questions: CMS Waivers, Flexibilities and the End of the COVID-19 Public health Emergency, 5/19/23, (Accessed Mar. 2024).

When physical and occupational therapists were allowed to provide services via telehealth, CMS used waiver authority to implement the Hospital Without Walls (HWW) policy that allowed the patients’ home to be classified as part of the hospital. This allowed the hospital “to bill both the hospital facility payment in association with professional services billed under the PFS and single payment for a limited number of practitioners services, when statute or other applicable rules only allow the hospital to bill for services personally provided by their staff. These services are either billed by hospitals or by professionals, there would not be separate facility and professional billing.” When the PHE ended, CMS originally thought to end this policy but is now considering whether some institutions may be able to bill for certain services provided remotely by employed practitioners. Therefore, institutional staff providing outpatient therapy, DSMT and MNT services via telehealth may bill the same way they did during the PHE until the end of 2024. For hospitals, beneficiaries’ homes will no longer need to be registered as provider-based departments of the hospital to allow for hospitals to bill for these services. With the exception of Method II critical access hospitals (CAHs), the 95 modifier will be used on each applicable line if telehealth is used. CAHs using Method II payment will continue using GT/GQ.

SOURCE: Center for Medicare and Medicaid Services, CY 2024 Physician Fee Schedule, Final Rule, CMS 1784-F, (Accessed Mar. 2024).

GEOGRAPHIC LIMITS

Temporary Policy – Ends Dec. 31, 2024

In the case that the emergency period described in section 1320b–5(g)(1)(B) of this title ends before December 31, 2024, with respect to telehealth services identified in subparagraph (F)(i) as of March 15, 2022, that are furnished during the period beginning on the first day after the end of such emergency period and ending on December 31, 2024, the term “originating site” means any site in the United States at which the eligible telehealth individual is located at the time the service is furnished via a telecommunications system, including the home of an individual.

SOURCE:  Social Security Act, Sec. 1834(m) (Title 42, Sec. 1395m).  (Accessed Mar. 2024).

Permanent Policy

The term “originating site” means only those sites described below:

• In an area that is designated as a rural health professional shortage area under section 332(a)(1)(A) of the Public Health Service Act
• In a county that is not included in a Metropolitan Statistical Area; or
• From an entity that participates in a Federal telemedicine demonstration project that has been approved by (or receives funding from) the Secretary of Health and Human Services as of December 31, 2000.

The geographic requirements shall not apply with respect to telehealth services furnished on or after January 1, 2019, for purposes of the home dialysis monthly ESRD-related visit, at a hospital-based or critical access hospital-based renal dialysis center, a renal dialysis facility, or the home.

Additional exceptions exist for treatment of acute stroke, substance use disorder and mental health (see below).

The Health Resources and Services Administration (HRSA) decides HPSAs and the Census Bureau decides MSAs. Find potential Medicare telehealth originating site payment eligibility at HRSA’s Medicare Telehealth Payment Eligibility Analyzer.

SOURCE:  Social Security Act, Sec. 1834(m) (Title 42, Sec. 1395m), (Accessed Mar. 2024).

Treatment of stroke telehealth services

The geographic requirements shall not apply with respect to telehealth services furnished on or after January 1, 2019, for purposes of diagnosis, evaluation, or treatment of symptoms of an acute stroke, as determined by the Secretary.

With respect to telehealth services to treat acute stroke, the term “originating site” shall include any hospital or critical access hospital, any mobile stroke unit, or any other site determined appropriate by the Secretary, at which the eligible telehealth individual is located at the time the service is furnished via a telecommunications system.

SOURCE:  Social Security Act, Sec. 1834(m) (Title 42, Sec. 1395m).  (Accessed Mar. 2024).

An originating site is the location where a patient gets physician or practitioner medical services through telehealth. Before the COVID-19 PHE, patients needed to get telehealth at an originating site located in a certain geographic location.

Through December 31, 2024, all patients can get telehealth wherever they’re located. They don’t need to be at an originating site, and there aren’t any geographic restrictions.

After December 31, 2024:

• For non-behavioral or mental telehealth, there may be originating site requirements and geographic location restrictions
• For behavioral or mental telehealth, all patients can continue to get telehealth wherever they’re located, with no originating site requirements or geographic location restrictions

SOURCE: Centers for Medicare and Medicaid Services (CMS), Telehealth Services MLN Fact Sheet, Feb. 2024, (Accessed Mar. 2024).

Except as provided in paragraph (b)(4)(iv) of this section, originating sites must be:

• Located in a health professional shortage area (as defined under section 332(a)(1)(A) of the Public Health Service Act that is either outside of a Metropolitan Statistical Area (MSA) as of December 31st of the preceding calendar year or within a rural census tract of an MSA as determined by the Office of Rural Health Policy of the Health Resources and Services Administration as of December 31st of the preceding calendar year, or
• Located in a county that is not included in a Metropolitan Statistical Area as defined in section 1886(d)(2)(D) of the Act as of December 31st of the preceding year, or
• An entity participating in a Federal telemedicine demonstration project that has been approved by, or receive funding from, the Secretary as of December 31, 2000, regardless of its geographic location.

The geographic requirements specified above do not apply to the following telehealth services:

• Home dialysis monthly ESRD-related clinical assessment services furnished on or after January 1, 2019, at an originating site described in paragraphs (b)(3)(vi), (ix) or (x) of this section, in accordance with section 1881(b)(3)(B) of the Act; and
• Services furnished on or after January 1, 2019, for purposes of diagnosis, evaluation, or treatment of symptoms of an acute stroke.
• Services furnished on or after July 1, 2019 to an individual with a substance use disorder diagnosis, for purposes of treatment of a substance use disorder or a co-occurring mental health disorder.
• Services furnished on or after January 1, 2025 for the purposes of diagnosis, evaluation, and/or treatment of a mental health disorder. Payment will not be made for a telehealth service furnished under this paragraph unless the physician or practitioner has furnished an item or service in person, without the use of telehealth, for which Medicare payment was made (or would have been made if the patient were entitled to, or enrolled for, Medicare benefits at the time the item or service is furnished) within 6 months prior to the initial telehealth service and within 6 months of any subsequent telehealth service.

SOURCE: 42 CFR Sec. 410.78 (Accessed Mar. 2024).

Accountable Care Organizations (two-sided model tested or expanded under 1115A of the Social Security Act)

In the case of telehealth services for which payment would otherwise be made under this title furnished on or after January 1, 2020, the geographic limitation shall not apply with respect to any eligible originating site (including the home of a beneficiary) subject to State licensing requirements.

SOURCE:  Social Security Act Sec. 1899 (Accessed Mar. 2024).

FACILITY/TRANSMISSION FEE

Eligible originating sites are eligible for a facility fee equal to:

• for the period beginning on October 1, 2001, and ending on December 31, 2001, and for 2002, $20; and
• for a subsequent year, the facility fee specified in subclause (I) or this subclause for the preceding year increased by the percentage increase in the MEI (as defined in section 1842(i)(3)) for such subsequent year.

No facility fee shall be paid under this subparagraph to an originating site that is the home.

Treatment of Acute Stroke:  No facility fee shall be paid to an originating site with respect to a telehealth service if the originating site does not otherwise meet the requirements for an originating site, including geographic requirements.

SOURCE:  Social Security Act, Sec. 1834(m) (Title 42, Sec. 1395m).  (Accessed Mar. 2024).

No facility fee for new sites. In the case that the emergency period described in section 1320b–5(g)(1)(B) of this title ends before December 31, 2024, with respect to telehealth services identified in paragraph (4)(F)(i) as of March 15, 2022, that are furnished during the period beginning on the first day after the end of such emergency period and ending December 31, 2024, a facility fee shall only be paid under this subparagraph to an originating site that is described in paragraph (4)(C)(ii) (other than subclause (X) of such paragraph).

SOURCE:  Social Security Act, Sec. 1834(m) (Title 42, Sec. 1395m).  (Accessed Mar. 2024).

Hospital Originating Site Facility Fee for Professional Services Furnished Via Telehealth: When a physician or nonphysician practitioner, who typically furnishes professional services in the hospital outpatient department, furnishes telehealth services to the patient’s home during the COVID-19 PHE as a “distant site” practitioner, they bill with a hospital outpatient place of service, since that is likely where the services would have been furnished if not for the COVID19 PHE. The physician or practitioner is paid for the service under the PFS at the facility rate, which does not include payment for resources, such as clinical staff, supplies, or office overhead, since those things are usually supplied by the hospital outpatient department. The hospital may bill under the OPPS for the originating site facility fee associated with the telehealth service.

SOURCE: Centers for Medicare and Medicaid Services, Hospitals and CAHs (including Swing Beds, DPUs), ASCs and CMHCs: CMS Flexibilities to Fight COVID-19, 6/26/23, (Accessed Mar. 2024).

After the end of the PHE, can hospitals bill for the originating site facility fee (HCPCS code Q3014) when a beneficiary is not in the hospital but a hospital-based outpatient department physician furnishes a Medicare telehealth service and the hospital provides administrative and clinical support?

No. Following the anticipated end of the PHE (May 11, 2023), hospitals will no longer be able to bill HCPCS code Q3014 to account for the resources associated with administrative support for a professional Medicare telehealth service.

SOURCE: Centers for Medicare and Medicaid Services, Frequently Asked Questions: CMS Waivers, Flexibilities and the End of the COVID-19 Public health Emergency, 5/19/23, (Accessed Mar. 2024).

HCPCS Code Q3014 describes the Medicare telehealth originating sites facility fee. Bill your MAC for the separately billable Part B originating site facility fee. The payment amount for HCPCS code Q3014 (Telehealth originating site facility fee) is 80% of the lesser of the actual charge ($28.64 for CY 2023 services and $29.96 for CY 2024 services). We base this on the percentage increase in the Medicare Economic Index (MEI) as defined in section 1842(i)(3) of the Social Security Act. The 2023 MEI increase is 3.8%. The patient is responsible for any unmet deductible amount and coinsurance. See MLN Matters Article MM12982 to learn about the CY 2023 Medicare Physician Fee Schedule Final Rule Summary.

SOURCE: Centers for Medicare and Medicaid Services (CMS), Telehealth Services MLN Fact Sheet, Feb. 2024, (Accessed Mar. 2024).

POLICY

This general information is related to the telehealth medical services rendered by Alabama Medicaid (Medicaid) providers. Providers are expected to comply with Alabama’s Telehealth Medical Services law (Code of Alabama, Sections 34-24-701 through 34-24-707) at all times.

Services must be administered via an interactive audio or audio and video telecommunications system which permits two-way communication between the distant site provider and the site where the recipient is located (this does not include electronic mail message or facsimile transmission between the provider and recipient).

Providers meeting the telemedicine provider requirements listed above must append one of the following modifiers indicating the mode of telemedicine service delivery:

• GT for covered telemedicine services delivered via audio and visual telecommunications.
• FQ for covered telemedicine services delivered via audio only telecommunications.

Additional modifiers may be required. Refer to the chapter of the Provider Billing Manual that describes services provided for further information.

Reimbursement for services provided via telemedicine, audio only and audio and video telecommunications, will be paid at parity to those services provided face-to-face. Medicaid will continue to monitor and reevaluate, if deemed necessary.

SOURCE: AL Medicaid Management Information System Provider Manual, Telemedicine Services, Ch. 112, Jan. 2024, (Accessed Feb. 2024).

Telemedicine: Telemedicine services are covered for limited specialties and under special circumstances. Refer to the Alabama Medicaid Provider Manual, Chapter 28 for details on coverage.

SOURCE:  AL Admin. Code r. 560-X-6-.14(f)(5). (Accessed Feb. 2024).

Therapy Services

Services must be administered via an interactive audio and video telecommunications system which permits two-way communication between the distant site provider and the origination site where the recipient is located (this does not include a telephone conversation, electronic mail message, or facsimile transmission between the provider, recipient, or a consultation between two providers).

Telemedicine health care providers shall ensure that the telecommunication technology and equipment used at the recipient site and at the provider site, is sufficient to allow the provider to appropriately evaluate, diagnose, and/or treat the recipient for services billed to Medicaid. Transmissions must utilize an acceptable method of encryption adequate to protect the confidentiality and integrity of the transmission information. Transmissions must employ acceptable authentication and identification procedures by both the sender and the receiver.

SOURCE: AL Medicaid Management Information System Provider Manual, Therapy Services, Jan. 2024, pg. 16, (Accessed Feb. 2024).

Several manual chapters refer to telemedicine chapter for information.

ELIGIBLE SERVICES/SPECIALTIES

Services rendered via telecommunication system must be provided by a provider who is licensed, registered, or otherwise authorized to engage in his or her healthcare profession in the state where the patient is located. Per Alabama law, the provision of telemedicine medical services is deemed to occur at the patient’s originating site within this state.

Services must be within the provider’s scope of license.

Services must be provided to a recipient that is an established patient of the provider or practice or due to a referral made by a patient’s licensed physician with whom the patient has an established physician-patient relationship, in the usual course of treatment of the patient’s existing health condition.

A covered telemedicine service will count as part of each recipient’s benefit limit of 14 annual physician office visits currently allowed, if applicable.

Specific covered services list provided in manual by provider type (page. 8-10).

Services NOT Eligible for Reimbursement for Telemedicine Services

Common examples of services via telemedicine not considered for reimbursement (not exhaustive):

• Chart reviews
• Electronic mail messages (between providers and recipients)
• Facsimile transmissions (between providers and recipients)
• Consultation between two providers
• Internet based communications that are not HIPAA-compliant or secure
• Services not directly provided by an enrolled provider or by office staff
• Services not normally charged for during an office visit
• Services not specifically listed in Provider Billing Manual chapters
• Communication that is not secure or HIPAA-compliant (e.g., Skype, FaceTime)

Exceptions may be made to the lists for providers and services not reimbursable under this policy in the event of a public health emergency, however, separate guidance would be issued in those instances.

BMI Requirements

The BMI will be required for office visits including the telemedicine visits. The BMI is required at least once per calendar year on all claims with procedure codes 99201-99205, 99211- 99215, and 99241-99245 and EPSDT procedure codes 99382-99385 and 99392-99395. Providers should use subjective data to calculate the BMI which can include providers asking the recipient for his or her height and weight during the telemedicine visit. The BMI should be calculated, based on the information provided by the recipient, and appended to the claim for reimbursement. The BMI should also be documented in the recipient’s medical record.

SOURCE: AL Medicaid Management Information System Provider Manual, Telemedicine Services, Ch. 112, Jan. 2024 (Accessed Feb. 2024).

Telemedicine services are covered for limited specialties and under special circumstances.

SOURCE:  AL Admin. Code r. 560-X-6-.14(f)(5). (Accessed Feb. 2024).

Rehabilitation services that are delivered face to face can either be in person or via telemedicine/telehealth, as approved by the Alabama Medicaid Agency.  Some services in manual specify that they can be delivered in person or via telemedicine.

SOURCE: AL Medicaid Management Information System Provider Manual, Rehabilitative Services – DMH, DHR, DYS, DCA, Ch. 105,   Jan. 2024. (Accessed Feb. 2024).

ABA Therapy Services

Telemedicine health care providers shall ensure that the telecommunication technology and equipment used at the recipient site and at the provider site, is sufficient to allow the provider to appropriately evaluate, diagnose, and/or treat the recipient for services billed to Medicaid.

SOURCE: AL Medicaid Management Information System Provider Manual, Therapy Services, Jan. 2024, pg. 16, (Accessed Feb. 2024).

Nurse-Family Partnership

NFP nurse visiting services include care coordination, assessments and screenings, case management, and preventative health education and counseling. These nursing services are tailored to each woman’s needs and delivered in-person or via telehealth in the home setting, or in an alternative community setting as indicated by recipient’s need.

Effective January 1, 2024, at least one of the minimal two monthly visits must be in-person or face-to-face to be eligible for reimbursement by Medicaid.

SOURCE: AL Medicaid Management Information System Provider Manual, Nurse Family Partnership, Ch. 41, Jan. 2024, (Accessed Feb. 2024).

Prescriptions for Certain Home Health Services

The required face-to-face visit may be conducted using telehealth systems.

SOURCE: AL Admin Code 560-X-6-.01, (Accessed Feb. 2024).

ELIGIBLE PROVIDERS

Providers must submit the Telemedicine Service Agreement/Certification to Medicaid’s fiscal agent. The form is located on the Medicaid website at: www.medicaid.alabama.gov. Once the form is received, providers will be enrolled with Medicaid with a specialty type of 931 (Telemedicine Service). Providers must have the specialty type of 931 to bill for telemedicine services.

Provider Types Eligible for Reimbursement for Telemedicine Services

• Physicians
• Certified Registered Nurse Practitioners (CRNPs)
• Physician Assistants
• Rehabilitative Option Providers
• Psychologists
• Licensed Professional Counselors
• Associate Licensed Counselors
• Licensed Marriage and Family Therapist and Associates
• Licensed Master Social Workers
• Licensed Independent Clinical Social Workers
• Licensed Psychological Technicians
• Speech Therapists
• Optometrists
• Applied Behavior Analysts
• Early Intervention
• Children’s Rehabilitation Service
• Pharmacists/Pharmacies
• Targeted Case Management

Provider Types NOT Eligible for Telemedicine Reimbursement

• Physical Therapists
• Occupational Therapists
• DME suppliers
• Ambulance providers
• Chiropractors
• Home Infusion
• Laboratory

Refer to the respective Alabama Medicaid Provider Billing Manual chapter that describes the service rendered by providers listed above for general enrollment information.

Telemedicine Provider Requirements

Providers must identify themselves to the recipient with their credentials and name at the time of service.

Providers must obtain prior written or verbal consent from the recipient before services are rendered.

Telemedicine services may only be provided as a result of a patient’s request, part of an expected follow up, or a referral from the patient’s licensed physician with whom the patient has an established patient-physician relationship.

Services rendered via telecommunication system must be provided by a provider who is licensed, registered, or otherwise authorized to engage in his or her healthcare profession in the state where the patient is located. Per Alabama law, the provision of telemedicine medical services is deemed to occur at the patient’s originating site within this state.

Services must be within the provider’s scope of license.

Services must be provided to a recipient that is an established patient of the provider or practice or due to a referral made by a patient’s licensed physician with whom the patient has an established physician-patient relationship, in the usual course of treatment of the patient’s existing health condition.

Telemedicine services provided to minors under the age of medical consent must have a parent or legal guardian attend the telemedicine visit.

Only the provider rendering the services via telemedicine may submit for reimbursement for services.

Providers must indicate an in-state or qualifying bordering state site of practice address from which telemedicine services will be provided. This policy does not expand or grant any authority outside that authority granted to the provider by their respective licensure board or by federal or state law.

SOURCE: AL Medicaid Management Information System Provider Manual, Telemedicine Services, Ch. 112, Jan. 2024, (Accessed Feb. 2024).

Telemedicine providers who render maternity related services are required to sign a DHCP agreement with one of the ACHNs to receive reimbursement from Medicaid. Refer to Chapter 112 of the Provider Billing Manual to determine further requirements and procedure codes for telemedicine services.

Beginning July 8, 2020, Medicaid will allow physicians enrolled with the specialties OB/GYN (specialty type 328) and telemedicine (specialty type 931) to be reimbursed for maternity services with a referral from either an ACHN or the referring DHCP. The NPI of the ACHN, the DHCP, or the referring DHCP’s group must be on the claim for reimbursement. Refer to section 40.43.2 (DHCP Selection Referral Number) for more detailed billing information.

Telemedicine providers who render maternity-related services are required to sign a Non-Delivering Telemedicine DHCP Participation agreement with at least one of the ACHNs in order to receive reimbursement from Medicaid. Refer to Chapter 112 of the Provider Billing Manual to determine further requirements and procedure codes allowed for telemedicine services.

SOURCE: AL Medicaid Management Information System Provider Manual, Alabama Coordinated Health Network (ACHN) Primary Care Physician (PCP) and Delivering Healthcare Professional (DHCP) Billing, (Manual Ch. 40-p. 33). Jan. 2024, (Accessed Feb. 2024).

Rehabilitation services that are delivered face to face can either be in person or via telemedicine/telehealth, as approved by the Alabama Medicaid Agency.

All services rendered by a physician, physician assistant, or nurse practitioner that meet the definition above should be billed under this code including those rendered via teleconference with a direct service or consultation recipient. Please refer to the section titled Telehealth Billing Guidelines for more information.

SOURCE: AL Medicaid Management Information System Provider Manual, Rehabilitative Services – DMH, DHR, DYS, DCA(105, p. 1 & 16). Jan. 2024. (Accessed Feb. 2024).

The face-to-face encounter required for the ordering of home health services may be conducted using telehealth systems.

SOURCE: AL Medicaid Management Information System Provider Manual, Home Health (17-p. 2) Jan. 2024, (Accessed Feb. 2024).

The required face-to-face visit may be conducted using telehealth systems.

SOURCE: AL Medicaid Management Information System Provider Manual, Durable Medical Equipment, 14-10,  Jan. 2024. (Accessed Feb. 2024).

Therapy Services

The provider shall maintain appropriately trained staff, or employees, familiar with the recipient’s treatment plan, immediately available in-person to the recipient receiving a telemedicine service to attend to any urgencies or emergencies that may occur during the session. The provider shall implement confidentiality protocols that include, but are not limited to:

• specifying the individuals who have access to electronic records; and
• usage of unique passwords or identifiers for each employee or other person with access to the client records; and
• ensuring a system to prevent unauthorized access, particularly via the Internet; and
• ensuring a system to routinely track and permanently record access to such electronic medical information

These protocols and guidelines must be available to inspection at the telemedicine site and to the Medicaid Agency upon request.

SOURCE: AL Medicaid Management Information System Provider Manual, Therapy Services, Jan. 2024, pg. 16-17, (Accessed Feb. 2024).

For ABA therapy or PBS services listed above provided via telemedicine, enrolled providers are eligible to participate in the Telemedicine Program to provide medically necessary telemedicine services to Alabama Medicaid eligible recipients. In order to participate in the telemedicine program:

• Providers must be enrolled with Alabama Medicaid with a specialty type of 931 (Telemedicine Service).
• To be enrolled with the 931 specialty, providers must submit the Telemedicine Service Agreement/Certification form which is located on the Medicaid website at: www.medicaid.alabama.gov. Electronic signatures will be acceptable for the telemedicine agreement. The agreement may be uploaded through the provider web portal along with a request to add the 931 specialty. See Chapter 2 – Becoming a Medicaid Provider for further information.
• Providers must obtain prior consent from the recipient before services are rendered. A sample recipient consent form is attached to the Telemedicine Service Agreement.

SOURCE: AL Medicaid Management Information System Provider Manual, Therapy Services, Jan. 2024, pg. 16, (Accessed Feb. 2024).

Provider-Based RHCs and RHCs Independent

When not physically present, the physician must be available at all times through direct telecommunication for consultation, assistance with medical emergencies or patient referral.

SOURCE:  AL Medicaid Management Information System Provider Manual, Provider-Based RHCs, Jan. 2024, Ch. 32, pg. 2, & AL Medicaid Management Information System Provider Manual, RHCs Independent, Jan. 2024, Ch. 36, pg. 2, (Accessed Feb. 2024).

Certified Registered Nurse Practitioner and Physician Assistant

CRNPs are assigned a provider type of 09 (Nurse Practitioner). Valid specialties for CRNPs include the following: …

• Telemedicine Service (931)

SOURCE: AL Medicaid Management Information System Provider Manual, Certified Registered Nurse Practitioner and Physician Assistant, Ch. 21 Jan. 2024, pg. 2, (Accessed Feb. 2024).

Eye Care Services

Opticians are assigned a provider type of 19. Optometrists are assigned a provider type of 18. Valid specialties for Eye Care providers include the following: …

• Telemedicine (931) Ophthalmologist and Optometrist

SOURCE: AL Medicaid Management Information System Provider Manual, Eye Care Services, Ch. 15, Jan. 2024, pg. 2, (Accessed Feb. 2024).

ELIGIBLE SITES

The following are required for the origination site where the patient is located:

• The site provider shall ensure that the telecommunication technology and equipment used at the origination site is HIPAA compliant and is sufficient to allow the appropriate evaluation, diagnosis, and/or treatment of the patient.
• The site provider shall implement protocols that ensure the same confidentiality of the telemedicine visit as for in-person visits.
• Regardless of the location of the recipient, it is the provider’s responsibility to ensure the telemedicine visit meets all required HIPAA rules and regulations regarding telemedicine visits.

The following sites are recognized by Medicaid as origination sites:

• Physician and practitioner offices
• Hospitals
• Rural Health Clinics (RHCs)
• Federally Qualified Health Centers (FQHCs)
• Hospital-based or CAH-based Renal Dialysis Centers (including satellites)
• Skilled Nursing Facilities (SNFs)
• Community Mental Health Centers (CMHCs)
• Renal Dialysis Facilities
• Mobile Stroke Units
• Alabama Department of Public Health

Telemedicine services can be rendered to a recipient in their home. However, a recipient’s home should not be considered an origination site entitled to receive an origination site fee.

SOURCE: AL Medicaid Management Information System Provider Manual, Telemedicine Services, Ch. 112, Jan. 2024, pg. 5, (Accessed Feb. 2024).

Targeted Case Management

02 Place of Service code (telehealth – Services provided through telecommunication technology) is listed in the manual.

SOURCE: AL Medicaid Management Information System Provider Manual, Targeted Case Management, Ch. 106-26, Jan. 2024, (Accessed Feb. 2024).

Certified Registered Nurse Practitioner and Physician Assistant

The following place of service codes apply when filing claims for CRNP services:

• 02 – Telemedicine Services

SOURCE: AL Medicaid Management Information System Provider Manual, Certified Registered Nurse Practitioner and Physician Assistant, Ch. 21 Jan. 2024, pg. 6, (Accessed Feb. 2024).

GEOGRAPHIC LIMITS

No reference found.

FACILITY/TRANSMISSION FEE

Effective April 1, 2020, Medicaid pays an origination site facility fee of $20.00. The origination fee will be limited to one per date of service per recipient and may be billed by all of the providers listed above under Origination Sites.

No origination site facility fee will be paid for an origination site not listed above.  See manual for billing instructions.

Note: If a Medicaid-enrolled provider performs another medically necessary service(s), the provider may bill for the covered service(s) in addition to providing his/her facility as an origination site and be eligible for reimbursement for the origination site facility fee and the other medically necessary service(s).  A recipient’s home should not be considered an origination site entitled to receive an origination site fee.

SOURCE: AL Medicaid Management Information System Provider Manual, Telemedicine Services, Ch. 112, Jan. 2024, (Accessed Feb. 2024).

POLICY

The department shall pay for all services covered by the medical assistance program provided through telehealth if the department pays for those services when provided in person (see Eligible Services Section below for eligible services).

The department shall adopt regulations for services provided by telehealth, including setting rates of payment. The department may set a rate of payment for a services provided through telehealth that is different from the rate of payment for the same service provided in person.  The department may exclude or limit coverage or reimbursement for a service provided by telehealth, or limit the telehealth modes that may be used for a particular service, only if the department

1. specifically excludes or limits the service from telehealth coverage or reimbursement by regulations adopted under this subsection;
2. determines, based on substantial medical evidence, that the service cannot be safely provided using telehealth or using the specified mode; or
3. determines that providing the service using the specified mode would violate federal law or render the service ineligible for federal financial participation under applicable federal law.

All services delivered through telehealth under this section must comply with the Health Insurance Portability and Accountability Act of 1996 (P.L. 104-191).

SOURCE: AK Statute Sec. 47.07.069, (Accessed Feb. 2024).

Subject to the requirements of 7 AAC 110.620 — 7 AAC 110.639, the department will pay for a service delivered by means of one of the following telehealth modalities if the modality and use of the modality meet the requirements of P.L. 104 — 191 (Health Insurance Portability and Accountability Act of 1996 (HIPAA)):

• Synchronous: live or interactive, through a real-time, interactive
  • two-way audio-video technology that includes, at a minimum, an operational camera, microphone, speaker or headphones, and capability to view video feed;
  • two-way audio-only technology that allows for oral communication between the provider and the recipient

SOURCE: AK Admin. Code, Title 7, 110.625. (Accessed Nov. 2023).

Alaska Medicaid will pay for a covered medical service furnished through telemedicine application if the service is:

• Covered under traditional, non-telemedicine methods;
• Provided by a treating, consulting, presenting or referring provider;
• Appropriate for provision via telemedicine

Note: Manual is under review.

Source: State of AK Dept. of Health and Social Svcs, Alaska Medical Assistance Provider Billing Manuals for Physician, PA, ARNP Services (5/13), p. 31, (Accessed Feb. 2024).

On July 13th, 2023, the Department of Health (DOH) adopted revised regulations for Medicaid coverage and payment for healthcare services provided through telehealth. These regulations went into effect September 1st, 2023. The department is in process of amending current telehealth guidance and updating system rules to accommodate these changes. This document is intended to answer common questions regarding Alaska Medicaid coverage and reimbursement of services provided through a telehealth modality as of September 1st, 2023.

What are the covered modalities for telehealth services?

Synchronous through a real-time, interactive:

• Two-Way Audio-Video Technology: Includes, at minimum, an operational camera, microphone, speaker or headset, and capability to view video feed, or
• Two-Way Audio Only Technology: Includes an operational microphone and speaker or headphones.

Asynchronous:

• Store-and-Forward: The transfer between healthcare providers of recorded digital images, video, or sounds from one location to another.

Patient-Initiated Online Digital Services:

• Synchronous or asynchronous: Evaluation, assessment, and management services of an established patient through a secure platform such as an electronic record portal, secure electronic mail, or digital application.

SOURCE: Alaska Medicaid Frequently Asked Questions Coverage of Telehealth Modalities, Sept. 19, 2023), (Accessed Feb. 2024).

ELIGIBLE SERVICES/SPECIALTIES

Subject to the requirements of 7 AAC 110.620 — 7 AAC 110.639, the department will pay for a service delivered by means of a telehealth modality if the service

• Would be covered under 7 AAC 105 — 7 AAC 160 if delivered in person; and
• Is delivered in compliance with
  • The same requirements of 7 AAC 105 — 7 AAC 160, including prior authorization requirements and service limitations, as if the service was delivered in person; and
  • The requirements of AS 08.01, AS 08.68, AS 47.07, and 7 AAC 105 — 7 AAC 160, including the telehealth requirements and limitations of 7 AAC 110.620 — 7 AAC 110.639, as applicable to the service, the provider, and the mode of delivery.

SOURCE: AK Admin. Code, Title 7, 110.620. (Accessed Feb. 2024).

1. behavioral health services;
2. services covered under home and community-based waivers;
3. services covered under state plan options under 42 U.S.C. 1396-1396p (Title XIX, Social Security Act);
4. services provided by a community health aide or a community health practitioner certified by the Community Health Aide Program Certification Board;
5. services provided by a behavioral health aide or behavioral health practitioner certified by the Community Health Aide Program Certification Board;
6. services provided by a dental health aide therapist certified by the Community Health Aide Program Certification Board;
7. services provided by a chemical dependency counselor certified by a certifying entity for behavioral health professionals in the state specified by the department in regulation;
8. services provided by a rural health clinic or a federally qualified health center;
9. services provided by an individual or entity that is required by statute or regulation to be licensed or certified by the department or that is eligible to receive payments, in whole or in part, from the department;
10. services provided through audio, visual, or data communications, alone or in any combination, or through communications over the Internet or by telephone, including a telephone that is not part of a dedicated audio conference system, electronic mail, text message, or two-way radio;
11. assessment, evaluation, consultation, planning, diagnosis, treatment, case management, and the prescription, dispensing, and administration of medications, including controlled substances; and
12. services covered under federal waivers or demonstrations other than home and community-based waivers.

The department shall adopt regulations for services provided by telehealth, including setting rates of payment. The department may set a rate of payment for a services provided through telehealth that is different from the rate of payment for the same service provided in person.  The department may exclude or limit coverage or reimbursement for a service provided by telehealth, or limit the telehealth modes that may be used for a particular service, only if the department

1. specifically excludes or limits the service from telehealth coverage or reimbursement by regulations adopted under this subsection;
2. determines, based on substantial medical evidence, that the service cannot be safely provided using telehealth or using the specified mode; or
3. determines that providing the service using the specified mode would violate federal law or render the service ineligible for federal financial participation under applicable federal law.

All services delivered through telehealth under this section must comply with the Health Insurance Portability and Accountability Act of 1996 (P.L. 104-191).

SOURCE: AK Statute Sec. 47.07.069, (Accessed Feb. 2024).

See list of telehealth services allowed in Alaska Medicaid’ temporary telehealth services fee schedule for FY 2024.

SOURCE: Alaska Medicaid, Telehealth Services: Temporary Fee Schedule, Effective 9/1/2023, (Accessed Feb. 2024).

Check behavioral health fee schedules and Section 1115 Medicaid Waiver Services Administrative Manuals for services allowed via telehealth.

SOURCE: Medicaid Provider Assistance Information, Division of Behavioral health, Fee Schedules, (Accessed Feb. 2024).

Eligible services:

• Initial
• One follow-up office visit;
• Consultation made to confirm diagnosis;
• A diagnostic, therapeutic or interpretive service;
• Psychiatric or substance abuse assessments;
• Psychotherapy; or
• Pharmacological management services on an individual recipient basis.

Note: Manual is under review.

SOURCE: State of AK Dept. of Health and Social Svcs., Alaska Medical Assistance Provider Billing Manuals for Physician, ARNP, PA Services (5/13), p. 31, (Accessed Feb. 2024).

Dental services do not require the use of the telemedicine modifier.

Note: Manual is under review.

SOURCE: AK Dept. of Health and Social Svcs.  Dental Services.  Tribal Services Manual (1/3/17), pg. 97, (Accessed Feb. 2024).

For patient-initiated online digital service, whether synchronous or asynchronous, the following are not reimbursable:

• Nonevaluative or nonmanagement services including appointment scheduling and electronic communication of test results;
• Provider-initiated online digital service;
• Patient-initiated online digital service within the postoperative period of a completed procedure or within seven days of an in-person visit and related to the illness, injury, or other reason for that visit.

The department will not pay

• for the use, or any costs associated with the use, of technological equipment and systems associated with the delivery of a service by means of a telehealth modality;
• a provider for communication with that provider’s supervising provider or communication with a provider who is acting in a supervisory capacity;
• a supervising provider or a provider who is acting in a supervisory capacity for communication with a supervisee or for review of a supervisee’s work;
• a provider participating in a telehealth encounter whose sole purpose is to facilitate the telehealth encounter between the recipient and a rendering provider or a consulting provider;
• for a failed or unsuccessful telehealth connection or transmission;
• for the following services when provided by means of a telehealth modality:
  • chiropractic services;
  • dental services;
  • private-duty nursing services;
  • pharmacy dispensing services;
  • durable medical equipment and related services;
  • prosthetic and orthotic devices and related services;
  • transportation services;
  • accommodation services;
  • personal care services;
  • home health services;
  • community First Choice services;
  • home and community-based waiver services, except for
    • care coordination services under 7 AAC 130.240;
    • day habilitation services under 7 AAC 130.260;
    • employment services under 7 AAC 130.270; or
    • intensive active treatment services under 7 AAC 130.275;

SOURCE:  AK Admin. Code, Title 7, 110. 625 & 635 (Accessed Feb. 2024).

Alaska Medicaid will not pay for

• The use of telemedicine equipment and systems
• Services delivered by telephone when not part of a dedicated audio conference system
• Services delivered by facsimile

No reimbursement for:

• Direct entry midwife
• Durable medical equipment (DME)
• End-stage renal disease
• Home and community-based waiver
• Personal care assistant
• Pharmacy
• Private duty nursing
• Transportation and accommodation
• Vision (includes visual care, dispensing, or optician services)

Note: Manual under review.

SOURCE: State of AK Dept. of Health and Social Svcs., Alaska Medical Assistance Provider Billing Manuals for Physician, ARNP and PA Services (5/13), pg. 32-33 (Feb. 2024).

The department will pay in accordance with 7 AAC 145.020 for a service delivered by means of a telehealth modality by a rendering provider or a consulting provider in accordance with 7 AAC 110.620 — 7 AAC 110.639 as set out under 7 AAC 145.020.

The department will pay a rendering provider or a consulting provider in the same manner as payment is made for the same service provided through in-person mode of delivery, not to exceed 100 percent of the rate established under 7 AAC 145.050.

SOURCE: AK Admin Code, Title 7, 145.270, (Accessed Feb. 2024).

The department will not pay a physician for experimental therapy, nonmedical outpatient therapy, or nonmedical counseling, including any of the following services:

• interaction between recipient and provider by means of the Internet, except as provided in 7 AAC 110.620 — 7 AAC 110.639 for telehealth services.

SOURCE: Alaska Admin Code, Title 7, 110.445, (Accessed Feb. 2024).

Non-Emergency Medical Transportation and Escort Coverage

Clarifies types of services feasible for telehealth throughout the document.

SOURCE: Alaska Medicaid Policy Clarification Non-Emergency Medical Transportation, Sept. 18, 2023 (revised 11/29/23), (Accessed Feb. 2024).

Does Alaska Medicaid cover problem focused exams delivered through a telehealth modality?

Patient Initiated: Yes, service may be covered under CPT code 99441-99443.

Scheduled Visit or Provider Initiated: Yes, Problem focused evaluation and management services (CPT 99202-99205 and 99211-99215) are covered when delivered through Two-Way Audio-Video Technology or through store-and-forward.

Are therapy services (PT, OT, SLP) covered when delivered through a telehealth modality?

Yes: Therapy services (PT, OT, SLP) are covered when delivered through Two-Way Audio-Video Technology if the service is identified on the Telehealth Services Temporary Fee Schedule.

Use the same procedure codes as you would for an in-person encounter and apply a procedure modifier of either GT or 95.

Are initial hospital services reimbursable if performed via telehealth?

Yes: The professional component may be reimbursed using CPT codes 99221-99223 when services are delivered through Two-Way Audio-Video Technology.

Are initial nursing facility care services reimbursable if performed via telehealth?

Yes: The professional component may be reimbursed using CPT codes 99304-99306 when services are delivered through Two-Way Audio-Video Technology.

Can ventilator management services be conducted via a telehealth mode of delivery?

Yes: Ventilator management is reimbursable when performed via telehealth. Only the healthcare provider managing the ventilator may be reimbursed for ventilator management; any bedside adjustments are not separately reimbursable.

SOURCE: Alaska Medicaid Frequently Asked Questions Coverage of Telehealth Modalities, Sept. 19, 2023, (Accessed Feb. 2024).

DME Oxygen Guidelines and Concerns

Telehealth is included of definition of face-to-face encounter between the treating practitioner and the beneficiary and the encounter must be used for the purpose of gathering subjective and objective information associated with diagnosing, treating, or managing a clinical condition for which the DMEPOS is ordered.

SOURCE: Alaska Dep. of Health, Letter to DME Providers, RE Review of Oxygen Guidelines and Concerns, Dec. 29, 2023, (Accessed Feb. 2024).

ELIGIBLE PROVIDERS

Subject to the requirements of 7 AAC 110.620 — 7 AAC 110.639, to be eligible for payment under 7 AAC 105 — 7 AAC 160 for providing a service by means of a telehealth modality, a provider must meet the following requirements:

• the provider must have an active license under AS 08 or AS 47, an active certification in the state, or an active license under the applicable laws of the jurisdiction in which the provider is located;
• the provider must be enrolled under 7 AAC 105.210;
• the provider, if licensed under AS 08 and required under 12 AAC 02.600, must be registered under 12 AAC 02.600 (telemedicine business registry);
• the service must be delivered within the rendering provider’s, and if applicable, consulting provider’s scope of licensure or certification;
• a claim submitted to the department must include applicable telehealth modifiers and place-of-service coding;
• if the rendering provider or consulting provider determines, during a telehealth encounter, that a service extends beyond the scope of that provider’s license or certification, the provider must discontinue the encounter and refer the recipient to an appropriate provider; the rendering provider or consulting provider may bill only for the portion of the encounter that was within that provider’s scope of license or certification and only if the rendered portion of the encounter met all criteria of a separately billable service;
• except as otherwise provided in 7 AAC 105 — 7 AAC 160, a recipient must be present during and participate in a telehealth encounter;
• the provider must comply with all record keeping requirements set out under 7 AAC 105.230 for all telehealth services rendered;
• the rendering provider and consulting provider, when delivering a service by means of a synchronous telehealth modality, must annotate the patient’s clinical record with the method of delivery, the recipient’s location during the delivery of the service, and confirmation that the recipient has consented to a telehealth method of delivery.

SOURCE:  AK Admin. Code, Title 7, 110. 630 (Accessed Feb. 2024).

How do I bill for a services when a telehealth modality was used?

Procedure Code Modifier:

• Two-Way Audio-Video Technology: GT or 95
• Store-and-Forward: GQ
• Two-Way Audio Only Technology : FQ and 93

Procedure Codes Defined as Audio Only: Failure to include either modifier FQ or modifier 93 will result in denial of payment for audio only services.

Patient Initiated Online Digital Services: Do not use telehealth modifiers when billing CPT codes 98970 – 98972 and 99421 – 99423.

Telehealth for Acute Stroke: Use procedure code modifier G0 (G-Zero) and the appropriate telehealth modifier (GT, 95, GQ, or FQ).

Helpful Hint: Modifier G0 (G-Zero) often gets confused with GO (G-Oh). Please ensure the appropriate modifier is utilized when billing either G0 (G-Zero) or GO (G-Oh).

Are services provided by therapy assistants covered when provided via a telehealth modality?

Yes: Services provided by enrolled physical and occupational therapy assistant and speech language pathology assistant are covered to the same extent as the supervising therapist.

Are outpatient rehabilitation Hospitals able to bill telehealth for therapy services (OT, PT, SLP) using a UB-04 or 837I and are there any additional requirements for identifying the claim as a telehealth claim?

Yes: Therapy services provided in an outpatient rehabilitation hospital setting are covered when delivered through Two-Way Audio-Video Technology for services identified on the Telehealth Services Temporary Fee Schedule.

Additional Requirements: Effective for dates of service on and after 7/1/2023, claims submitted with therapy revenue codes 042X, 043X, and 044X will require an appropriate CPT/HCPCS procedure code in form locater 44, HCPCS/Accommodation Rates/HIPPS Rate Codes.

Can direct entry midwives provide telehealth services?

Yes: Effective 9/1/2023 services provided by direct entry midwives are covered if identified on the Telehealth Services Temporary Fee Schedule.

Can optometrists provide telehealth services?

Yes: Effective 9/1/2023 services provided by optometrists are covered if identified on the Telehealth Services Temporary Fee Schedule.

SOURCE: Alaska Medicaid Frequently Asked Questions Coverage of Telehealth Modalities, Sept. 19, 2023, (Accessed Feb. 2024).

The department shall pay for all services covered by the medical assistance program provided through telehealth if the department pays for those services when provided in person, including:

…

1. services provided by a community health aide or a community health practitioner certified by the Community Health Aide Program Certification Board;
2. services provided by a behavioral health aide or behavioral health practitioner certified by the Community Health Aide Program Certification Board;
3. services provided by a dental health aide therapist certified by the Community Health Aide Program Certification Board;
4. services provided by a chemical dependency counselor certified by a certifying entity for behavioral health professionals in the state specified by the department in regulation;
5. services provided by a rural health clinic or a federally qualified health center;
6. services provided by an individual or entity that is required by statute or regulation to be licensed or certified by the department or that is eligible to receive payments, in whole or in part, from the department;

SOURCE: AK Statute Sec. 47.07.069, (Accessed Feb. 2024).

Providers fall into three categories:

1. Referring Provider: Evaluates a patient, determines the need for a consultation, and arranges services of a consulting provider for the purpose of diagnosis and treatment.
2. Presenting Provider: Introduces a patient to the consulting provider during an interactive telemedicine session (may assist in the telemedicine consultation).
3. Consulting Provider: Evaluates the patient and/or medical data/images using telemedicine mode of delivery upon recommendation of the referring provider.

NOTE: Manual is under review.

SOURCE: AK Dept. of Health and Social Svcs. Billing for Telemedicine Services. Section II: Professional Claims Management, Feb. 6, 2020 (section revised 6/12), pg. 20, (Accessed Feb. 2024).

Mental Health

An entity designated by the department under AS 47.30.520 – 47.30.620 may provide community mental health services authorized under AS 47.30.520 – 47.30.620 through telehealth to a patient in this state.

If an individual employed by an entity designated by the department under AS 47.30.520 – 47.30.620, in the course of a telehealth encounter with a patient, determines that some or all of the encounter will extend beyond the community mental health services authorized under AS 47.30.520 – 47.30.620, the individual shall advise the patient that the entity is not authorized to provide some or all of the services to the patient, recommend that the patient contact an appropriate provider for the services the entity is not authorized to provide, and limit the encounter to only those services the entity is authorized to provide. The entity may not charge a patient for any portion of an encounter that extends beyond the community mental health services authorized under AS 47.30.520 – 47.30.620.

A fee for a service provided through telehealth under this section must be reasonable and consistent with the ordinary fee typically charged for that service and may not exceed the fee typically charged for that service.

An entity permitted to provide telehealth under this section may not be required to document a barrier to an in-person visit to provide health care services through telehealth. The department may not limit the physical setting from which an entity may provide health care services through telehealth.

Nothing in this section requires the use of telehealth when an individual employed by an entity designated by the department under AS 47.30.520 – 47.30.620 determines that providing services through telehealth is not appropriate or when a patient chooses not to receive services through telehealth.

SOURCE: AK Statute Sec. 47.30.585, (Accessed Feb. 2024).

Uniform Alcoholism and Intoxication Treatment

A public or private treatment facility approved under AS 47.37.140 may provide health care services authorized under AS 47.37.030 – 47.37.270 through telehealth to a patient in this state.

If an individual employed by a public or private treatment facility approved under AS 47.37.140, in the course of a telehealth encounter with a patient, determines that some or all of the encounter will extend beyond the health care services authorized under AS 47.37.030 – 47.37.270, the individual shall advise the patient that the facility is not authorized to provide some or all of the services to the patient, recommend that the patient contact an appropriate provider for the services the facility is not authorized to provide, and limit the encounter to only those services the facility is authorized to provide. The facility may not charge a patient for any portion of an encounter that extends beyond the health care services authorized under AS 47.37.030 – 47.37.270.

A fee for a service provided through telehealth under this section must be reasonable and consistent with the ordinary fee typically charged for that service and may not exceed the fee typically charged for that service.

A facility permitted to practice telehealth under this section may not be required to document a barrier to an in-person visit to provide health care services through telehealth. The department may not limit the physical setting from which a facility may provide health care services through telehealth.

Nothing in this section requires the use of telehealth when an individual employed by a facility approved under AS 47.37.140 determines that providing services through telehealth is not appropriate or when a patient chooses not to receive services through telehealth.

SOURCE: AK Statute Sec. 47.37.145, (Accessed Feb. 2024).

Various services are allowed in for Alaska Behavioral Health Providers.  See manual.

SOURCE: State of Alaska Department of Health and Social Services Division of Behavioral Health Services, Alaska Behavioral Health Providers Services Standards & Administrative Procedures for Behavioral Health Provider Services, (Accessed Feb. 2024).

Stand-alone vaccine counseling may be covered when provided via telehealth if the appropriate telehealth modifier and place of service are reported on the claim.

Stand-alone vaccine counselling, rendered in person or telehealth, is not separately reimbursable if the vaccine associated with the counselling is administered within one month of counseling.

SOURCE:  Alaska Medicaid Provider Billing Manual, Immunization Services, pg. 12, (Accessed Feb. 2024).

Do I need to register with the Telemedicine Business Registry to offer telehealth services?

Yes, in most cases: All businesses engaged in or planning to engage in distance delivery of health care to a patient located in Alaska must register with the state’s Telemedicine Business Registry. Providers who are an employee of a business do not need to register.

Providers subject to Telemedicine Business Registry requirements:

• Alaska-licensed audiologist or speech-language pathologist; behavior analyst; chiropractor; professional counselor; dentist or dental hygienist; dietitian or nutritionist; naturopath; marital and family therapist; physician, podiatrist, osteopath, or physician assistant; direct-entry midwife; nurse or advanced practice registered nurse (APRN); dispensing optician; optometrist; pharmacist; physical therapist or occupational therapist; psychologist or psychological associate; social worker; or a physician licensed in another state.

* This information is based off of May 22nd, 2023, DCCED publication. See DCCED’s Telehealth Information Webpage for updates.

SOURCE: Alaska Medicaid Frequently Asked Questions Coverage of Telehealth Modalities, Sept. 19, 2023), (Accessed Feb. 2024).

ELIGIBLE SITES

How do I bill for a services when a telehealth modality was used?

Place of Service Code:

• Place of Service Code 02: Telehealth- member not located at home during encounter
• Place of Service Code 10: Telehealth – member is located at home during encounter

SOURCE: Alaska Medicaid Frequently Asked Questions Coverage of Telehealth Modalities, Sept. 19, 2023, (Accessed Feb. 2024).

GEOGRAPHIC LIMITS

No reference found.

FACILITY TRANSMISSION FEE

The department will not pay

• for the use, or any costs associated with the use, of technological equipment and systems associated with the delivery of a service by means of a telehealth modality;
• a provider for communication with that provider’s supervising provider or communication with a provider who is acting in a supervisory capacity;
• a supervising provider or a provider who is acting in a supervisory capacity for communication with a supervisee or for review of a supervisee’s work;
• a provider participating in a telehealth encounter whose sole purpose is to facilitate the telehealth encounter between the recipient and a rendering provider or a consulting provider;
• for a failed or unsuccessful telehealth connection or transmission

SOURCE: AK Admin. Code, Title 7, 110.635. (Accessed Feb. 2024).

POLICY

Fee-for-Service Provider Manual

AHCCCS covers medically necessary, non-experimental and cost-effective services provided via telehealth. There are no geographic restrictions for telehealth; services delivered via telehealth are covered by AHCCCS in rural and metropolitan regions.

Telehealth may include healthcare services delivered via asynchronous (store and forward), remote patient monitoring, teledentistry, or telemedicine (interactive audio and video).

SOURCE: AZ Health Care Cost Containment System, AHCCCS Fee-For-Service Provider Billing Manual, Ch. 10: Individual Practitioner Services, (5/31/2023), pg. 49, & IHS/Tribal Provider Billing Manual, (5/31/2023), pg. 53 (Accessed Feb. 2024).

The Contractor and FFS programs shall cover medically necessary, non-experimental, and cost effective services delivered via Telehealth by AHCCCS registered providers for AHCCCS covered services.

This Policy applies to ACC, ACC-RBHA, ALTCS E/PD, DCS/CHP (CHP), and DES/DDD (DDD) Contractors; Fee-For-Service (FFS) Programs including: the American Indian Health Program (AIHP), DES/DDD Tribal Health Program (DDD THP), Tribal ALTCS, TRBHA; and all FFS populations, excluding Federal Emergency Services (FES). (For FES, refer to AMPM Chapter 1100). This Policy establishes the requirements regarding telehealth.

SOURCE: AZ Health Care Cost Containment System, AHCCCS Medical Policy for AHCCCS Covered Services, Ch. 300, (320-I pg. 1). Approved 8/29/23. (Accessed Feb. 2024).

ELIGIBLE SERVICES/SPECIALTIES

Some of the services that can be covered via real-time telehealth include, but are not limited to:

• Behavioral Health
• Cardiology
• Dentistry
• Dermatology
• Endocrinology
• Hematology/Oncology
• Home Health
• Infectious Diseases
• Inpatient Consultations
• Medical Nutrition Therapy (MNT)
• Neurology
• Obstetrics/Gynecology
• Oncology/Radiation
• Ophthalmology
• Orthopedics
• Office Visits (adult and pediatric)
• Outpatient Consultations
• Pain Clinic
• Pathology & Radiology
• Pediatrics and Pediatric Subspecialties
• Pharmacy Management
• Rheumatology
• Surgery Follow-Up and Consultations

Behavioral health services are covered for all Medicaid-eligible AHCCCS beneficiaries and KidsCare members.

Covered behavioral health services can include, but are not limited to:

• Diagnostic consultation and evaluation,
• Psychotropic medication adjustment and monitoring,
• Individual and family counseling, and
• Case management.

For a complete code set of services, along with their eligible place of service and modifiers, that can be billed as telehealth please visit the AHCCCS Medical Coding Resources webpage.

For real time behavioral health services, the member’s physician, case manager, behavioral health professional, or tele-presenter may be present with the member during the consultation, but their presence is not required.

SOURCE: AZ Health Care Cost Containment System, AHCCCS Fee-For-Service Provider Billing Manual, Ch. 10: Individual Practitioner Services, (5/31/2023), pg. 49-55; IHS/Tribal Provider Billing Manual, Ch. 8 Individual Practitioner Services, (5/31/23), pg. 52-54 (Accessed Feb. 2024).

Prolonged preventive services, beyond the typical service of the primary procedure, that require direct patient contact and occur in either the office or another outpatient setting are covered under telehealth. See manual for example codes.

SOURCE: AZ Health Care Cost Containment System, AHCCCS Fee-For-Service Provider Manual, Ch. 10: Individual Practitioner Services, (5/31/2023), pg. 52, (Accessed Feb. 2024).

AHCCCS Policy Manual

The Contractor and FFS programs may not limit or deny the coverage of services provided through Telehealth and may apply only the same limits or exclusions on a service provided through Telehealth that are applicable to an in-person encounter for the same service, except for services for which the weight of evidence, based on practice guidelines, peer-reviewed clinical publications or research or recommendations by the Telehealth advisory committee on Telehealth best practices established by A.R.S. § 36-3607, determines not to be appropriate to be provided through Telehealth.

Services delivered via Telehealth shall not replace member or provider choice for healthcare delivery modality. As specified in A.R.S. § 36-3605i , a provider shall make a good faith effort in determining both of the following:

• Whether a service should be provided through Telehealth instead of in-person. The provider shall use clinical judgment in considering whether the nature of the services necessitates physical interventions and close observation and the circumstances of the member, including diagnosis, symptoms, history, age, physical location and access to telehealth; and
• The communication medium of Telehealth and, whenever reasonably practicable, the telehealth communication medium that allows the provider to most effectively assess, diagnose and treat the member. Factors the provider may consider in determining the communication medium include the member’s lack of access to or inability to use technology or limits in telecommunication infrastructure necessary to support interactive Telehealth encounters.

Telemedicine services include health care delivery, diagnosis, consultation, treatment, and the transfer of medical data through real-time synchronous interactive audio and video communications that occur in the physical presence of the member.

The Contractor and FFS Programs shall reimburse providers at the same level of payment for equivalent services as identified by Healthcare Common Procedure Coding System (HCPCS) whether provided via telemedicine or in-person office/facility setting.

The AHCCCS Telehealth code set defines which codes are billable as a Telemedicine service and the applicable modifier(s) and place of service providers must use when billing for a service provided via Telemedicine.

Refer to the AHCCCS coding webpage for coding requirements for Telehealth services, including applicable modifiers and POS available:
https://www.azahcccs.gov/PlansProviders/MedicalCodingResources.html

AHCCCS covers Teledentistry for Early and Periodic Screening, Diagnostic and Treatment (EPSDT) aged members when provided by an AHCCCS registered dental provider. Refer to AMPM Policy 431 for more information on oral health care for EPSDT aged members including covered dental services.

Teledentistry includes the provision of preventative and other approved therapeutic services by the AHCCCS registered Affiliated Practice Dental Hygienist, who provides dental hygiene services under an affiliated practice relationship with a dentist. Refer to AMPM Policy 431 for information on Affiliated Practice Dental Hygienist.

Teledentistry does not replace the dental examination by the dentist. Limited exams may be billed through the use of Teledentistry. Periodic and comprehensive examinations cannot be billed through the use of teledentistry alone.

SOURCE: AZ Medical Policy for AHCCCS Covered Services. Telehealth and Telemedicine Ch 300, (320-I pg. 1-2 & 4-5), Approved 8/29/23. (Accessed Feb. 2024)

Arizona health care cost containment system administration shall implement teledentistry services for enrolled members who are under twenty-one years of age.

SOURCE: AZ Statute, Sec. 36-2907.13. (Accessed Feb. 2024).

Remote Monitoring:

• G2010 – Remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment.
• G2012 – Brief communication technology-based service, e.g., virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion.

SOURCE: AZ Administrative Code Title 20, Ch. 5, pg. 336. (Accessed Feb. 2024).

Medication management should be provided by a board certified or qualified child and adolescent psychiatrist whenever possible; in rural or underserved locations, this may be met through the use of telemedicine.

SOURCE: AZ Medical Policy for AHCCCS Covered Services. Psychiatric and Psychotherapeutic best practices for children birth through five years of age, Ch 211, (pg. 14-15), Approved 8/12/21. (Accessed Feb. 2024).

Home Health Services

A Face-To-Face visit, in person or via telehealth, with a member’s PCP or non-physician practitioner, related to the primary reason the member requires home health services [42 CFR 440.70].

The Face-to-Face encounter may occur through telehealth.

SOURCE: AZ Medical Policy for AHCCCS Covered Services. Home Health Services, Ch 211, (pg. 1 & 5), Approved 12/16/21. & FFS Manual, Home Health, Ch. 20, Revised 10/1/18, pg. 2, & IHS/Tribal Billing Manual, Ch. 13 Home Health, (Revised 10/1/18) pg. 2, (Accessed Feb. 2024).

Medical Equipment, Medical Appliances and Medical Supplies

The face-to-face encounter may occur through telehealth.

SOURCE: AZ Medical Policy for AHCCCS Covered Services. Medical Equipment, Medical Appliances and Medical Supplies, Ch 310-P, (pg. 3), Approved 6/6/23 & FFS Billing Manual, Ch. 13, .pg 4, (Revised 5/31/23),  (Accessed Feb. 2024).

Transportation

Treatment on scene may also be performed, when medically indicated, via a telehealth visit performed in accordance with AMPM Policy 320-I.

SOURCE: AZ Medical Policy for AHCCCS Covered Services. Transportation, Ch 310-BB, (pg. 4), Approved 4/7/22. (Accessed Feb. 2024).

To initiate and facilitate a members’ receipt of medically necessary covered service(s) by a Qualified Health Care Partner at the scene of a 9-1-1 response either in-person on the scene or via telehealth (Treatment in Place).

SOURCE: FFS Billing Manual, Ch. 14, .pg 7, (Revised 1/30/23), & IHS/Tribal Billing Manual, Ch. 11, (Revised 6/16/23) pg. 7, (Accessed Feb. 2024).

Therapeutic Foster Care for Children (TFC)

TFC visits may occur in-person or via telemedicine (i.e. interactive audio/video communications).

SOURCE: AZ Medical Policy for AHCCCS Covered Services. Therapeutic Foster Care for Children, Ch 320-W, (pg. 8), Approved 7/7/22. (Accessed Feb. 2024).

Out-Of-State Placements for Behavioral Health Treatment

When appropriate, the member/Health Care Decision Maker and designated representative is involved throughout the duration of the placement. This may include family counseling in-person or by telemedicine.

SOURCE: AZ Medical Policy for AHCCCS Covered Services. Out-Of-State Placements for Behavioral Health Treatment, Ch 450, (pg. 4), Approved 6/18/20. (Accessed Feb. 2024).

ELIGIBLE PROVIDERS

Fee-for-Service Provider Manual & IHS/Tribal Provider Billing Manual

Telehealth, including Teledentistry services, may be provided by AHCCCS registered providers, within their scope of practice.

SOURCE: AZ Health Care Cost Containment System, AHCCCS Fee-For- Service Provider Billing Manual, Ch. 10: Individual Practitioner Services, (5/31/23), pg. 52,  & IHS/Tribal Provider Billing Manual (5/31/23), pg. 55. (Accessed Feb. 2024).

For Reimbursement at the A–R – Revenue Codes 0510, 0512 and 0516 may be submitted to AHCCCS on a UB-04 claim form. To indicate that the clinic visit (0510), a dental visit (0512) or urgent clinic visit (0516) was done via telehealth a modifier (GT or GQ) shall be included on the claim.

For Reimbursement at the Capped FFS Rate or APM Ra–e – For a complete code set of services, along with their eligible place of service and modifiers that can be billed as telehealth, please visit the AHCCCS Medical Coding Resources web page at: https://www.azahcccs.gov/PlansProviders/MedicalCodingResources.html

SOURCE: AZ Health Care Cost Containment System, AHCCCS IHS/Tribal Provider Billing Manual (5/31/23), pg. 55. (Accessed Feb. 2024).

Telehealth and telemedicine may qualify as a FQHC/RHC visit if it meets the requirements as specified in AMPM Policy 320-I.

SOURCE: AZ Health Care Cost Containment System, AHCCCS. Provider Qualifications and Provider Requirements.  Ch. 600, Oct. 2015, pg. 3, & AZ Health Care Cost Containment System, AHCCCS Fee-For-Service Provider Billing Manual, Ch. 10 Addendum: FQHC/RHC, (8/25/22), pg. 3, (Accessed Feb. 2024).

Telehealth may qualify as a Federally Qualified Healthcare Center/Rural Health Clinic (FQHC/RHC) visit, if all other applicable conditions in this Policy are met. Refer to AMPM Policy 670.

SOURCE: AZ Medical Policy for AHCCCS Covered Services. Telehealth and Telemedicine Ch 300, (320-I pg. 5), Approved 8/29/23; AZ Health Care Cost Containment System, AHCCCS Fee-For- Service Provider Billing Manual, Ch. 10: Addendum FQHC/RHC, (8/25/2022), pg. 3, (Accessed Feb. 2024).

School Based Claiming Program

For DSC services provided via telehealth, all providers shall be an AHCCCS registered provider and licensed in Arizona by the governing board for the profession or specialty or may provide services via telehealth if all requirements for the
provision of telehealth are met, including board registration as specified in A.R.S § 36-3606 and AMPM Policy 320-I.

SOURCE: AZ Medical Policy for AHCCCS Covered Services. School Based Claiming Program Ch 300, (710 pg. 3), Approved 8/3/21. (Accessed Feb. 2024).

ELIGIBLE SITES

The Place of Service (POS) listed on the CMS 1500 claim form shall be the originating site (where the AHCCCS member is located or where the asynchronous service originates).

For Medicare Dual members, claims may be submitted with the POS listed as 02 (Telemedicine) to comply with Medicare guidelines. The POS 02 (Telemedicine) will designate the service being provided as a telehealth service.

Fee-for-Service Provider Manual definitions:

Distant site means “the site at which the provider delivering the service is located at the time the service is provided via telehealth.”

Originating site means “the location of the AHCCCS member at the service is being furnished via telehealth or where the asynchronous service originates. This is considered the place of service.”

SOURCE: AZ Health Care Cost Containment System, AHCCCS Fee-For- Service Provider Billing Manual, Ch. 10: Individual Practitioner Services, (3/31/23), pg. 51 & IHS/Tribal Provider Billing Manual, (5/31/23). pg. 53-54 (Accessed Feb. 2024).

There are no Place Of Service (POS) restrictions for distant site.

SOURCE: AZ Medical Policy for AHCCCS Covered Services. Telehealth and Telemedicine Ch 300, (320-I pg. 4), 8/29/23. (Accessed Feb. 2024).

GEOGRAPHIC LIMITS

There are no geographic restrictions for telehealth. Services delivered via telehealth are covered by AHCCCS in rural and urban/metropolitan regions.

SOURCE: AZ Medical Policy for AHCCCS Covered Services. Telehealth and Telemedicine Ch 300, (320-I pg. 1), Approved 8/29/23 ; AZ Health Care Cost Containment System, AHCCCS Fee-For-Service Provider Billing Manual, Ch. 10: Individual Practitioner Services, (5/31/23), pg. 49, & IHS/Tribal Provider Billing Manual, (5/31/23), pg. 52. (Accessed Feb. 2024).

FACILITY/TRANSMISSION FEE

No Reference Found

POLICY

Arkansas Medicaid provides payment to a licensed or certified healthcare professional or a licensed or certified entity for services provided through telemedicine if the service provided through telemedicine is comparable to the same service provided in-person.

Coverage and reimbursement for services provided through telemedicine will be on the same basis as for services provided in-person. While a distant site facility fee is not authorized under the Telemedicine Act, if reimbursement includes payment to an originating site (as outlined in the above paragraph), the combined amount of reimbursement to the originating and distant sites may not be less than the total amount allowed for healthcare services provided in-person.

SOURCE: AR Medicaid Provider Manual. Section I General Policy.  Rule 105.190. p. I-13 Updated Jan. 1, 2022 (Accessed Feb. 2024).

Arkansas Medicaid shall provide payment for telemedicine healthcare services to licensed or certified healthcare professionals or entities that are authorized to bill Arkansas Medicaid directly for healthcare services. Coverage and reimbursement for healthcare services provided through telemedicine shall be reimbursed on the same basis as healthcare services provided in person.

SOURCE: Section III Billing Documentation.  Rule 305.000. , p. III-8 Updated Jan. 1, 2022.  (Accessed Feb. 2024).

Rural Health Centers

In order for a telemedicine encounter to be covered by Medicaid, the practitioner and the patient must be able to see and hear each other in real time.

SOURCE: AR Medicaid Provider Manual. Section II Rural Health.  Rule 211.300. p. II-6 Updated Oct. 13, 2003. (Accessed Feb. 2024).

Occupational Therapy, Physical Therapy and Speech-Language Pathology Services

The service provider is responsible for ensuring service delivery through telemedicine is equivalent to in-person, face-to-face service delivery.

• The service provider is responsible for ensuring the calibration of all clinical instruments and the proper functioning of all telecommunications equipment.
• All services delivered through telemedicine must be delivered in a synchronous manner, meaning through real-time interaction between the practitioner and client via a telecommunication link.
• A store and forward telecommunication method of service delivery where either the client or practitioner records and stores data in advance for the other party to review at a later time is prohibited, although correspondence, faxes, emails, and other non-real time interactions may supplement synchronous telemedicine service delivery.

Services delivered through telemedicine are reimbursed in the same manner and subject to the same benefit limits as in-person, face-to-face service delivery. View or print the billable telecommunication codes and descriptions.

SOURCE: AR Medicaid Provider Manual. Section II Occupational Therapy, Physical Therapy and Speech-Language Pathology Services, Rule 214.600. Updated Jan. 1, 2022, (Accessed Feb. 2024).

ELIGIBLE SERVICES/SPECIALTIES

A health benefit plan [includes Arkansas Medicaid] shall provide coverage and reimbursement for healthcare services provided through telemedicine on the same basis as the health benefit plan provides coverage and reimbursement for health services provided in person, unless this subchapter specifically provides otherwise.

A health benefit plan is not required to reimburse for a healthcare service provided through telemedicine that is not comparable to the same service provided in person.

SOURCE: AR Code 23-79-1602(c). (Accessed Feb. 2024).

Covered counseling services are outpatient services. Specific Counseling Services are available to inpatient hospital patients (as outlined in Sections 240.000 and 220.100), through telemedicine, and to nursing home residents.  Counseling Services are billed on a per unit or per encounter basis as listed.  All services must be provided by at least the minimum staff within the licensed scope of practice to provide the service.

Telemedicine is listed as an allowed delivery mode for certain services throughout the Counseling Services Manual (formerly the Outpatient Behavioral Health Services manual).

SOURCE: AR Medicaid Manual, Section II Counseling Services, Updated Jan. 1, 2024, (Accessed Feb. 2024).

Occupational Therapy, Physical Therapy and Speech-Language Pathology Services

An enrolled provider may be reimbursed for medically necessary occupational therapy, physical therapy, and speech-language pathology services delivered through telemedicine.

Occupational therapy, physical therapy, and speech-language pathology evaluation and treatment planning services may not be conducted through telemedicine and must be performed through traditional in-person methods.

SOURCE: AR Medicaid Provider Manual. Section II Occupational Therapy, Physical Therapy and Speech-Language Pathology Services, Rule 214.600. Updated Jan. 1, 2022, (Accessed Feb. 2024).

Rural Health Centers

Arkansas Medicaid covers RHC encounters and two ancillary services (fetal echography and echocardiology) as “telemedicine services”. Physician interpretation of fetal ultrasound is covered as a telemedicine service if the physician views the echography or echocardiography output in real time while the patient is undergoing the procedure.

SOURCE: AR Medicaid Provider Manual. Section II Rural Health.  Rule 211.300. Updated Oct. 13, 2003. (Accessed Feb. 2024).

Patient-Led Arkansas Shared Savings Entity (PASSE) Program

Virtual services can be provided using mobile secure telecommunication devices, electronic monitoring equipment and include clinical provider care, behavioral health therapies, speech, occupational and physical therapy services, and treatment provided to an individual at their residence.  Virtual provider services may use various evidence-based and innovative independence at-home strategies. They may include the provision of on-going care management, remote telehealth monitoring and consultation, face to face or through the use secure web-based communication and mobile telemonitoring technologies to remotely monitor and evaluate the patient’s functional and health status. Virtual and telehealth services are provided in lieu of providing the same services at a practice site or provided at the individual’s place of residence.

SOURCE: PASSE Program, Section. II, p. 8, (1/1/23).  (Accessed Feb. 2024).

A healthcare professional may use telemedicine to perform group meetings for healthcare services, including group therapy.

Telemedicine for group therapy provided to adults who are participants in a program or plan authorized and funded under 42 U.S.C. § 1396a, as approved by the United States Secretary of Health and Human Services, may only be permitted if the Centers for Medicare and Medicaid Services allows telemedicine for group therapy provided to adults.

Telemedicine shall not be used for group therapy provided to a child who is eighteen (18) years of age or younger.

SOURCE: AR CODE 17-80-404 (Accessed Feb. 2024).

Home Health 

The face-to-face encounter may occur through telemedicine when applicable to the program manual of the performing provider of the encounter.

SOURCE: AR Medicaid Provider Manual. Section II Nurse Practitioner.  Rule 203.020, II-6. Updated July 1, 2017 & AR Medicaid Provider Manual. Section II Home Health.  Rule 206.000, II-5. Updated July 1, 2017 & AR Medicaid Provider Manual. Section II Certified Nurse-Midwife.  Rule 204.101, II-6. Updated July 1, 2017. (Accessed Feb. 2024).

Behavioral Health Conditions and Services

Screening for behavioral health conditions and behavioral health services as described in subsection (a) of this section may be provided via telemedicine and reimbursed by the Arkansas Medicaid Program as required under § 20-77-141.

SOURCE:  AR Code 20-77-149, (Accessed Feb. 2024).

Ambulance Services – Newly Passed Legislation

An ambulance service’s operators may triage and transport a patient to an alternative destination in this state or treat in place if the ambulance service is coordinating the care of the patient through telemedicine with a physician for a medical-based complaint or with a behavioral health specialist for a behavioral-based complaint.

SOURCE: AR Code 20-13-108, (Accessed Feb. 2024).

On and after January 1, 2024, a healthcare insurer [includes Medicaid] that offers, issues, or renews a health benefit plan in this state shall provide coverage for:

• An ambulance service to:
  • Treat an enrollee in place if the ambulance service is coordinating the care of the enrollee through telemedicine with a physician for a medical-based complaint or with a behavioral health specialist for a behavioral-based complaint; or
  • Triage or triage and transport an enrollee to an alternative destination if the ambulance service is coordinating the care of the enrollee through telemedicine with a physician for a medical-based complaint or with a behavioral health specialist for a behavioral-based complaint; or

• An encounter between an ambulance service and enrollee that results in no transport of the enrollee if:
  • The enrollee declines to be transported against medical advice; and
  • The ambulance service is coordinating the care of the enrollee through telemedicine with a physician for a medical-based complaint or with a behavioral health specialist for a behavioral-based complaint.

See statute for additional restrictions.

The reimbursement rate for an ambulance service whose operators triage, treat, and transport an enrollee to an alternative destination, or triage, treat, and do not transport an enrollee if the enrollee declines to be transported against medical advice, if the ambulance service is coordinating the care of the enrollee through telemedicine with a physician for a medical-based complaint or with a behavioral health specialist for a behavioral-based complaint under this section shall be at least at the rate:

• Contracted with a local government entity where the alternative destination is located; or
• Established by the Workers’ Compensation Commission under its schedule for emergency Advance Life Support Level 1.

SOURCE: AR Code 23-79-2703, (Accessed Feb. 2024).

Group Therapy – General Professional Requirement (Not Medicaid exclusive)

A healthcare professional may use telemedicine to perform group meetings for healthcare services, including group therapy.  Telemedicine for group therapy provided to adults who are participants in a program or plan authorized and funded under 42 U.S.C. § 1396a, as approved by the United States Secretary of Health and Human Services, may only be permitted if the Centers for Medicare and Medicaid Services allows telemedicine for group therapy provided to adults. Telemedicine shall not be used for group therapy provided to a child who is eighteen (18) years of age or younger.

SOURCE: AR CODE 17-80-404 (Accessed Feb. 2024).

Life360 HOMES

The Rural Life360 will provide the following care coordination supports: … Provide intensive care coordination and coaching supports for enrolled clients. Intensive care coordination and coaching include: … Providing supports through any of the following:

1. Home visits in such frequency as is necessary to assist the client meet his/her documented PCAP goals
2. Office visits
3. Video-supported visits
4. Telephone or text message contacts in conjunction with in-person visits

SOURCE: AR Medicaid Provider Manual. Section II Life360 HOMES.  Rule 210.500 & 210.600, Updated 11-1-23. (Accessed Feb. 2024).

AR Independent Assessment (ARIA)

Behavioral Health Services:

A reassessment will be completed by staff employed by the independent assessment contractor utilizing the current approved assessment instrument (ARIA), which was approved prior to April 1, 2021, to assess functional need. An interview will be conducted in person for initial assessments, with the option of using telemedicine to complete Behavioral Health reassessments. The telemedicine tool must meet the 1915(i) requirement for the use of telemedicine under 42 CFR 441.720 (a)(1)(i)(A) through (C).

To continue to receive Complex Care services, members must receive a complex care assessment annually and be assessed as needing Complex Care services. A reassessment will be completed by appropriate DHS-approved staff using the appropriate Complex Care assessment tool. If a member does not meet the need for Complex Care services, the member will be placed back in Tier 3. An in-person interview will be conducted for initial assessments, with the option of using telemedicine to complete reassessments for members who meet the criteria for Complex Care. The telemedicine tool must meet the 1915(i) requirement for the use of telemedicine under 42 CFR 441.720 (a)(1)(i)(A) through (C).

SOURCE: AR Medicaid Provider Manual, Section II, AR Independent Assessment (ARIA), 210.100 & .600, 1-1-24, (Accessed Feb. 2024).

Life Choices Lifeline and Continuum of Care Program

The purpose of the Life Choices Lifeline and Continuum of Care Program is to provide a statewide telemedicine network and care program to provide community outreach, direct services, support, social services case management, care coordination, consultation, and referrals to:

• Encourage healthy childbirth;
• Support childbirth as an alternative to abortion;
• Promote family formation;
• Aid in successful parenting;
• Assist parents in establishing successful parenting techniques; and
• Increase families’ economic self-sufficiency.

SOURCE:  AR Rules for Life Choices Lifeline and Continuum of Care Program, Sec. 102, (Accessed Feb. 2024).

ELIGIBLE PROVIDERS

The distant site is the location of the healthcare provider delivering telemedicine services.

SOURCE: Section III Provider Billing Documentation.  Rule 305.000.  Updated Jan. 1, 2022 (Accessed Feb. 2024).

Services at the distant site must be provided by an enrolled Arkansas Medicaid Provider who is authorized by Arkansas law to administer healthcare.

The professional or entity at the distant site must be an enrolled Arkansas Medicaid Provider.

SOURCE: AR Medicaid Provider Manual. Section I General Policy.  Rule 105.190.  Updated Jan. 1, 2022 & Section III Billing Documentation.  Rule 305.000.  Updated Jan. 1, 2022, (Accessed Feb. 2024).

The provider of the distant site must submit claims for telemedicine services using the appropriate CPT or HCPCS code for the professional service delivered. The provider must use Place of Service two (02) (telemedicine distant site) when billing the CPT or HCPCS codes.

SOURCE: AR Medicaid Provider Manual. Section III Billing Documentation.  Rule 305.000.  Updated Jan. 1, 2022. (Accessed Feb. 2024)

The distant site healthcare provider will not utilize telemedicine services with a client unless a professional relationship exists between the provider and the client. A professional relationship exists when, at a minimum:

• The healthcare provider has previously conducted an in-person examination of the client and is available to provide appropriate follow-up care;
• The healthcare provider personally knows the client and the client’s health status through an ongoing relationship and is available to provide follow-up care;
• The treatment is provided by a healthcare provider in consultation with, or upon referral by, another healthcare provider who has an ongoing professional relationship with the client and who has agreed to supervise the client’s treatment including follow-up care;
• An on-call or cross-coverage arrangement exists with the client’s regular treating healthcare provider or another healthcare provider who has established a professional relationship with the client;
• A relationship exists in other circumstances as defined by the Arkansas State Medical Board (ASMB) or a licensing or certification board for other healthcare providers under the jurisdiction of the appropriate board if the rules are no less restrictive than the rules of the ASMB.
  • A professional relationship is established if the provider performs a face to face examination using real time audio and visual telemedicine technology that provides information at least equal to such information as would have been obtained by an in-person examination. (See ASMB Regulation 2.8);
  • If the establishment of a professional relationship is permitted via telemedicine under the guidelines outlined in ASMB regulations, telemedicine may be used to establish the professional relationship only for situations in which the standard of care does not require an in-person encounter and only under the safeguards established by the healthcare professional’s licensing board (See ASMB Regulation 38 for these safeguards including the standards of care); or
• The healthcare professional who is licensed in Arkansas has access to a client’s personal health record maintained by a healthcare professional and uses any technology deemed appropriate by the healthcare professional, including the telephone, with a client located in Arkansas to diagnose, treat, and if clinically appropriate, prescribe a noncontrolled drug to the client.

See Miscellaneous section for additional restrictions.

SOURCE: AR Medicaid Provider Manual. Section I General Policy. Rule 105.190. Updated Jan. 1, 2022 (Accessed Feb. 2024).

Medication Assisted Treatment (MAT) for Opioid Use Disorder

The provider at the distance site shall use both the GT modifier and the X2 or X4 modifier on the service claim.

SOURCE: AR Medicaid Provider Manual Physician Section II-129, Feb. 1, 2022, (Accessed Feb. 2024)

Patient-Led Arkansas Shared Savings Entity (PASSE) Program

The provision of virtual care can include an interdisciplinary care team or be provided by individual clinical service provider.

SOURCE: PASSE Program, p. II-8 (1/1/23).  (Accessed Feb. 2024).

Medication-Assisted Treatment for Opioid Use Disorder

Providers are encouraged to use telemedicine services when in-person treatment is not readily accessible.

SOURCE: AR Admin. Rule 230.000 (Lexis Nexis: 016-06 CARR 036) p. 12 (9/1/2020) (Accessed Feb. 2024).

The Arkansas Medicaid Program shall reimburse for the following behavioral and mental health services provided via telemedicine:

• Counseling and psychoeducation provided by a person licensed as:
  • A psychologist;
  • A psychological examiner;
  • A professional counselor;
  • An associate counselor;
  • An associate marriage and family therapist;
  • A marriage and family therapist;
  • A clinical social worker; or
  • A master social worker;
• Crisis intervention services;
• Substance abuse assessments;
• Mental health diagnosis assessments for an individual under twenty-one (21) years of age; and
• Group therapy for individuals who are eighteen (18) years of age or older under the current service definition determined by the Arkansas Medicaid Program and when provided via audio-visual technology that is compliant with the HIPPA and composed of beneficiaries of similar age and clinical presentation to qualified beneficiaries.

SOURCE: AR Code 20-77-141 (Accessed Feb. 2024).

ELIGIBLE SITES

Patient-Led Arkansas Shared Savings Entity (PASSE) Program

Virtual and telehealth services can be provided at the individual’s home or in a community setting.

SOURCE: PASSE Program, II-8 (1/1/23).  (Accessed Feb. 2024).

“Originating site” means a site at which a patient is located at the time healthcare services are provided to him or her by means of telemedicine, which includes the home of a patient.

SOURCE: AR Code 23-79-1601(4) (Accessed Feb. 2024).

School Based

Regardless of whether the provider is compensated for healthcare services, if a healthcare provider seeks to provide telemedicine services to a minor in a school setting and the minor client is enrolled in Arkansas Medicaid, the healthcare provider shall:

• Be the designated Primary Care Provider (PCP) for the minor client;
• Have a cross-coverage arrangement with the designated PCP of the minor client; or
• Have a referral from the designated PCP of the minor client.

If the minor client does not have a designated PCP, this section does not apply. Only the parent or legal guardian of the minor client may designate a PCP for a minor client.

SOURCE: AR Medicaid Provider Manual. Section I General Policy.  Rule 105.190.  Updated Jan. 1, 2022 (Accessed Feb. 2024).

GEOGRAPHIC LIMITS

No Reference Found

FACILITY/TRANSMISSION FEE

Payment will include a reasonable facility fee to the originating site (the site at which the patient is located at the time telemedicine healthcare services are provided). In order to receive reimbursement, the originating site must be operated by a healthcare professional or licensed healthcare entity that is authorized to bill Medicaid directly for healthcare services.

There is no facility fee for the distant site. The professional or entity at the distant site must be an enrolled Arkansas Medicaid Provider. Any other originating sites are not eligible to bill a facility fee.

SOURCE: AR Medicaid Provider Manual. Section I General Policy.  Rule 105.190.  Updated Jan. 1, 2022.  & Section III Billing Documentation.  Rule 305.000.  Updated Jan. 1, 2022, (Accessed Feb. 2024).

The originating site shall submit a telemedicine claim under the billing providers “pay to” information, using HCPCS code Q3014. The code must be submitted for the same date of service as the professional code and must indicate the place of service (where the member was at the time of the telemedicine encounter). Except in the case of hospital facility claims, the provider who is responsible for the care of the member at the originating site shall be entered as the performing provider in the appropriate field of the claim. For outpatient claims that occur in a hospital setting, the provider must also use Place of Service code twenty-two (22) with the originating site billing Q3014. In the case of in-patient services, HCPCS code Q3014 is not separately reimbursable because it is included in the hospital per diem.

SOURCE:  AR Medicaid Provider Manual. Section III Billing Documentation.  Rule 305.000. III-8 to 9, Updated Jan. 1, 2022 (Accessed Feb. 2024).

Federally Qualified Health Centers

Use procedure code and type of service code Y (paper claims only) to indicate telemedicine charges.

The charge associated with this procedure code should be an amount attributable to the telemedicine service, such as line (or wireless) charges. Medicaid will deny the charge and capture it in the same manner as with ancillary charges.

SOURCE:  AR Medicaid Provider Manual. Section II FQHC. Rule 262.120. Updated Feb. 1, 2022. pg. II-34, (Accessed Feb. 2024).

A health benefit plan shall provide a reasonable facility fee to an originating site operated by a healthcare professional or a licensed healthcare entity if the healthcare professional or licensed healthcare entity is authorized to bill the health benefit plan directly for healthcare services.

SOURCE: AR Code 23-79-1602(d) (1). (Accessed Feb. 2024).

POLICY

Synchronous Interaction

“Synchronous interaction” means a real-time interaction between a patient and a health care provider located at a distant site.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth (Aug. 2020). Pg. 2. (Accessed Apr. 2024).

Medi-Cal covered benefits or services, identified by CPT or HCPCS codes and subject to all existing Medi-Cal coverage and reimbursement policies, including any treatment authorization request requirements, may be provided via a telehealth modality, as outlined in this section, only if all of the following are satisfied:

• The treating health care provider at the distant site believes that the benefits or services being provided are clinically appropriate based upon evidence-based medicine and/or best practices to be delivered via telehealth;
• The benefits or services delivered via telehealth meet the procedural definition and components of the CPT or HCPCS code(s), as defined by the American Medical Association (AMA), associated with the Medi-Cal covered service or benefit, as well as any extended guidelines as described in this section of the Medi-Cal provider manual;
• The benefits or services provided via telehealth meet all laws regarding confidentiality of health care information and a patient’s right to his or her medical information.

Covered benefits or services provided via a telehealth modality are reimbursable when billed in one of two ways:

• For services or benefits provided via synchronous, interactive audio and visual telecommunications systems, the health care provider bills with modifier 95.
• For services or benefits provided via asynchronous store and forward telecommunications systems, the health care provider bills with modifier GQ.
• For services or benefits provided via synchronous telephone or other real-time interactive audio-only telecommunications systems, the health care provider bills with modifier 93.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth (Mar. 2024). Pg. 8. (Accessed Apr. 2024).

CA Medicaid and Medi-Cal managed care plans are required to reimburse health care providers of applicable health care services delivered via video synchronous interaction, synchronous audio-only modality, or asynchronous store and forward, as applicable, at payment amounts that are not less than the amounts the provider would receive if the services were delivered via in-person, face-to-face contact, so long as the services or settings meet the applicable standard of care and meet the requirements of the service code being billed.

In-person, face-to-face contact between a health care provider and a patient is not required under the Medi-Cal program for covered health care services and provider types designated by the department, when provided by video synchronous interaction, asynchronous store and forward, as defined in subdivision (a) of Section 2290.5 of the Business and Professions Code, audio-only synchronous interaction, remote patient monitoring, or other permissible virtual communication modalities, when those services and settings meet the applicable standard of care and meet the requirements of the service code being billed.

Applicable health care services appropriately provided through video synchronous interaction, asynchronous store and forward, audio-only synchronous interaction, remote patient monitoring, or other permissible virtual communication modalities are subject to billing, reimbursement, and utilization management policies imposed by the department. Utilization management protocols adopted by the department pursuant to this section shall be consistent with, and no more restrictive than, those authorized for health care service plans pursuant to Section 1374.13 of the Health and Safety Code.

Pursuant to an effective date designated by the department that is no sooner than January 1, 2024, a provider furnishing services through video synchronous interaction or audio-only synchronous interaction shall also maintain and follow protocols to do one of the following:

• Offer those services via in-person, face-to-face contact.
• Arrange for a referral to, and a facilitation of, in-person care that does not require a patient to independently contact a different provider to arrange for that care. (This clause does not require a provider to schedule an appointment with a different provider on behalf of a patient.)

In implementing this subdivision, the department shall consider additional recommendations from affected stakeholders regarding the need to maintain access to in-person services without unduly restricting access to telehealth services.

SOURCE: Welfare and Institutions Code 14132.725, as amended by SB 184 (2022 Session) and AB 1241 (2023 Session). (Accessed Apr. 2024).

In-person contact between a health care provider and a patient shall not be required under the Medi-Cal program for services appropriately provided through telehealth, subject to reimbursement policies adopted by the department to compensate a licensed health care provider who provides health care services through telehealth that are otherwise reimbursed pursuant to the Medi-Cal program.

SOURCE: Sec. 14132.72 of the Welfare and Institutions Code. (Accessed Apr. 2024).

Providers may establish a relationship with new patients via synchronous video telehealth visits.

SOURCE: Welfare and Institutions Code 14132.725; CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth (Mar. 2024). Pg. 3. (Accessed Apr. 2024).

Patient Choice of Telehealth Modality

Medi-Cal providers can offer a variety of telehealth modalities for covered Medi-Cal services to the extent that the service can be appropriately rendered via the allowable telehealth modalities. For Medi-Cal providers who do offer telehealth modalities, they are required to offer Medi-Cal recipients the ability to choose whether they want to receive covered Medi-Cal services via:

• Synchronous, interactive audio/visual telecommunication systems (for example, video) or
• Synchronous, telephone or other interactive audio-only telecommunications systems.

While Medi-Cal providers are required to offer both video and telephone telehealth modalities, Medi-Cal recipients may freely choose, and change at any time, their desired telehealth modalities, which includes the ability to decline video modalities and select audio-only (telephone) modalities if preferred and/or necessary given the recipient’s needs. For example, if the visit is related to sensitive services as defined in subsection (s) of Section 56.05 of the Civil Code, then the Medi-Cal recipient may prefer to utilize an audio-only (telephone) modality. Medi-Cal recipients shall be given the choice of how they receive their covered Medi-Cal services.

Exception to Telehealth Modalities Provider Requirement

Since broadband is necessary to ensure quality and effective communication between Medi-Cal providers and recipients, Medi-Cal providers are exempt from the requirement to offer both telehealth modalities if the Medi-Cal provider does not have access to broadband. Note: Broadband refers to high-speed internet access that is always on and faster than traditional dial-up access. Broadband includes several high-speed transmission technologies, such as fiber, wireless, satellite, digital subscriber line, and cable. For the purposes of delivering telehealth services to patients, DHCS uses the Federal Communications Commission’s (FCC) definition of broadband and the FCC minimum mbps upload/download speeds. Medi-Cal providers claiming this exception must maintain appropriate supporting documentation, which should be made available to DHCS upon request. For example, supporting documentation might include confirmation from an internet services provider regarding the lack of broadband service in a particular coverage area.

Right to In-person Services

Medi-Cal providers furnishing services to Medi-Cal recipients through telehealth modalities must also either offer services in-person or have a documented process in place to link Medi-Cal recipients to in-person care within a reasonable time if in-person services are unavailable from the provider.

If the Medi-Cal provider chooses to link the Medi-Cal recipient to in-person care to satisfy this requirement, then they must provide a referral to and facilitation of in-person care that does not require a recipient to independently contact a different Medi-Cal provider to arrange for such care. The Medi-Cal provider may initiate a process by which a different Medi-Cal provider in their office or an affiliated in-person care site contacts the Medi-Cal recipient directly to schedule an in-person visit. T

he referring Medi-Cal provider or a member of their staff must confirm the referred Medi-Cal provider has at least attempted to contact the recipient to schedule an in-person appointment. However, the Medi-Cal referring provider is not required to schedule an appointment with a different provider on behalf of the Medi-Cal recipient. The Medi-Cal provider must offer referral and facilitation support that is minimally burdensome to the Medi-Cal recipient. Medi-Cal providers must maintain documentation of their process to link Medi-Cal recipients to in-person care, which should be made available to DHCS upon request.›

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth (Mar. 2024). Pg. 6-7. (Accessed Apr. 2024).

Brief Virtual Communications and Check-ins

Virtual or telephonic communication includes a brief communication with an established patient not physically present (face-to-face). Medi-Cal providers may be reimbursed using HCPCS codes G2010 and G2012 for brief virtual communications.

HCPCS code G2012: Brief communication technology-based service, e.g., virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5 to 10 minutes of medical discussion. G2012 can be billed when the virtual communication via a telephone call.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth (Mar. 2024). Pg. 12. (Accessed Apr. 2024).

Federally Qualified Health Center (FQHC) & Rural Health Clinic (RHC) 

Telehealth services must meet all billing requirements that would have applied if the applicable services were delivered via a face-to-face encounter with a billable provider and meet the applicable standard of care.

Services rendered via telehealth must be FQHC or RHC covered services.  Synchronous interaction means a real-time audio-visual, two-way interaction between a new or established patient and an FQHC or RHC billable provider at a distant site. Medi-Cal benefits or services being provided are clinically appropriate and meet the procedural and billing requirements that would have applied if the applicable services were delivered via a face-to-face encounter. An FQHC patient who receives telehealth services shall otherwise be eligible to receive in-person services from the FQHC pursuant to the federal Health Resources Services Administration requirements. A patient may be “established” via synchronous interaction if all of the conditions of the “New Patient” requirements in this manual section are met.

See manual for billing examples.

In regard to patient choice of telehealth modality and right to in-person services requirements, FQHC/RHC providers are directed to refer to the policies found in more detail in the Telehealth Manual.

SOURCE: CA Dept. of Health Care Services, Part 2 Manual, Medi-Cal Rural Health Clinics and Federally Qualified Health Centers (Mar. 2024), p. 12-13, 15-16.  (Accessed Apr. 2024).

Visits shall also include an encounter between an FQHC or RHC patient and a physician, physician assistant, nurse practitioner, certified nurse-midwife, clinical psychologist, licensed clinical social worker, visiting nurse, comprehensive perinatal services program practitioner, dental hygienist, dental hygienist in alternative practice, or marriage and family therapist using video synchronous interaction, when services delivered through that interaction meet the applicable standard of care. A visit described in this clause shall be reimbursed at the applicable FQHC’s or RHC’s per-visit PPS rate to the extent the department determines that the FQHC or RHC has met all billing requirements that would have applied if the applicable services were delivered via a face-to-face encounter.

An FQHC or RHC is not precluded from establishing a new patient relationship through video synchronous interaction.

Effective on a date designated by the department that is no sooner than January 1, 2024, an FQHC or RHC furnishing services through video synchronous interaction or audio-only synchronous interaction shall also do one of the following:

• Offer those services via in-person, face-to-face contact.
• Arrange for a referral to, and a facilitation of, in-person care that does not require a patient to independently contact a different provider to arrange for that care.

SOURCE: Welfare and Institutions Code 14132.100, as amended by SB 184 (2022 Session) and AB 32 (2022 Session). (Accessed Apr. 2024).

Family PACT

Family PACT providers must ensure that the covered Family PACT service or benefit being delivered via telehealth meets the procedural definition and components of the CPT or HCPCS code(s) associated with the Family PACT covered service or benefit, as well as any other requirements described in this manual. In addition, Family PACT services rendered by the use of a telehealth modality must follow ICD-10-CM diagnosis code billing policy as noted in this manual. All healthcare practitioners rendering Family PACT covered benefits or services under this policy must comply with all applicable state and federal laws.

SOURCE: CA Department of Health Care Services.  Family Planning, Access, Care and Treatment Program. Benefits Manual. Jun. 2023, Pg. 6. (Accessed Apr. 2024).

A Family PACT provider may enroll and recertify clients through synchronous video or audio-only synchronous telehealth modalities. See manual for more information.

SOURCE: CA Department of Health Care Services. Family PACT Client Eligibility Manual. Apr. 2023. Pg. 1. (Accessed Apr. 2024).

Managed Care

To ensure proper payment and record of Covered Services provided via Telehealth, all Providers must use the modifiers defined in the Medi-Cal Provider Manual with the appropriate CPT-4 or HCPCS codes when coding for services delivered through both synchronous interactions and asynchronous store and forward telecommunications. Regarding the rate of reimbursement, unless otherwise agreed to by the MCP and Provider, MCPs must reimburse Network Providers at the same rate, whether a Covered Service is provided in-person or through Telehealth, if the service is the same regardless of the modality of delivery, as determined by the Provider’s description of the service on the claim.

SOURCE: CA Department of Health Care Services (DHCS). All Plan Letter 23-007: Telehealth Services Policy. Apr. 10, 2023. (Accessed Apr. 2024).

Indian Health Services, Memorandum of Understanding Agreement (IHS-MOA)

Services rendered via telehealth must be IHS-MOA covered services.

Services provided through synchronous telehealth for an established patient are subject to the same program restrictions, limitations and coverage that exist when the service is provided in-person.

• IHS-MOA clinics must submit claims for telehealth services using the appropriate per visit IHS-MOA billing codes, modifiers and related claims submission requirements. Providers may refer to the Indian Health Services (IHS), Memorandum of Agreement (MOA) 638, Clinics: Billing Codes section in the appropriate Part 2 manual.
• IHS-MOA clinics are not eligible to bill an originating site fee or transmission charges. The costs of these services should be included in the IHS-MOA rate.

See manual for billing examples.

SOURCE: CA Department of Health Care Services (DHCS).  Indian Health Services, Memorandum of Agreement (MOA) 638, Clinics Manual. Jan. 2023. Pg. 8. (Accessed Apr. 2024).

Local Educational Agency (LEA)

For dates of service on or after May 12, 2023, LEAs may bill for covered direct medical services under the LEA Medi-Cal Billing Option Program according to the following guidelines. All LEA services covered under the LEA Medi-Cal Billing Option Program may be billed by participating LEAs when performed via telehealth, except for services that preclude a telehealth modality, such as specialized medical transportation services. Services delivered via telehealth must meet the requirements described in the Medi-Cal provider manual.

Practitioners must use the “LEA Services Billing Codes Chart” in the Local Educational Agency (LEA) Billing Codes and Reimbursement Rates provider manual section to find LEA services that are reimbursable when rendered by telehealth. The first column of the chart indicates “Add modifier 95 if via telehealth” when the telehealth service is reimbursable under the LEA Medi-Cal Billing Option Program.

SOURCE: CA Department of Health Care Services (DHCS). Local Education Agency (LEA) Telehealth. Jun. 2023. Pg. 1, 5.  (Accessed Apr. 2024).

Dental Services

The Department of Health Care Services has opted to permit the use of teledentistry (including live video) as an alternative modality for the provision of select dental services.

Synchronous interaction, or live transmission, is a real-time interaction between a member and a provider located at a distant site. Live transmissions are limited to 90 minutes per member per provider, per day.  Please note, live transmissions may be provided at the member’s request or if the health care provider believes the service is clinically appropriate.  See manual for billing codes.

SOURCE: CA Department of Health Care Services (DHCS). Dental Provider Handbook. (2023) Pg. 4-22 – 4-24 (Accessed Apr. 2024).

Drug Medi-Cal Treatment Program

A county that enters into a Drug Medi-Cal Treatment Program contract with the department shall reimburse Drug Medi-Cal certified providers for medically necessary Drug Medi-Cal reimbursable services, as defined in Section 14124.24, provided by a licensed practitioner of the healing arts, or a registered or certified alcohol or other drug counselor or other individual authorized by the department to provide Drug Medi-Cal reimbursable services when those services meet the standard of care, meet the requirements of the service code being billed, and are delivered through video synchronous interaction or audio-only synchronous interaction.

SOURCE: Welfare and Institutions Code 14132.731, as amended by SB 184 (2022 Session). (Accessed Apr. 2024).

ELIGIBLE SERVICES/SPECIALTIES

Medi-Cal covered benefits or services, identified by CPT or HCPCS codes and subject to all existing Medi-Cal coverage and reimbursement policies, including any treatment authorization request requirements, may be provided via a telehealth modality if all of the following are satisfied:

• The treating health care provider at the distant site believes that the benefits or services being provided are clinically appropriate based upon evidence-based medicine and/or best practices to be delivered via telehealth;
• The benefits or services delivered via telehealth meet the procedural definition and components of the CPT or HCPCS code(s), as defined by the American Medical Association, associated with the Medi-Cal covered service or benefit, as well as any extended guidelines as described in this section of the Medi-Cal provider manual; and
• The benefits or services provided via telehealth meet all laws regarding confidentiality of health care information and a patient’s right to his or her medical information.

Covered benefits or services provided via a telehealth modality are reimbursable when billed in one of two ways:

• For services or benefits provided via synchronous, interactive audio and visual telecommunications systems, the health care provider bills with modifier 95.
• For services or benefits provided via asynchronous store and forward telecommunications systems, the health care provider bills with modifier GQ.
• For services or benefits provided via synchronous telephone or other real-time interactive audio-only telecommunications systems, the health care provider bills with modifier 93.

Certain types of benefits or services that would not be expected to be appropriately delivered via telehealth include, but are not limited to, benefits or services that are performed in an operating room or while the patient is under anesthesia, require direct visualization or instrumentation of bodily structures, involve sampling of tissue or insertion/removal of medical devices and/or otherwise require the in-person presence of the patient for any reason.

The amount paid by DHCS and Medi-Cal managed care plans for a service rendered via telehealth is the same as the amount paid for the applicable service when rendered in-person.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth (Mar. 2024). Pg. 4, 8. (Accessed Apr. 2024).

Medi-Cal covers an ‘e-visit’ which are communications between a patient and their provider through an online patient portal.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth (Aug. 2020). Pg. 2. (Accessed Apr. 2024).

Federally Qualified Health Center (FQHC) & Rural Health Clinic (RHC)

Synchronous interaction means a real-time audio-visual, two-way interaction between a new or established patient and an FQHC or RHC billable provider at a distant site.

Medi-Cal benefits or services being provided are clinically appropriate and meet the procedural and billing requirements that would have applied if the applicable services were delivered via a face-to-face encounter.

SOURCE: CA Department of Health Care Services (DHCS).  Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHC) Outpatient Services Manual. Mar. 2024. Pg. 16. (Accessed Apr. 2024).

Indian Health Services, Memorandum of Understanding Agreement (IHS-MOA)

Services provided through synchronous telehealth for an established patient are subject to the same program restrictions, limitations and coverage that exist when the service is provided in-person.

• IHS-MOA clinics must submit claims for telehealth services using the appropriate per visit IHS-MOA billing codes, modifiers and related claims submission requirements. Providers may refer to the Indian Health Services (IHS), Memorandum of Agreement (MOA) 638, Clinics: Billing Codes section in the appropriate Part 2 manual.

SOURCE: CA Department of Health Care Services (DHCS).  Indian Health Services, Memorandum of Agreement (MOA) 638, Clinics Manual. Jan. 2023. Pg. 7-8. (Accessed Apr. 2024).

Dental Services

Synchronous interaction, or live transmission, is a real-time interaction between a member and a provider located at a distant site. Live transmissions are limited to 90 minutes per member per provider, per day. Please note, live transmissions may be provided at the member’s request or if the health care provider believes the service is clinically appropriate. All dental information transmitted during the delivery of Medi-Cal covered benefits or services via a telehealth modality must become part of the patient’s dental record maintained by the Medi-Cal provider at the distant site.

SOURCE: CA Department of Health Care Services (DHCS). Denti-Cal Manual. 2023. Pg. 4-24. (Accessed Apr. 2024).

Home Health & Durable Medical Equipment

Telehealth may be used to deliver a face-to-face encounter related to the primary reason a recipient requires home health services or a durable medical equipment item.

SOURCE: Department of Health Care Services. Home Health Agencies (HHA) Provider Handbook. (Feb. 2021), Pg. 3. & Department of Health Care Services. Durable Medical Equipment (DME): An Overview. (July 2021), Pg. 6. (Accessed Apr. 2024).

CA Children’s Services (CCS)

CA Children’s Services Program lists eligible CPT/HCPCS codes in Numbered Letters 16-1217 & 09-0718.  Codes specifically include tele-speech, tele-auditory verbal therapy, tele-auditory habilitation and tele-auditory rehabilitation services in the home, with the parent or guardian working with the speech therapist at the distant site.

SOURCE: Number Letter 09-0718 to CA Children’s Services Program.  Jul. 10, 2018.  (Accessed Apr. 2024). 

CCS providers must request prior authorization services from CCS paneled physicians (22, CCR Section 41412) who are available to provide telehealth services. Prior authorization requests are also authorized to CCS-approved hospitals and outpatient special care centers. GHPP providers must be Medi-Cal enrolled providers.

Physical and Occupational Therapy may be offered through appropriate telehealth modalities. Medical Therapy Unit therapists may offer remote/virtual teletherapy services as an alternative to in-person visits, as appropriate and directed by the Medical Therapy Conference and directing physicians. CCS clients receiving services through a Special Care Center and/or Medical Therapy Program Medical Therapy Conference must have an annual in-person evaluation by a CCS-paneled physician. GHPP clients require an annual evaluation to ensure continued program coverage.

Billing for telehealth services is contingent upon the CCS Program or GHPP clients meeting all eligibility criteria, with an approved CCS Program/GHPP SAR, and in conformance with required Medi-Cal claims submission procedures as outlined in the DHCS Medi-Cal Telehealth Policy.

• When submitting a SAR for synchronous telemedicine services, the provider must use codes provided in the American Medical Association (AMA’s) CPT Manual, Appendix P.
• Telehealth modifiers (93, 95 or GQ) are required on SARs to differentiate the telehealth service from the equivalent in-person service.
• For services or benefits provided via synchronous, interactive audio, and telecommunications systems, the health care provider bills with modifier 95.
• For services or benefits provided via synchronous, telephone or other interactive audio-only telecommunications systems, the health care provider bills with modifier 93.
• For services or benefits provided via asynchronous store-and-forward telecommunications systems, the health care provider bills with modifier GQ.

For Whole Child Model (WCM) counties, the client’s managed care plan (MCP) shall be responsible for authorizing, coordinating, and covering CCS telehealth services.

SOURCE: Department of Health Care Services. Numbered letter 03-0723 to the Children’s Services Program and Genetically Handicapped Persons Program (GHPP). Jul. 7, 2023 – supersedes Department of Health Care Services. Numbered letter 16-1217 to the CA Children’s Services Program and Genetically Handicapped Persons Program (GHPP). Dec. 22, 2017. (Accessed Apr. 2024).

Opioid Use Disorder Treatment Services

Outpatient treatment services for opioid use disorder (OUD), which include management, care coordination, psychotherapy and counseling are reimbursable using HCPCS codes G2086, G2087 and G2088. At least one psychotherapy service must be furnished in order to bill for HCPCS codes G2086 thru G2088. Although the descriptions for these codes refer to “office-based treatment,” these services may be delivered via telehealth when they meet Medi-Cal requirements. See Medi-Cal Telehealth Provider Manual.

HCPCS codes G2086 thru G2088 are not reimbursable for treatment in state-licensed Opioid Treatment Programs as defined in Health and Safety Code Section 11875. HCPCS codes G2086 and G2087 each have a frequency limit of once per calendar month, per recipient, any provider and G2088 has a frequency limit of two per calendar month, per recipient, any provider. Only one provider can be reimbursed for HCPCS code G2086, G2087 or G2088 per calendar month.

SOURCE: Department of Health Care Services. Evaluation & Management Manual. Page 47-48. Dec. 2022. (Accessed Apr. 2024).

ELIGIBLE PROVIDERS

The health care provider rendering Medi-Cal covered benefits or services provided via a telehealth modality must meet the requirements of Business and Professions Code (B&P Code), Section 2290.5(a)(3), or must be otherwise designated by the Department of Health Care Services (DHCS) pursuant to Welfare and Institutions Code (WIC) 14132.725 (b)(2)(A).

A licensed health care provider rendering Medi-Cal covered benefits or services via a telehealth modality must be licensed in California, enrolled as a Medi-Cal rendering provider or non-physician medical practitioner (NMP) and affiliated with an enrolled Medi-Cal provider group.

The enrolled Medi-Cal provider group for which the health care provider renders services via telehealth must meet all Medi-Cal program enrollment requirements and must be located in California or a border community.

For purposes of telehealth [the distant site] can be different from the administrative location.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth (Mar. 2024). Pg. 2-3. (Accessed Apr. 2024).

Federally Qualified Health Center (FQHC) & Rural Health Clinic (RHC)

Billable providers are eligible to deliver covered FQHC/RHC services. Providers may refer to “RHC/FQHC Covered Services” in this manual section.

SOURCE: CA Department of Health Care Services (DHCS).  Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHC) Outpatient Services Manual. Mar. 2024. Pg. 12. (Accessed Apr. 2024).

Indian Health Services, Memorandum of Understanding Agreement (IHS-MOA)

Billable providers are eligible to deliver available services offered under IHS-MOA services.

SOURCE: CA Department of Health Care Services (DHCS). Indian Health Services, Memorandum of Agreement (MOA) 638, Clinics Manual. Jan. 2023. Pg. 7-8. (Accessed Apr. 2024).

Dental Professionals

For Medi-Cal dental benefits or services, Medi-Cal enrolled dentists and allied dental professionals (under the supervision of a dentist) may render limited services via synchronous/live transmission teledentistry, so long as such services are within their scope of practice, when billed using CDT code D9995 for dates of service on or after May 16, 2020.

SOURCE: CA Department of Health Care Services (DHCS). Denti-Cal Manual. Jan. 2023. Pg. 4-24-26. (Accessed Apr. 2024).

Psychiatrists

Psychiatrists may bill for services delivered through telehealth in accordance with the Medicaid state plan.

SOURCE: Sec. 14132.73 of the Welfare and Institutions Code. (Accessed Apr. 2024).

Doula, Community Health Worker (CHW) and Asthma Preventive Services

Doulas may provide services described in the Doula Services manual via telehealth.

Community Health Workers (CHWs) may provide services described in the Community Health Worker (CHW) Preventive Services manual via telehealth

Asthma preventive education and training services described in the Asthma Preventive Services (APS) manual may be provided via telehealth by unlicensed asthma preventive service providers. In-home environmental trigger assessments for asthma may not be conducted via telehealth and must be conducted in-person.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth (Jan. 2023). Pg. 4. (Accessed Apr. 2024).

ELIGIBLE SITES

For purposes of reimbursement for covered treatment or services provided through telehealth, the type of setting where services are provided for the patient or by the health care provider is not limited (Welfare and Institutions Code [WIC] Section 14132.72(e)). This may include, but is not limited to, a hospital, medical office, community clinic, or the patient’s home.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth (Aug. 2020). Pg. 2. (Accessed Apr. 2024).

Federally Qualified Health Center (FQHC) & Rural Health Clinic (RHC)

The billable provider, employed or under direct contract with an FQHC or RHC can respond from any location, including their home, during a time that they are scheduled to work for the FQHC or RHC.

For the purposes of payment for covered treatment or services provided through telehealth, the department shall not limit the type of setting where services are provided for the patient or by the health care provider.

SOURCE: CA Department of Health Care Services (DHCS).  Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHC) Outpatient Services Manual. Mar. 2024. Pg. 17. (Accessed Apr. 2024).

Indian Health Services, Memorandum of Understanding Agreement (IHS-MOA)

Refers to fee-for-service policy for the definition of an ‘originating site’ and ‘distant site’.

SOURCE: CA Department of Health Care Services (DHCS). Indian Health Services, Memorandum of Agreement (MOA) 638, Clinics Manual. Jan. 2023. Pg. 7. (Accessed Apr. 2024).

Family PACT

Family PACT telehealth policy follows Medi-Cal telehealth policy to the extent it is applicable to the Family PACT Program and covered services. Exceptions include the definition for distant site:

• For Family PACT, the distant site must be the enrolled service site. In Medi-Cal, the distant site can be different than the administrative location, as stated in the Medicine: Telehealth section of the appropriate Part 2 Medi-Cal provider manual.

SOURCE: CA Department of Health Care Services. Medi-Cal Provider Bulletin. Family PACT Update. Jun. 2023. (Accessed Apr. 2024).

GEOGRAPHIC LIMITS

No Reference Found

FACILITY/TRANSMISSION FEE

The originating site facility fee is reimbursable only to the originating site when billed with HCPCS code Q3014 (telehealth originating site facility fee).  Transmission costs incurred from providing telehealth services via audio/video communication is reimbursable when billed with HCPCS code T1014 (telehealth transmission, per minute, professional services bill separately).

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth (Mar. 2024). Pg. 13. (Accessed Apr. 2024).

FQHC & RHC/IHS-MOA

FQHCs/RHCs/IHS-MOA are not eligible to bill an originating site fee or transmission charges. The costs of these services should be included in the PPS/AIR/IHS-MOA rates, as applicable.

SOURCE: CA Department of Health Care Services (DHCS).  Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHC) Outpatient Services Manual. Mar. 2024. Pg. 13; CA Department of Health Care Services (DHCS). Indian Health Services, Memorandum of Agreement (MOA) 638, Clinics Manual. Jan. 2023. Pg. 8.  (Accessed Apr. 2024).

Local Education Agency

Ancillary costs, such as equipment, technical support, facility fee, and transmission charges incurred while providing telehealth services via audio/video communication are not reimbursable.

SOURCE: CA Department of Health Care Services (DHCS). Local Education Agency (LEA) Telehealth. Jun. 2023. Pg. 5 (Accessed Apr. 2024).

Every Woman Counts Program

Effective retroactively for dates of service on or after November 1, 2013, HCPCS codes Q3014 (telehealth originating site facility fee) and T1014 (telehealth transmission, per minute, professional services bill separately) are benefits of the Every Woman Counts (EWC) program.

SOURCE: Department of Health Care Services. Every Woman Counts Program Manual. Pgs. 41-42. Nov. 2023. (Accessed Apr. 2024).

POLICY

CO Medicaid will cover medically necessary medical and surgical services furnished to eligible members.

Telemedicine services may be provided under two arrangements.

• The first arrangement is when a member receives services via a live audio/visual connection from a single provider. This is the predominant arrangement for telemedicine.
• The second arrangement is when a member and a provider are physically in the same location and additional services are provided by a second (distant) provider via a live audio/visual connection. In this arrangement the provider who is present with the member is called the “originating provider”, and the provider located at a different site, acting as a consultant, is called the “distant provider”.

The member must be present during any Telemedicine visit.

It is acceptable to use Telemedicine to facilitate live contact directly between a member and a provider.

SOURCE: CO Department of Health Care Policy and Financing.  “Telemedicine Billing Manual,” 1/24 (Accessed Jan. 2024). 

In-person contact between a health care or mental health care provider and a patient is not required under the state’s medical assistance program for health care or mental health care services delivered through telemedicine that are otherwise eligible for reimbursement under the program. Any health care or mental health care service delivered through telemedicine must meet the same standard of care as an in-person visit. Telemedicine may be provided through interactive audio, interactive video, or interactive data communication, including but not limited to telephone, relay calls, interactive audiovisual modalities, and live chat as long as the technologies are compliant with HIPAA.  The health care or mental health care services are subject to reimbursement policies developed pursuant to the medical assistance program. This section also applies to managed care organizations that contract with the state department pursuant to the statewide managed care system only to the extent that:

• Health care or mental health care services delivered through telemedicine are covered by and reimbursed under the Medicaid per diem payment program; and
• Managed care contracts with managed care organizations are amended to add coverage of health care or mental health care services delivered through telemedicine and any appropriate per diem rate adjustments are incorporated.

Reimbursement rate must be, at minimum, the same as a comparable in-person services.

SOURCE: CO Revised Statutes 25.5-5-320. (Accessed Jan. 2024).

Interim Therapeutic Restorations

In-person contact between a health care provider and a recipient is not required under the state’s medical assistance program for the diagnosis, development of a treatment plan, instruction to perform an interim therapeutic restoration procedure, or supervision of a dental hygienist performing an interim therapeutic restoration procedure. A health care provider may provide these services through telehealth, including store-and-forward transfer, and is entitled to reimbursement for the delivery of those services via telehealth to the extent the services are otherwise eligible for reimbursement under the program when provided in person. The services are subject to the reimbursement policies developed pursuant to the state medical assistance program.

SOURCE: CO Revised Statutes 25.5-5-321.5. (Accessed Jan. 2024).

ELIGIBLE SERVICES/SPECIALTIES

Colorado Medicaid will reimburse for medical and mental health services delivered through telemedicine that are otherwise eligible for reimbursement under the program.

Health care or mental health care services includes speech therapy, physical therapy, occupational therapy, hospice care, home health care and pediatric behavioral health care.

SOURCE: CO Revised Statutes 25.5-5-320. (Accessed Jan. 2024).

Services may be rendered via telemedicine when the service is:

• A covered Health First Colorado benefit,
• Within the scope and training of an enrolled provider’s license, and
• Appropriate to be rendered via telemedicine.

All services provided through telemedicine shall meet the same standard of care as in-person care.

Refer to the Telemedicine Website for a list of billing codes which may be used with Place of Service (POS) 02 or 10.

The reimbursement rate for a telemedicine service shall, as a minimum, be set at the same rate as the medical assistance program rate for a comparable in-person service.

Providers may only bill procedure codes which they are already eligible to bill.

Place of Services codes 02 and 10 can be used during telehealth encounters:

• POS 02: Telehealth provided other than in the patient’s home. The location where health services and health related services are provided or received, through telecommunication technology. Patient is not located in their home when receiving health services or health related services through telecommunication technology.
• POS 10: Telehealth Provided in Patient’s Home. The location where health services and health related services are provided or received through telecommunication technology. Patient is located in their home (which is a location other than a hospital or other facility where the patient receives care in a private residence) when receiving health services or health related services through telecommunication technology.

Additionally, modifiers FQ, FR, 93, and 95 can be added to POS 2 and 10:

• FQ: The service was furnished using audio-only communication technology.
• FR: The supervising practitioner was present through two-way, audio/video communication technology.
• 93: Synchronous Telemedicine Service Rendered Via Telephone or Other Real-Time Interactive Audio-Only Telecommunications System
• 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System

SOURCE: CO Department of Health Care Policy and Financing.  “Telemedicine – Provider Information”, CO Department of Health Care Policy and Financing, CO Department of Health Care Policy and Financing.  “Telemedicine Billing Manual”, 1/24. (Accessed Jan. 2024).

Physician services may be provided as telemedicine.  Any health benefits provided through telemedicine shall meet the same standard of care as in-person care.

SOURCE: Colorado Adopted Rule 8.200.3.B. (Accessed Jan. 2024).

Any Health First Colorado-covered physician services that are within the scope of a provider’s practice and training and appropriate for telemedicine may be rendered via telemedicine.

SOURCE: CO Department of Health Care Policy and Financing.  “Telemedicine – Provider Information”. (Accessed Jan. 2024).

Procedure codes listed below under “Telemedicine Modifier GT” will receive an additional $5.00 to the fee listed on the most recent Health First Colorado Fee Schedule when billed using modifier GT.

SOURCE: CO Department of Health Care Policy and Financing.  “Telemedicine Billing Manual” 1/24.  (Accessed Jan. 2024).

SOURCE: Colorado Adopted Rule 8.095.2, 8.095.4, 8.095.7. (Accessed Jan. 2024).

Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services

Other health care services may include other EPSDT benefits if the need for such services is identified. The services are a benefit when they meet the following requirements:

1. All goods and services described in Section 1905(a) of the Social Security Act are a covered benefit under EPSDT when medically necessary as defined at 10 C.C.R. 2505-10, Section 8.076.1.8, regardless of whether such goods and services are covered under the Colorado Medicaid State Plan.
2. For the purposes of EPSDT, medical necessity includes a good or service that will, or is reasonably expected to, assist the client to achieve or maintain maximum functional capacity in performing one or more Activities of Daily Living; and meets the criteria set forth at Section 8.076.1.8.b – g.
3. The service provides a safe environment or situation for the child.
4. The service is not for the convenience of the caregiver.
5. The service is medically necessary.
6. The service is not experimental or investigational and is generally accepted by the medical community for the purpose stated.
7. The service is the least costly.

SOURCE: CO Department of Health Care Policy and Financing.  “Telemedicine Billing Manual” 1/24.  (Accessed Jan. 2024).

Durable Medical Equipment Encounters

Face-to-face encounters for durable medical equipment, prosthetics, orthotics, and supplies may be performed via telehealth if available.

SOURCE: CO Department of Health Care Policy and Financing.  “Durable Medical Equipment, Prosthetics, Orthotics, and Supplies”, 1/24. (Accessed Jan. 2024).

Certain providers are authorized to order durable medical equipment and may conduct a related face-to-face encounter via telehealth or telemedicine if those services are covered by the Medical Assistance Program.

SOURCE: Colorado Adopted Rule 8.590.7.N. (Accessed Jan. 2024).

Pediatric Behavioral Therapy

Pediatric Behavioral Therapists are covered under the telemedicine policy.

SOURCE: CO Department of Health Care Policy and Financing.  “Pediatric Behavioral Therapies Billing Manual”, 1/23 (Accessed Jan. 2024). 

Pediatric Behavioral Therapy (PBT) providers will not be required to collect Electronic Visit Verification (EVV) data when the services are delivered via telehealth, effective May 1, 2023. EVV remains a requirement for all other PBT services when delivered in the home or community.

SOURCE: CO Dept. of Health Care Policy and Financing. Provider Bulletin. May 2023. (Accessed Jan. 2024).

Screening Brief Intervention Treatment

Screening Brief Intervention Treatment may be provided via telemedicine (simultaneous audio and video transmission or by telephone audio-only) with the member.

SOURCE: CO Department of Health Care Policy and Financing.  “Screening, Brief Intervention and Referral to Treatment”, 3/23. (Accessed Jan. 2024).

Education-Only Services

Colorado Medicaid provides reimbursement for education-only services provided through telemedicine. This includes services such as Diabetes Self-Management Education and Support (DSMES) and tobacco cessation counseling.

SOURCE: CO Department of Health Care Policy and Financing. Provider Bulletin B1900434. Aug. 2019. (Accessed Jan. 2024). 

Education-only services was removed from the list of “Not Covered Services” section in the provider manual in June 2019.

Health First Colorado does not pay for provider education via telemedicine.

SOURCE: CO Department of Health Care Policy and Financing.  “Telemedicine Billing Manual” 1/24. (Accessed Jan. 2024).

Abortion Services

Certain medicinal abortion services may be provided by telemedicine. Physicians (MDs/DOs), Certified Nurse Midwives (CNMs), Advanced Practice Nurses (APNs) or Physician Assistants (PAs) who wish to prescribe Mifepristone must complete a Prescriber Agreement Form prior to ordering and dispensing Mifepristone. The medicinal abortion method (not available for use in maternal life-endangering situations) can be provided by these identified provider types and identified places of service effective May 21, 2021, when prescribed or dispensed and provided by eligible Mifepristone-prescribing practitioners.

HCPCS S0199 covers:

• Office visit #1 or telemedicine counseling/communications
  • Patient check-in or telemedicine services, all counseling and consultation
  • Confirmation of pregnancy and fetal gestational age (either by hCG or ultrasound)
• Follow-up, may include a second office visit or consultation via telemedicine
  • Patient consultation: may include telemedicine consult or office visit check-in with in-person consult.
  • Confirmation of pregnancy termination (either by hCG or ultrasound)

Please see Provider Bulletin for further billing information and related requirements.

SOURCE: CO Department of Health Care Policy and Financing. Provider Bulletin B2200472. Jan. 2022. (Accessed Jan. 2024).

Community Mental Health Centers/Clinics

Group psychotherapy services shall be face-to-face, or interactive audio (including but not limited to telephone and relay calls), interactive video (including but not limited to interactive audiovisual modalities), or interactive data communication (including but not limited to live chat and excluding text messaging, electronic mail, and facsimile transmission) services that are insight-oriented, behavior modifying, and that involve emotional interactions of the group members. Group psychotherapy services shall assist in providing relief from distress and behavior issues with other clients who have similar problems and who meet regularly with a practitioner. Any health benefits provided through interactive audio, interactive video, or interactive data communication must meet the same standard of care as in-person care.

Individual psychotherapy services shall be face-to-face, or interactive audio (including but not limited to telephone and relay calls), interactive video (including but not limited to interactive audiovisual modalities), or interactive data communication (including but not limited to live chat and excluding text messaging, electronic mail, and facsimile transmission) services that are tailored to address the individual needs of the client. Services shall be insight-oriented, behavior modifying and/or supportive with the client in an office or outpatient facility setting. Individual psychotherapy services are limited to thirty-five visits per State fiscal year. Any health benefits provided through interactive audio, interactive video, or interactive data communication must meet the same standard of care as in-person care.

SOURCE: Colorado Adopted Rule 8.750.3.B. (Accessed Jan. 2024).

FQHC/RHC

Health First Colorado allows telemedicine visits to qualify as billable encounters for Federally Qualified Health Centers (FQHCs), Rural Health Clinic (RHCs), and Indian Health Services (IHS). Services allowed under telemedicine may be provided via telephone, live chat, or interactive audiovisual modality for these provider types.

When a Federally Qualified Health Center or a Rural Health Clinic provides care through telemedicine, the claim must include the modifier GT on line(s) identifying the service(s).

When used by an FQHC or RHC, the modifier GT identifies the services as being delivered through telemedicine modality. There is no enhanced payment to FQHCs and RHCs when using the modifier GT.

SOURCE: CO Department of Health Care Policy and Financing.  “Telemedicine Billing Manual” 1/24. (Accessed Jan. 2024).

For Health First Colorado a billable encounter at an FQHC is an in person or telemedicine face to face visit with a Health First Colorado member.

Telemedicine services are limited to the procedure codes identified on the Telemedicine-Provider Information web page at the Provider Telemedicine web page.

When a Federally Qualified Health Center or a Rural Health Clinic provides care through telemedicine, the claim must include the modifier GT on line(s) identifying the service(s).

Additionally, modifiers FQ and FR can be added to the claim:

• FQ: The service was furnished using audio-only communication technology.
• FR: The supervising practitioner was present through two-way, audio/video communication technology.

SOURCE: CO FQHC & RHC Billing Manual 8/22. (Accessed Jan. 2024).

The visit definition for a FQHC includes interactive audio (including but not limited to telephone and relay calls), interactive video (including but not limited to interactive audiovisual modalities), or interactive data communication (including but not limited to live chat and excluding text messaging, electronic mail, and facsimile transmission) encounters.  Any health benefits provided through interactive audio (including but not limited to telephone and relay calls), interactive video (including but not limited to interactive audiovisual modalities), or interactive data communication (including but not limited to live chat and excluding text messaging, electronic mail, and facsimile transmission) must meet the same standard of care as in-person care.

SOURCE: Colorado Adopted Rule 8.700.1. (Accessed Jan. 2024).

Visit for a RHC means a face-to-face encounter, or an interactive audio (including but not limited to telephone and relay calls), interactive video (including but not limited to interactive audiovisual modalities), or interactive data communication (including but not limited to live chat and excluding text messaging, electronic mail, and facsimile transmission) encounter between a clinic client and any health professional providing the services set forth in 8.740.4. Any health benefits provided through interactive audio, interactive video, or interactive data communication must meet the same standard of care as in-person care.

SOURCE: Colorado Adopted Rule 8.740.1. (Accessed Jan. 2024).

Long Term Services and Supports (LTSS), Home and Community-based Services (HCBS), Services for Individuals with Intellectual and Developmental Disabilities, Early Childhood Intervention Services

Upon department approval, certain eligibility determinations, assessments, referrals, and monitoring contacts may be completed by case managers at an alternate location, via telephone or using virtual technology methods. Such approval may be granted for situations in which face-to-face meetings would pose a documented safety risk to the case manager or Client (e.g. natural disaster, pandemic, etc.).

SOURCE: 10 CCR 2505-10 8.393; 8.506.4.B; 8.508.70; 8.509; 8 CCR 1405-1. (Accessed Jan. 2024).

Home and Community-Based Services

Home and Community-Based Services Telehealth (HCBS Telehealth)is a method of service delivery of certain HCBS services listed at Section 8.615.2.

SOURCE: 10 CCR 2505-10 8.615.1 (M). (Accessed Jan. 2024).

Adult Day Services (ADS)

Telehealth Adult Day Services are provided through virtual means in a group or on an individual basis. Telehealth ADS are ways for participants to engage in activities, with their community, and connect to staff and other ADS participants virtually or over the phone, only if a participant does not have access or the ability to use video chat technology. Services provided through Telehealth are not required to provide nutrition services. See rule for staffing, documentation, and written policy requirements specific to use of telehealth ADS.

SOURCE: 10 CCR 2505-10 8.491. (Accessed Jan. 2024).

Mobile Crisis Response (MCR) Services

MCR services may be provided via Telemedicine in accordance with Section 8.095 by any one (1) member of the MCR provider’s team, where appropriate. The initial Telemedicine face-to-face crisis response must include at least (1) in-person responder from the MCR team.

SOURCE: 10 CCR 2505-10 8.020. (Accessed Jan. 2024).

Behavioral Health

“Session” means a face-to-face, telehealth, or audio-only interaction of the individual and personnel. Session may include but is not limited to individual therapy, group therapy, medication-assisted treatment education and/or monitoring, family therapy, peer professional services, educational/occupational groups, recreational therapy, intake, discharge, service planning, and other therapies.

The BHE may use telehealth methods for the provision of services under these regulations except for services that specifically require in-person contact. If a service is allowable via telehealth according to state and federal regulations, appropriate methods will be noted within the applicable endorsement Chapter. If an individual prefers to receive services in-person and the BHE does not offer the appropriate service in-person, the BHE shall refer the individual to another entity that offers the service in-person.

If the BHE uses telehealth methods, it must develop and implement policies and procedures regarding telehealth services, including:

• Collection of required signatures;
• Training for personnel specific to the modality or manner for determining competence with the modality;
• Procedure for personnel response if an individual experiences an emergency while receiving services via telehealth, including collection of information about the individual’s remote location for each session;
• Confidentiality protocols designed to protect the individual’s privacy in accordance with state and federal law; and
• Specification as to whether policies apply to the BHE as a whole, a physical location, or a specific endorsement, as appropriate.

Services provided via telehealth methods must be documented in the individual’s record, consistent with documentation requirements for in-person services.

Screenings should be conducted in-person unless contraindicated. If contraindicated, screenings may be conducted via audio-visual or audio only telehealth. Clinical rationale must be documented in the case of a telehealth screening.

A peer support professional may provide services in a variety of settings, if permitted access, that may include but are not limited to audio-visual or audio-only telehealth.

Outpatient services may be delivered via in-person, audio-visual telehealth, or audio-only telehealth format in accordance with part 2.9 of these rules.

SOURCE: 2 CO Code of Regulation 502-1, 1.2, p. 18, 2.9, p. 40, 10.1, p. 174.  (Accessed Jan. 2024).

ELIGIBLE PROVIDERS

SOURCE: Colorado Adopted Rule 8.095.3. CO Department of Health Care Policy and Financing. “Telemedicine Billing Manual” 1/24. (Accessed Jan. 2024).

The following distant provider types may bill using modifier GT:

• Physician
• Clinic
• Osteopath
• FQHC
• Doctorate Psychologist
• MA Psychologist
• Physician Assistant
• Nurse Practitioner
• RHC

A primary care provider (PCP) is eligible to be reimbursed as the ‘originating provider’ when present with the patient. In order for a PCP to be reimbursed as a distant provider, the PCP must be able to facilitate an in-person visit in the state of CO if necessary for treatment of the member’s condition.

A specialist is eligible to be an originating provider (if present with the patient) or distant provider.

The distant provider may participate in the telemedicine interaction from any appropriate location.

When the patient is located in a hospital, please use the appropriate place of service code for where the patient is located.

SOURCE: CO Department of Health Care Policy and Financing. “Telemedicine Billing Manual” 1/24. (Accessed Jan. 2024).

Health First Colorado has expanded the list of providers eligible to deliver telemedicine services to include FQHCs, RHCs, IHS, physical therapists, occupational therapists, home health providers, hospice and pediatric behavioral health providers. Outpatient physical, occupational and speech therapy services must have an interactive audio/visual connection with the member to be provided via telemedicine.

SOURCE: CO Dept. of Health Care Policy and Financing, Provider Bulletin, June 2023. (Accessed Jan. 2024).

Physical Therapists, Occupational Therapists, Hospice, Home Health Providers and Pediatric Behavioral Health Providers

Physical therapists, occupational therapists, hospice, home health providers and pediatric behavioral health providers are eligible to deliver telemedicine services.

1. Home Health Agency services and therapies, Hospice, and Pediatric Behavioral Treatment may be provided via telephone-only.
2. Outpatient Physical, Occupational, and Speech Therapy services must have an interactive audio/visual connection with the member to be provided via telemedicine.

Telemedicine is covered for behavioral health providers under the capitated behavioral health benefit administered by the Regional Accountable Entities (RAEs). Behavioral health providers should contact their RAE for guidance. Visit the Accountable Care Collaborative Phase II web page for more information.

SOURCE: CO Department of Health Care Policy and Financing. “Telemedicine Billing Manual” 1/24. (Accessed Jan. 2024).

RHC/IHS/FQHC

A telemedicine service meets the definition of a face-to-face encounter for a rural health clinic, Indian health service, or federally qualified health center.  The reimbursement rate for a telemedicine service provided by a rural health clinic or federal Indian health service or federally qualified health center must be set at a rate that is no less than the medical assistance program rate for a comparable face-to-face encounter or visit.

SOURCE: CO Statute, Sec. 25.5-5-320. (Accessed Jan. 2024).

SOURCE: Colorado Adopted Rule 8.095.1, 8.095.3, 8.095.4, 8.095.6. (Accessed Jan. 2024).

As of October 30th, 2022, there is a provider specialty type for Clinic and Non-Physician Practitioner groups that meet the following definition:

• An eHealth entity is defined as a group practice that delivers services exclusively through telemedicine and is enrolled in a provider type that has an eHealth specialty.  Providers who meet this definition must update their enrollment to this provider specialty type.

SOURCE: CO Department of Health Care Policy and Financing. “Telemedicine Billing Manual” 1/24. (Accessed Jan. 2024).

The telemedicine rule 10 CCR 2505-10 8.095 regarding eHealth entities is effective as of October 30, 2022. An eHealth entity is defined as a group practice that delivers services exclusively through telemedicine and is enrolled in a provider type that has an eHealth specialty.

• Telemedicine-only providers are to use Specialty Code 878.
• Telemedicine and in-person providers will continue to use the appropriate specialty code for their chosen provider type.

SOURCE: CO Department of Health Care Policy and Financing, Health First CO Provider Bulletin B2200485, (Nov. 2022), (Accessed Jan. 2024).

ELIGIBLE SITES

If no originating provider is present during a Telemedicine Services appointment, then the location of the originating site is at the member’s discretion and can include the member’s home. However, members can be required to choose a location suitable to delivery of telemedicine services that may include adequate lighting and environmental noise levels suitable for easy conversation with a provider.

Services can be provided via telemedicine between a member and a distant provider when a member is located in their home or other location of their choice.

A primary care provider (PCP) is eligible to be reimbursed as the ‘originating provider’ when present with the patient. In order for a PCP to be reimbursed as a distant provider, the PCP must be able to facilitate an in-person visit in the state of CO if necessary for treatment of the member’s condition.

A specialist is eligible to be an originating provider (if present with the patient) or distant provider.

If practitioners at both the originating site and the distant site provide the same service to the member, both providers submit claims using the same procedure code with modifier 77 (Repeat procedure by another physician).

SOURCE: CO Department of Health Care Policy and Financing.  “Telemedicine Billing Manual” 1/24. (Accessed Jan. 2024).

Telemedicine can work:

• From a provider office:  You can connect through video with a provider in another office. Both offices must have telemedicine equipment.
• From your home or other location like a library:  You may be able to use your mobile phone, tablet or desktop computer to connect to a provider. Health First Colorado will not pay for the equipment.

SOURCE: CO Department of Health Care Policy and Financing. “Telemedicine”. (Accessed Jan. 2024).

Eligible place of service includes Telemedicine, including interactive audio (including but not limited to telephone and relay calls), interactive video (including but not limited to interactive audiovisual modalities), or interactive data communication (including but not limited to live chat and excluding text messaging, electronic mail, and facsimile transmission). Any health benefits provided through interactive audio (including but not limited to telephone and relay calls), interactive video (including but not limited to interactive audiovisual modalities), or interactive data communication (including but not limited to live chat and excluding text messaging, electronic mail, and facsimile transmission) must meet the same standard of care as in-person care.

SOURCE:  Colorado Adopted Rule 8.200.3.B.3.D.2.c.7. (Accessed Jan. 2024).

Speech Therapy

Telemedicine POS 02 and Telehealth POS 10 are allowed place of service codes.

SOURCE: CO Department of Health Care Policy and Financing.  “Speech Therapy”, 1/24. (Accessed Jan. 2024). 

Therapy Providers

POS Code 02 or 10 should be used to report services delivered via telecommunication depending on the location of the member when receiving telehealth services. POS 02 is used when the member is receiving telehealth service in a place that is not their home. POS 10 is used when a member is receiving telehealth services when the member is located in their home.

Outpatient physical, occupational, and speech therapy services must have an interactive audio/visual connection with the member to be provided via telemedicine.

SOURCE: CO Department of Health Care Policy and Financing. Provider Bulletin B2200480. July 2022. (Accessed Jan. 2024).

Home Health Services

Services shall be provided in the client’s place of residence or one of the following places of service:  Services may be provided using interactive audio (including but not limited to telephone and relay calls), interactive video (including but not limited to interactive audiovisual modalities), or interactive data communication (including but not limited to live chat and excluding text messaging, electronic mail, and facsimile transmission) instead of in-person contact. Any health benefits provided through interactive audio, interactive video, or interactive data communication must meet the same standard of care as in-person care.

SOURCE: Colorado Adopted Rule 8.520.4.B.g (Accessed Jan. 2024).

Telehealth monitoring is available for members who are eligible through the Home Health benefit and should not be billed as telemedicine. Providers rendering telehealth monitoring should consult the Home Health Billing Manual on the Billing Manuals web page under the CMS 1500 drop-down.

SOURCE: CO Department of Health Care Policy and Financing.  “Telemedicine Billing Manual” 1/24. (Accessed Jan. 2024).

Family Planning Services

Eligible places of service include telemedicine provided in accordance with Section 8.095.

SOURCE:  Colorado Adopted Rule 8.730.3.B. (Accessed Jan. 2024).

GEOGRAPHIC LIMITS

No Reference Found.

FACILITY/TRANSMISSION FEE

In some cases, the originating provider site will not be providing clinical services, but only providing a site and telecommunications equipment. In this situation, the telemedicine originating site facility fee is billed using procedure code Q3014.

Originating providers bill as follows:

• If the originating provider is making a room and telecommunications equipment available but is not providing clinical services, the originating provider bills Q3014 (the procedure code for the telemedicine originating site facility fee).
• If the originating provider also provides clinical services to the member, the provider bills the rendering provider’s appropriate procedure code and bills Q3014.
• The originating provider may also bill, as appropriate, on the UB-04 paper claim form or as an 837I transaction for any clinical services provided on-site on the same day that a telemedicine originating site claim is made. The originating provider must submit two separate claims for the member’s two separate services.

Providers eligible for the originating site facility fee include:

• Physician
• Clinic
• Osteopath
• FQHC
• Doctorate Psychologist
• MA Psychologist
• Physician Assistant
• Nurse Practitioner
• RHC

Provider types not listed above may facilitate Telemedicine Services with a distant provider but may not bill procedure code Q3014. Examples include Nursing Facilities, Intermediate Care Facilities, Assisted Living Facilities, etc.

Using modifier GT with specific codes adds $5.00 to the fee listed for the service.  A specific list of eligible codes is provided in the manual.  Other codes can be billed, but don’t pay the telemedicine transmission fee.

SOURCE: CO Department of Health Care Policy and Financing.  “Telemedicine Billing Manual” 1/24. (Accessed Jan. 2024).

The state department shall establish rates for transmission cost reimbursement for telemedicine services, considering, to the extent applicable, reductions in travel costs by health care or mental health care providers and patients to deliver or to access such services and such other factors as the state department deems relevant.

SOURCE: CO Revised Statutes 25.5-5-320(3). (Accessed Jan. 2024).

POLICY

Effective Now Until June 30, 2024

During the period beginning on May 10, 2021 and ending on June 30, 2024, a telehealth provider may only provide a telehealth service to a patient when the telehealth provider:

• Is communicating through real-time, interactive, two-way communication technology or store and forward transfer technology;
• Has determined whether the patient has health coverage that is fully insured, not fully insured or provided through the Connecticut medical assistance program, and whether the patient’s health coverage, if any, provides coverage for the telehealth service;
• Has access to, or knowledge of, the patient’s medical history, as provided by the patient, and the patient’s health record, including the name and address of the patient’s primary care provider, if any;
• Conforms to the standard of care applicable to the telehealth provider’s profession and expected for in-person care as appropriate to the patient’s age and presenting condition, except when the standard of care requires the use of diagnostic testing and performance of a physical examination, such testing or examination may be carried out through the use of peripheral devices appropriate to the patient’s condition; and
• Provides the patient with the telehealth provider’s license number, if any, and contact information

A telehealth provider that is an in-network provider or a provider enrolled in the Connecticut medical assistance program that provides telehealth services to a Connecticut medical assistance program recipient, may, during the period beginning on May 10, 2021 and ending on June 30, 2024, use any information or communication technology in accordance with the directions, modifications or revisions, if any, made by the Office for Civil Rights of the United States Department of Health and Human Services to the provisions of the Health Insurance Portability and Accountability Act of 1996 P.L. 104-191, as amended from time to time, or the rules and regulations adopted thereunder.

No telehealth provider shall provide health care or health services to a patient through telehealth unless the telehealth provider has determined whether or not the patient has health coverage for such health care or health services.

A telehealth provider who provides health care or health services to a patient through telehealth during the period beginning on May 10, 2021 and ending on June 30, 2024, shall accept as full payment for such health care or health services:

• An amount that is equal to the amount that Medicare reimburses for such health care or health services if the telehealth provider determines that the patient does not have health coverage for such health care or health services; or
• The amount that the patient’s health coverage reimburses, and any coinsurance, copayment, deductible or other out-of-pocket expense imposed by the patient’s health coverage, for such health care or health services if the telehealth provider determines that the patient has health coverage for such health care or health services. If the patient’s health coverage uses a provider network, the amount of such reimbursement, and such coinsurance, copayment, deductible or other out-of-pocket expense, shall not exceed the in-network amount regardless of the network status of such telehealth provider.

If a telehealth provider determines that a patient is unable to pay for any health care or health services described in subdivisions (1) and (2) of this subsection, the provider shall offer to the patient financial assistance, if such provider is otherwise required to offer to the patient such financial assistance, under any applicable state or federal law.

A telehealth provider may provide telehealth services pursuant to the provisions of this section from any location.

SOURCE: HB 5596 (2021 Session), Sec. 1, 6. & SB 2 (2022 Session), Sec. 32. (Accessed Apr. 2024).

Permanent Statute

CT Medicaid is required to provide coverage for telehealth services for categories of health care services that the commissioner determines are clinically appropriate to be provided through telehealth, cost effective for the state and likely to expand access to medically necessary services where there is a clinical need for those services to be provided by telehealth or for Medicaid recipients whom accessing healthcare poses an undue hardship.

The commissioner may provide coverage of telehealth services pursuant to this section notwithstanding any provision of the regulations of Connecticut state agencies that would otherwise prohibit coverage of telehealth services. The commissioner may implement policies and procedures as necessary to carry out the provisions of this section while in the process of adopting the policies and procedures as regulations.

SOURCE: CT General Statute 17b, Sec. 245e. (Accessed Apr. 2024).

To the extent permissible under federal law, the commissioner shall provide Medicaid reimbursement for services provided by means of telehealth to the same extent as if the service was provided in person.

SOURCE: CT General Statute 17b, Sec. 245g. (Accessed Apr. 2024).

Effective for dates of service on and after May 12, 2023, which is the first day after the federal COVID-19 public health emergency declaration ends, in accordance with sections 17b-245e and 17b-245g of the Connecticut General Statutes, the Department of Social Services (DSS) is issuing new guidance for services eligible for reimbursement under the Connecticut Medical Assistance Program (CMAP) when rendered via telehealth. DSS will continue to reimburse for specified services when rendered via telehealth as detailed in Provider Bulletin 2023-38 and on the CMAP Telehealth Table. This guidance applies to services rendered under CMAP for all HUSKY Health members.

Telehealth includes:

• telemedicine (synchronized audio-visual two-way communication services) and,
• where specified by DSS, audio-only two-way synchronized communication services delivered via telephone.

DSS’ continued expectation is that enrolled CMAP providers will perform clinically appropriate services including, but not limited to, ensuring timely access to in-person services when medically necessary or requested by the HUSKY Health member for optimum quality of care. Therefore, all enrolled billing entities must have the capacity to deliver services in-person and must provide services in-person to the full extent that is clinically appropriate for their patients and to the full extent necessary if the HUSKY Health member does not consent to receiving one or more services via telehealth. Having the capacity means that the provider must have a physical location in CT, (or an approved applicable border state as approved as part of enrollment) where the provider has a room or set of rooms to see members in-person and can maintain the member’s privacy and confidentiality during the visit.

All applicable federal and state requirements for the equivalent in-person service apply to telehealth services. Therefore, consistent with all services billed to CMAP, all telehealth services must meet the statutory definition of medical necessity in section 17b-259b of the Connecticut General Statutes and all other applicable federal and state statutes, regulations, requirements, and guidance.

SOURCE: CT Policy – Provider Bulletin 2023-38. May 2023. (Accessed Apr. 2024).

Connecticut’s Medical Assistance Program will not pay for information or services provided to a client by a provider electronically or over the telephone. However, there is an exception for case management behavioral health services for clients age eighteen and under.

SOURCE: CT Provider Manual. Physicians and Psychiatrists. Sec. 17b-262-342.  Pg. 9, Oct. 2020; CT Provider Manual. Psychologists. Sec. 17b-262-472. Oct. 2020. Pg. 7; & CT Provider Manual. Behavioral Health. Sec. 17b-262-918. Oct. 2020. Pg. 6. (Accessed Apr. 2024).

A telehealth provider shall only provide telehealth services to a patient when the telehealth provider: (A) Is communicating through real-time, interactive, two-way communication technology or store and forward technologies; (B) has access to, or knowledge of, the patient’s medical history, as provided by the patient, and the patient’s health record, including the name and address of the patient’s primary care provider, if any; (C) conforms to the standard of care applicable to the telehealth provider’s profession and expected for in-person care as appropriate to the patient’s age and presenting condition, except when the standard of care requires the use of diagnostic testing and performance of a physical examination, such testing or examination may be carried out through the use of peripheral devices appropriate to the patient’s condition; and (D) provides the patient with the telehealth’s provider license number and contact information.

SOURCE: CA Gen. Statutes Sec. 19a-906(b)(1). (Accessed Apr. 2024).

ELIGIBLE SERVICES/SPECIALTIES

See specified services reimbursed when rendered via telehealth as detailed in Provider Bulletin 2023-38 and on the CMAP Telehealth Table. Comprehensive information regarding the specific procedure codes eligible are posted on the CMAP Telehealth Webpage as well. This web page will provide information on telehealth requirements, approved procedure codes, required modifiers, specific policy criteria and/or limitations, effective dates, and other telehealth policy information, including the Telehealth FAQs.

Providers are responsible for verifying coverage of a specific procedure code as a telehealth service as well as a covered service on their applicable fee schedule prior to delivering and billing CMAP for the service. Billing for a service via telehealth that is not listed as an approved service on the CMAP Telehealth Table or listed as a covered service on the applicable fee schedule or failure to adhere to the policy and applicable telehealth criteria/limitations, may result in a denied claim or may be at-risk for a financial adjustment during a post-payment review.

Services rendered via telehealth will be reimbursed at the same rate as if the service was rendered in-person. Providers must refer to their applicable reimbursement methodology or fee schedule to ensure that the service identified as eligible to be rendered as a telehealth service is payable for their specific provider type and the reimbursement rate.

SOURCE: CT Policy – Provider Bulletin 2023-38. May 2023. (Accessed Apr. 2024).

Modifiers: One of the following telehealth modifiers should be used when submitting claims:

• Modifier GT: Via interactive audio and video telecommunication systems
• Modifier 95: Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system
• Modifier FQ: This service was furnished using audio-only communication technology (use with applicable behavioral health services )

SOURCE: CMAP Telehealth Table. (Accessed Apr. 2024).

Effective June 12, 2023, providers must ensure that the provision of 90853 (group psychotherapy) is performed via telemedicine (synchronized audio-visual) only. Providers are encouraged to monitor the CMAP website (www.ctdssmap.com) frequently for updates to the DSS Telehealth policy and to ensure that you are accessing the most current version of the CMAP Telehealth Table.

SOURCE: CT Dept. of Social Services. Provider Message. June 2023. (Accessed Apr. 2024).

Effective June 21, 2023, and forward, providers eligible for reimbursement for procedure code T1017 (Targeted case management, 15 minutes) may perform this service via audio-only or telemedicine under the CMAP Telehealth policy.

SOURCE: CT Dept. of Social Services. Provider Message. June 2023. (Accessed Apr. 2024).

Effective for dates of service May 12, 2023, and forward, Medical Equipment Devices (MEDS) providers must comply with the face-to-face (F2F) requirements for certain DME as specified by 42 CFR 440.70. Compliance with this requirement includes the provision of the F2F encounter via telehealth as specified by 42 CFR 440.70(f)(6) when the service billed complies with the telehealth policies as outlined and specified by DSS.

Effective for dates of service May 12, 2023, and forward, physicians can conduct assessments for complex rehabilitative technology (CRT) equipment either in person or via synchronized telemedicine with the assistance of the physical therapist (PT) or occupational therapist (OT) which must be in person with the HUSKY Health member. The requirement of the PT or OT in-person with the member is to ensure the demonstration of the equipment and any features on a customized wheelchair will meet the clinical needs of members residing in skilled nursing facilities.

SOURCE: CT Policy – Provider Bulletin 2023-33. Apr. 2023. (Accessed Apr. 2024).

Effective for dates of service October 16, 2023, and forward, providers eligible for reimbursement for procedure code S0199 (Med abortion inc all ex drug) may perform this service via telemedicine only (synchronized audio-visual), under the CMAP Telehealth policy.

SOURCE: CT Policy – Provider Important Message. Oct. 2023. (Accessed Apr. 2024).

Opioid Treatment Programs are required to perform a complete, fully documented physical evaluation prior to admission. The program physician may render the physical evaluation component of MAT services via telemedicine only when all of the following are met:

• The CMAP member’s originating site is another CMAP-enrolled Opioid Treatment Program (Methadone Maintenance Clinic) that is part of the same billing entity as the originating site;
• The originating site is providing all the other required components of MAT services including the intake and psychiatric evaluation;
• As required by 42 CFR 8.12(f), an authorized healthcare professional under the supervision of a program physician is present with the member at the originating site; and
• The distant site provider must be located at a different service location/address than the originating site.

Induction services must always be rendered face-to-face (in-person) and only after the physical and psychiatric evaluation has been performed. Once a CMAP member has been inducted, routine psychotherapy services may be rendered via telemedicine.

MAT services that may be rendered via telemedicine include medication management and psychotherapy services.

SOURCE: CT Policy – Provider Bulletin 2020-09. March 2020. (Accessed Apr. 2024).

CT does not pay for information or services furnished by a licensed behavioral health clinician to the client electronically or over the telephone, except for case management behavioral health services for clients age eighteen and under.

SOURCE: CT Provider Manual. Behavioral Health. Sec. 17b-262-918. Oct. 2020. Pg. 6. (Accessed Apr. 2024).

Outpatient Hospitals

With the exception of nutritional counseling and PT/OT/SLP services, medical telehealth services are considered professional services and therefore no reimbursement will be provided to the hospital. Behavioral health telehealth services, including medication management, are considered an all-inclusive rate to the hospital and therefore professional fees will not be paid separately.

SOURCE: CT Policy – Provider Bulletin 2023-38. May 2023. & CMAP Telehealth Table. (Accessed Apr. 2024).

Outpatient hospitals may bill for nutritional counseling services when rendered via telemedicine under procedure code G0463 – “clinic visit”. It should be noted that procedure code G0463 is approved for telemedicine nutritional counseling services only and that nutritional counseling can only be billed via telemedicine and cannot be billed via audio-only.

SOURCE: CT Medicaid Assistance Program Telehealth FAQ (May 2023), p. 3. (Accessed Apr. 2024).

School Based Child Health Providers

School Based Child Health Providers are limited to the following services: 90791, 90832, 90847, 90853, H0031, H2014, 92507, 92521, 92522, 92523, 97110 – Refer to the policy guidelines in the CMAP Telehealth Table.

SOURCE: CT Policy – Provider Bulletin 2023-23. March 2023. & CMAP Telehealth Table. (Accessed Apr. 2024).

Targeted Case Management for Integrated Care for Kids (InCK) in New Haven

Monitoring and follow-up activities include making necessary adjustments in the care plan and related changes in the services performed by the provider, which may be performed by staff face-to-face, telehealth, or telephone contact with the individual; by chart review; by case conference; by collateral contact with individuals, family members, providers, legal representatives, or other persons or entities for the benefit of the Medicaid member; or any combination thereof. The care plan must be reviewed every 90 days and adjusted if needed. See bulletin for more information.

SOURCE: CT Policy – Provider Bulletin 2023-55. Jul. 2023. (Accessed Apr. 2024).

Sick Visits

Sick Visits for adults and children are allowed to be performed via telehealth. Refer to CMAP Telehealth Table.

Hospice and Home Health Services, and Well Visits

Hospice and home health services, in addition to Well Visits, cannot be performed via telemedicine. These services must be rendered in person. Refer to Provider Bulletin 2023-38.

SOURCE: CT Medicaid Assistance Program Telehealth FAQ (May 2023), p. 3. (Accessed Apr. 2024).

ELIGIBLE PROVIDERS

Effective Now Until June 30, 2024

A telehealth provider may provide telehealth services from any location.

Telehealth providers include the following who are providing health care or other health services through the use of telehealth within such person’s scope of practice and in accordance with the standard of care applicable to the profession:

• Any physician licensed under chapter 370
• Physical therapist or physical therapist assistant licensed under chapter 376
• Chiropractor licensed under chapter 372
• Naturopath licensed under chapter 373
• Podiatrist licensed under chapter 375
• Occupational therapist or occupational therapy assistant licensed under chapter 376a
• Optometrist licensed under 380
• Registered nurse or advanced practice registered nurse licensed under chapter 378
• Physician assistant licensed under chapter 370
• Psychologist licensed under chapter 383
• Marital and family therapist licensed under chapter 383a
• Clinical social worker or master social worker licensed under chapter 383b
• Alcohol and drug counselor licensed under chapter 376b
• Professional counselor licensed under chapter 383c
• Dietitian-nutritionist licensed under chapter 384b
• Speech and language pathologist licensed under chapter 399
• Respiratory care practitioner licensed under chapter 381a
• Audiologist licensed under chapter 397a
• Pharmacist licensed under chapter 400j
• Paramedic licensed under chapter 384d

SOURCE: HB 5596 (2021 Session), Sec. 1, & SB 2 (2022 Session), Sec. 32. (Accessed Apr. 2024).

Permanent Policy

Only the following categories of CMAP-enrolled providers may provide and bill for such psychotherapy services or psychiatric diagnostic evaluations within their scope of practice via telemedicine:

• Physician
• Physician Assistant
• Advanced Practice Registered Nurses
• Licensed Behavioral Health Clinicians (defined below and which includes only the following: Licensed Psychologists, Licensed Clinical Social Workers, Licensed Marital and Family Therapists, Licensed Professional Counselors, and Licensed Alcohol and Drug Counselors)
• Behavioral Health Clinics – including Enhanced Care Clinics (ECCs)
• Behavioral Health Federally Qualified Health Centers (FQHCs)
• Medical Clinics – excluding School Based Health Centers (SBHCs)
• Rehabilitation Clinics
• Outpatient Hospital Behavioral Health (BH) Clinics
• Outpatient Psychiatric Hospitals
• Outpatient Chronic Disease Hospitals (CDHs)

Modifiers GT is used when the member’s originating site is located in a healthcare facility or office; or modifier 95 Is used when the member is located at home.

SOURCE: CT Policy – Provider Bulletin 2020-09. March 2020. (Accessed Apr. 2024).

Medication Assisted Treatment

Eligible providers:

• Physician
• APRNs
• PAs
• Behavioral Health Clinics

Medication Management

Eligible Providers:

• Physicians
• PAs
• APRNs
• Medical Clinics – excluding SBHCs
• Behavioral Health Clinics – including ECCs
• Behavioral Health FQHCs
• Outpatient Hospital BH Clinics
• Outpatient Chronic Disease Hospitals

Eligible providers for out of state surgery and homebound patients include:

• Physicians
• PAs
• APRNs
• CNMs
• Podiatrists

Eligible providers to determine if patient to be homebound and/or provide and bill for such service:

• Physicians
• PAs
• APRNs
• CNMs
• Podiatrists

For homebound patients, provider must document the reason the member is being determined homebound.

Documentation must be maintained by both the originating site provider and the distant site provider to substantiate the services provided. Originating site documentation must indicate the member received or has been referred for telehealth services.

SOURCE: CT Policy – Provider Bulletin 2020-09. March 2020. (Accessed Apr. 2024).

Telehealth providers includes the following who are providing health care or other health services through the use of telehealth within such person’s scope of practice and in accordance with the standard of care applicable to the profession:

• Any physician licensed under chapter 370
• Physical therapist licensed under chapter 376
• Chiropractor licensed under chapter 372
• Naturopath licensed under chapter 373
• Podiatrist licensed under chapter 375
• Occupational therapist or licensed under chapter 376a
• Optometrist licensed under 380
• Registered nurse or advanced practice registered nurse licensed under chapter 378
• Physician assistant licensed under chapter 370
• Psychologist licensed under chapter 383
• Marital and family therapist licensed under chapter 383a
• Clinical social worker or master social worker licensed under chapter 383b
• Alcohol and drug counselor licensed under chapter 376b
• Professional counselor licensed under chapter 383c
• Dietitian-nutritionist licensed under chapter 384b
• Speech and language pathologist licensed under chapter 399
• Respiratory care practitioner licensed under chapter 381a
• Audiologist licensed under chapter 397a
• Pharmacist licensed under chapter 400j
• Paramedic licensed under chapter 384d
• Nurse-Midwife licensed under chapter 377
• Behavior Analyst licensed under chapter 382a

SOURCE: CT Gen. Statutes Sec. 19a-906(a)(12). (Accessed Apr. 2024).

Medication Assisted Treatment – Opioid Treatment Program

The distant site provider cannot bill for the physical evaluation component rendered via telemedicine.

SOURCE: CT Policy – Provider Bulletin 2020-09. March 2020. (Accessed Apr. 2024).

FQHCs

Federally Qualified Health Centers (FQHCs) are eligible to bill their encounter rate when an approved, medically necessary telehealth service is rendered. FQHCs must use the services identified on the Telehealth Table in combination with their approved scope of service to identify the services eligible to be rendered using telehealth. FQHCs must continue to bill HCPCS code, T1015 and all eligible telehealth procedure codes to reflect all of the services rendered during the telehealth visit.

SOURCE: CMAP Telehealth Table. (Accessed Apr. 2024).

Effective July 1, 2024

A telehealth provider also is to include an appropriately licensed, certified or registered provider as listed below in another state or territory of the United States or the District of Columbia, who (i) provides telehealth services under any relevant order issued pursuant to section 33 of this act, (ii) provides mental or behavioral health care through the use of telehealth within such person’s scope of practice and in accordance with the standard of care applicable to the profession, and (iii) maintains professional liability insurance, or other indemnity against liability for professional malpractice, in an amount that is equal to or greater than that required for similarly licensed, certified or registered Connecticut mental or behavioral health care providers:

• physician
• naturopath
• registered nurse
• advanced practice registered nurse
• physician assistant
• psychologist
• marital and family therapist
• clinical social worker
• master social worker
• alcohol and drug counselor
• professional counselor
• dietitian-nutritionist
• nurse-midwife
• behavior analyst
• music therapist
• art therapist

SOURCE: SB 2 (2022 Session), Sec. 30. (Accessed Apr. 2024).

ELIGIBLE SITES

There is no limitation on the originating site for a member receiving individual therapy, family therapy or psychotherapy with medication management.

Psychiatric diagnostic evaluations may be rendered via telemedicine only if the member is located at a CMAP-enrolled originating site.

Modifiers GT is used when the member’s originating site is located in a healthcare facility or office; or modifier 95 Is used when the member is located at home.

Documentation must be maintained by both the originating site provider and the distant site provider to substantiate the services provided. Originating site documentation must indicate the member received or has been referred for telehealth services.

SOURCE: CT Policy – Provider Bulletin 2020-09. March 2020, (Accessed Apr. 2024).

Place of Service/Facility Type Code – Bill the appropriate POS/FTC code that is applicable to the location of the member at the time of the telehealth service.

SOURCE: CMAP Telehealth Table. (Accessed Apr. 2024).

A practitioner who is enrolled with CMAP as an independent provider or as part of an independent provider group, or as a FQHC or outpatient hospital and maintains an approved service location as part of the CMAP enrollment, has the flexibility to perform eligible telehealth services even when the performing/rendering practitioner is not physically in-person at one of the enrolled CT or border service locations at the time of the service, so long as the practitioner complies with all applicable state and federal requirements.

SOURCE: CT Policy – Provider Bulletin 2023-38. May 2023. (Accessed Apr. 2024).

Medication Assisted Treatment

Due to Opioid Treatment Programs (Methadone Maintenance Clinics) receiving a daily payment rate for all MAT services provided, the daily payment rate will continue to be paid to the originating site only. The distant site provider must be located at a different service location/address than the originating site.

SOURCE: CT Policy – Provider Bulletin 2020-09. March 2020. (Accessed Apr. 2024).

GEOGRAPHIC LIMITS

No Reference Found

FACILITY/TRANSMISSION FEE

Effective Now Until June 30, 2024

No telehealth provider shall charge a facility fee for a telehealth service provided during the period beginning on May 10, 2021 and ending on June 30, 2024.

SOURCE: HB 5596 (2021 Session), Sec. 1. & SB 2 (2022 Session), Sec. 32. (Accessed Apr. 2024).

Permanent Statute

No telehealth provider or hospital shall charge a facility fee for telehealth services. Such prohibition shall apply to hospital telehealth services whether provided on campus or otherwise. For purposes of this subsection, “hospital” has the same meaning as provided in section 19a490 and “campus” has the same meaning as provided in section 19a508c.

SOURCE: CT Gen. Statutes Sec. 19a-906(h). (Accessed Apr. 2024).

POLICY

DMAP covers medically necessary telehealth services and procedures covered under the Title XIX State Plan. Qualifying practitioner services include any covered State Plan service that would typically be provided to an eligible individual in an inperson setting by an enrolled practitioner. Telehealth is not limited based on the diagnosed medical condition of the eligible recipient. All telehealth services must be furnished within the limits of provider program policies and within the scope and practice of the referring provider’s and distant telehealth practitioner’s professional standards as described and outlined in DMAP Provider Manuals. The service provided by the consulting/rendering provider or distant telehealth practitioner must be a service covered by DMAP. If a service is not covered in a face-to-face setting, it is not covered if provided through telehealth. A service provided through telehealth is subject to the same program restrictions, limitations, and coverage exist for the service when not provided through telehealth.

SOURCE: DE Medical Assistance Program. Practitioner Provider Specific Manual, 1/12/24. Sec. 16.6.2, pg. 78. (Accessed Apr. 2024).

DMAP will reimburse up to three (3) different consulting/distant telehealth practitioners for separately identifiable telehealth services provided to a member per date of service.

SOURCE: DE Medical Assistance Program. Practitioner Provider Specific Manual, 1/12/24. Sec. 16.6.3, pg. 79; Adult Behavioral Health Service Certification and Reimbursement. Dec. 1, 2016. Sec. 1.8, p. 14. (Accessed Apr. 2024).

The same procedure codes and rates apply as for services delivered in person (enrolled providers will bill Usual and Customary). Practitioners should use 02 Modifier as Place of Service for all telehealth charges. When billing the DMAP, the provider must use the appropriate CPT® procedure codes.

SOURCE: DE Medical Assistance Program. Practitioner Provider Specific Manual, 1/12/24. Sec. 16.6.2, 16.6.5.2.1-3, pg. 78-80. (Accessed Apr. 2024).

The GT modifier (which indicates the service occurred via interactive audio and video telecommunication system) can be used for Early and Periodic Screening, Diagnostic and Treatment Services through the School Based Health Services program in  Group Physical Therapy treatment utilizing code 97150 + the GT modifier.

SOURCE: DE School Based Health Services Specific Policy Manual, pg. 53 & 57 (4/1/16). (Accessed Apr. 2024).

The referring provider is not required to be present at the originating site, however the recipient of the services must be present. The Distant Site provider must be located within the continental United States.

Reimbursement to the referring provider will only occur when providing a separately identifiable covered service.

SOURCE: DE Medical Assistance Program. Practitioner Provider Specific Manual, 1/12/24. Ch. 16.5.1, 16.3.4, & 16.6.2, pg. 75-76. & Adult Behavioral Health Service Certification and Reimbursement. Dec. 1, 2016. Sec. 1.8, p. 12. (Accessed Apr. 2024).

Except for instances listed in 24 Del.C. Chapter 60, health-care providers may not deliver health-care services by telehealth and telemedicine in the absence of a health-care provider-patient relationship. A health-care provider-patient relationship may be established either in-person or through telehealth but must meet the requirements of Del.C. 24 §6003.

Consent is required to assure that the patient is a willing participant in the telehealth delivered service and to assure that the recipient retains a voice in their treatment plan. The patient must be informed and given an opportunity to request an in-person assessment before receiving a telehealth assessment. This consent must be documented in the patient’s record and must identify that the covered medical service was delivered by telehealth. The recipient must be able to adequately communicate, either directly or through a representative, with the originating and distant site practitioners.

The provision of services through telehealth must include accommodations, including interpreter and audio-visual modification, where required under the ADA, to ensure effective communication.

The distant site provider or other coverage must be available for appropriate followup care with the patient.

SOURCE: DE Medical Assistance Program. Practitioner Provider Specific Manual, 1/12/24. Ch. 16.4.1-2, 16.5.2, pg. 75-76 (Accessed Apr. 2024).

ELIGIBLE SERVICES/SPECIALTIES

The service must be medically necessary, written in the patient’s treatment plan and, follow generally accepted standards of care. The service provided by the distant provider must be a service covered by DMAP.

SOURCE: DE Medical Assistance Program. Practitioner Provider Specific Manual, 1/12/24. Sec. 16.4.1, 16.6.2, pg. 75, 78 & Adult Behavioral Health Service Certification and Reimbursement. Dec. 1, 2016. Sec. 1.8, p. 12. (Accessed Apr. 2024).

Interactive audio and video telecommunications can be used for group physical therapy in the Early and Periodic Screening, Diagnostic and Treatment Services through the School Based Health Services program for group physical therapy treatment.

SOURCE: DE School Based Health Services Specific Policy Manual, pg. 53 & 57 (4/1/16). (Accessed Apr. 2024).

Tele-Dentistry

Synchronous real-time tele-dentistry services must be provided in accordance with the recommendations provided by the American Dental Association.  The evaluation is limited to a specific oral health problem or complaint.

SOURCE: DE Medical Assistance Program. Adult Dental Program Services Provider Specific Manual. 7/21/23. Sec. 4.2. p. 7-8 (Accessed Apr. 2024).

Adult Behavioral Health Service

Rate Methodologies for the CPT codes under the telemedicine section of the State Plan for Adult Behavioral Health Services are paid at a lower rate and provided in the manual.

SOURCE: DE Medical Assistance Program. Adult Behavioral Health Service Certification and Reimbursement. Dec. 1, 2016. Sec. 1.8. p. 14 (Accessed Apr. 2024).

Durable Medical Equipment

The face-to-face encounter may occur through telehealth; as implemented by DMAP. In addition, the face-to-face encounter occurred through telehealth may be performed by any of the practitioners described above with the exception of certified nurse-midwives.

SOURCE: DE Medical Assistance Program, Durable Medical Equipment Provider Specific Manual, 3.1.6, p. 20 (Feb. 26, 2024). (Accessed Apr. 2024).

ELIGIBLE PROVIDERS

In order to provide telehealth under DMAP, providers at both the originating and distant site must be enrolled with DMAP and must meet all requirements for their discipline as specified in the Delaware Code and the Medicaid State Plan. For services delivered through telehealth technology to be covered, referring providers and distant telehealth practitioners (including out-of-region practitioners) must:

• Act within their scope of practice;
• Be licensed to provide telehealth services for which they bill DMAP in Delaware, or the State in which the provider is located if allowed under Delaware State law to provide telehealth services without a Delaware license through the Interstate Medical Licensure Compact or otherwise;
• Be in good standing in all states in which provider is licensed;
• Not be the subject of an administrative complaint or under investigation by another state’s licensing authority or board;
• Be enrolled with DMAP; and
• Have provider billing numbers (NPI and Taxonomy).

Distant telehealth practitioners may also need to enroll with the Department of Services for Children, Youth and their Families (DSCYF), Division of Prevention and Behavioral Health Services (DPBHS), and Division of Substance Abuse and Mental Health (DSAMH) as appropriate to provide and be reimbursed for behavioral health services.

The distant telehealth practitioner must be located within the continental United States. As required by §6505 of the Affordable Care Act, DMAP will not make any payments for items or services provided under the State Plan or under a waiver to any financial institution or entity located outside of the United States.

SOURCE: DE Medical Assistance Program. Practitioner Provider Specific Manual, 1/12/24. Sec. 16.3, pg. 75-76. (Accessed Apr. 2024).

To receive payment for services delivered through telemedicine technology from DMAP or MCOs, healthcare practitioners must:

• Act within their scope of practice;
• Be licensed (in Delaware, or the State in which the provider is located if exempted under Delaware State law to provide telemedicine services without a Delaware (license) for the service for which they bill DMAP;
• Be enrolled with DMAP/MCOs;
• Be located within the continental United States;
• Be credentialed by DMMA-contracted MCOs, when needed;
• Submit a DMMA Disclosure Form.

SOURCE: Adult Behavioral Health Service Certification and Reimbursement. Dec. 1, 2016. Sec. 1.8. Pg. 11 (Accessed Apr. 2024).

Eligible distant site providers include:

• Inpatient/outpatient hospitals (including ER)
• Physicians (or PAs under the physician’s supervision)
• Certified Nurse Practitioners
• Nurse Midwives
• Licensed Psychologists
• Licensed Clinical Social Workers
• Licensed Professional Counselors of Mental Health
• Speech Language Therapists
• Audiologists
• Other providers as approved by the DMAP

SOURCE: Adult Behavioral Health Service Certification and Reimbursement. Dec. 1, 2016. Sec. 1.8. Pg. 12 (Accessed Apr. 2024).

ELIGIBLE SITES

Originating Site refers to where the patient is located at the time health care services are provided to the patient by means of telehealth. An approved originating site may include the DMAP member’s place of residence, day program, or alternate location in which the member is physically present, and telehealth can be effectively utilized.

Distant Site refers to the site at which a health care practitioner, legally allowed to practice in the state of Delaware or the state in which the provider is located if allowed under Delaware State law to provide telehealth services without a Delaware license through the Interstate Medical Licensure Compact or otherwise, is located while providing health care services by means of telehealth.

All telehealth sites, both originating and distant sites, must have a written procedure detailing a contingency plan for when a failure or interoperability of the transmission or other technical difficulties render the service undeliverable. Telehealth services are not billable to DMAP or MCOs when technical difficulties preclude the delivery of part or all of the telehealth session.

The referring provider’s medical records must document all components of the services being billed. All distant telehealth practitioners are required to develop and maintain written documentation in the form of evaluations and progress notes, the same as if the documentation had originated during an in-person visit or consultation, including the mode of communication (telehealth). Distant telehealth practitioners may opt to use electronic medical records in place of paper-based written records.

SOURCE: DE Medical Assistance Program. Practitioner Provider Specific Manual, 1/12/24. Sec. 16.2.5-6, 16.5.3.7, 16.5.4.1-2, pg. 73-74, 77. (Accessed Apr. 2024).

An originating site refers to the facility in which the Medicaid patient is located at the time the telemedicine service is being furnished. An approved originating site may include the DMAP member’s place of residence, day program, or alternate location in which the member is physically present and telemedicine can be effectively utilized.

Medical Facility Sites:

• Outpatient Hospitals
• Inpatient Hospitals
• Federally Qualified Health Centers
• Rural Health Centers
• Renal Dialysis Centers
• Skilled Nursing Facilities
• Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID)
• Intermediate Care Facilities/Institutions for Mental Diseases (ICF/IMDs)
• Outpatient Mental Health/Substance Abuse Centers/Clinics
• Community Mental Health Centers/Clinics
• Public Health Clinics
• PACE Centers
• Assisted Living Facilities
• School-Based Wellness Centers
• Patient’s Home (must comply with HIPAA, privacy, secure communications, etc., and does not warrant an originating site fee)
• Other Sites as approved by the DMAP

Medical Professional Sites:

• Physicians (or Physicians Assistants under the supervision of a physician)
• Certified Nurse Practitioners
• Medical and Behavioral Health Therapists

SOURCE: Adult Behavioral Health Service Certification and Reimbursement. Dec. 1, 2016. Sec. 1. 8. pg. 11 & 12 (Accessed Apr. 2024).

GEOGRAPHIC LIMITS

There are no geographical limitations within Delaware regarding the location of an originating site provider.

SOURCE: DE Adult Behavioral Health Service Certification and Reimbursement. Dec. 1, 2016. Sec. 1.8, p. 12. (Accessed Apr. 2024).

FACILITY/TRANSMISSION FEE

DMAP reimburses the originating site fee for telehealth services per completed transmission to licensed practitioners that are enrolled in DMAP. A facility fee for the originating site is covered, unless the originating site is the patient’s home. Although a home can be considered an originating site, it is not eligible for reimbursement of the originating site fee.

DMAP will reimburse the originating site fee for up to three (3) different originating site providers for separately identifiable telehealth services provided to a member per date of service. Each originating site provider will only be reimbursed one (1) originating site fee per member per day. DMAP will not reimburse the referring provider at the originating site on the same date of service unless the referring provider is billing for a separate identifiable covered service. Medical records must document that all components of the service being billed were provided to the recipient.

Practitioners should use HCPCS Level II procedure code Q3014 when billing for the facility fee.

SOURCE: DE Medical Assistance Program. Practitioner Provider Specific Manual, 1/12/24. Sec. 16.6.2-3, 16.6.5.1.1, pg. 79. (Accessed Apr. 2024).

A facility fee is covered for originating sites.

Facility fees for the distant site are not covered.

Only one facility fee is permitted per date, per member.

SOURCE: DE Adult Behavioral Health Service Certification and Reimbursement. Dec. 1, 2016. Sec. 1.8, p. 11. (Accessed Apr. 2024).

POLICY

DC Medicaid must reimburse for health care services through telehealth if the same service would be covered when delivered in person.

SOURCE: DC Code Sec. 31-3863 (Accessed Mar. 2024).

The DC Medical Assistance Program will reimburse telemedicine services, if the Medicaid beneficiary meets the following conditions:

• Be enrolled in the DC Medicaid Program;
• Be physically present at the originating site at the time the telemedicine service is rendered; and
• Provide written or verbal consent to receive telemedicine services in lieu of in-person healthcare services, consistent with all applicable DC laws.

SOURCE: DC Municipal Regulation. Title 29, Ch. 9, Sec. 910.5, Physicians Billing Manual. DC Medicaid. Jan. 2024, Sec. 15.2. P. 51 & Department of Health Care Finance – Telemedicine Provider Guidance, Jan. 2023, pg. 2, Clinic Billing Manual (Sept. 2023) 15.2, P. 49; Behavioral Health Billing Manual (Feb. 2024) 14.2, p. 68. FQHC Billing Manual (Oct. 2023), 15.2, P 51. (Accessed Mar. 2024).

ELIGIBLE SERVICES/SPECIALTIES

Medicaid shall cover and reimburse for healthcare services appropriately delivered through telehealth if the same services would be covered when delivered in person.

SOURCE: DC Code Sec. 31-3863 (Accessed Mar. 2024)

Covered Services:

• Evaluation and management
• Consultation of an evaluation and management of a specific healthcare problem requested by an originating site provider
• Behavioral healthcare services including, but not limited to, psychiatric evaluation and treatment, psychotherapies, and counseling
• Speech therapy (Outpatient Hospital Billing Guide states: Rehabilitation services including speech therapy)

SOURCE: DC Municipal Regulation. Title 29, Ch. 9, Sec. 910.11 & Physicians Billing Manual. DC Medicaid. (Jan. 2024) Sec. 15.7. P. 53-54, Clinic Billing Manual, DC Medicaid (Sept. 2023), Sec. 15.7, P. 51-52. FQHC Billing Manual, DC Medicaid 15.6.1, P. 53-54. (Oct. 2023), Behavioral Health Billing Manual (Feb. 2024) 14.7, p. 70-71. & Department of Health Care Finance – Telemedicine Provider Guidance, Jan. 2023, pg. 5-6, Outpatient Hospital Billing Guide, 15.8.5, p. 75 (Sept. 2023), Inpatient Hospital Billing Guide, 11.7, p. 62-63 (Jan. 2024), Long-Term Care Billing Manual, 15.7, p. 53-54 (Sept. 2023). (Accessed Mar. 2024).

The provider shall determine if the service can reasonably be delivered at the standard of care via telemedicine.

SOURCE: Department of Health Care Finance – Telemedicine Provider Guidance, Jan. 2023, pg. 6. Physicians Billing Manual.  DC Medicaid.  (Jan. 2024) Sec. 15.7. P. 54, Clinic Billing Manual, DC Medicaid (Sept. 2023), Sec. 15.7, P. 51-52. FQHC Billing Manual, DC Medicaid 15.6.1, P. 54. (Oct. 2023), Behavioral Health Billing Manual (Feb. 2024) 14.7, p. 71, Inpatient Hospital Billing Guide, 11.7, p. 63 (Jan. 2024), Long-Term Care Billing Manual, 15.7, p. 54 (Sept. 2023) (Accessed Mar. 2024).

Distant site providers may only bill for the appropriate codes outlined.

SOURCE: DC Municipal Regulation. Title 29, Ch. 9, Sec. 910.12.(Accessed Mar. 2024).

Telemedicine listed as a covered service in the following manuals, but no other information is provided.

SOURCE:  DC MMIS Provider Billing Manual (Dental) Feb. 27, 2024, 2.4, p. 12. DC MMIS Provider Billing Manual (Dialysis), 2.4, p. 11 (Sept. 14, 2023). DC MMIS Provider Billing Manual (DME/POS), 2.4, p. 12 (Sept. 14, 2023), DC MMIS Provider Billing Manual (EPSDT), 2.4, p. 12 (May 14, 2023), DC MMIS Provider Billing Manual (Home Health), 2.4, p. 10-11. (Sept. 14, 2023), DC MMIS Provider Billing Manual (Hospice) 2.4, p. 10-11, (Sept. 14, 2023), DC MMIS Provider Billing Manual (Independent Lab & X-Ray), 2.4, p. 10-11 (Sept. 14, 2023), DC MMIS Provider Billing Manual (Podiatry), 2.4, p. 10-11 (Sept. 15, 2023), DC MMIS Provider Billing Manual (Residential Treatment Facilities), 2.4, p. 9-10 (Sept. 15, 2023), DC MMIS Provider Billing Manual (Transportation), 2.4, p. 10-11, (Sept. 15, 2023), DC MMIS Provider Billing Manual (Vision), 2.4, p. 10-11 (Sept. 15, 2023). (Accessed Mar. 2024).

Education-Related Services

Office of the State Superintendent of Education shall only bill for distant site services that are allowable healthcare services to be delivered by the individual fee-for-service providers delivering Strong Start DC Early Intervention Program (DC EIP) services under them and can be delivered at the standard of care via telemedicine.

The following reimbursement parameters apply for services delivered under the Office of the State Superintendent of Education through the Strong Start DC Early Intervention Program:

• The LEA shall only bill for distant site services that are allowable healthcare services to be delivered at DCPS/DCPCS and can be delivered at the standard of care via telemedicine;
• The LEA shall provide an appropriate primary support professional to attend the medical encounter with the member at the originating site. In instances where it is clinically indicated, an appropriate healthcare professional shall attend the encounter with the member at the originating site.

SOURCE: Department of Health Care Finance – Telemedicine Provider Guidance, Jan. 2023, pg. 5. Physicians Billing Manual.  DC Medicaid.  (Jan. 2024) Sec. 15.6. P. 53, Clinic Billing Manual, DC Medicaid (Sept. 2023), Sec. 15.6, P. 51. FQHC Billing Manual, DC Medicaid 15.6, P. 53. (Oct. 2023), Behavioral Health Billing Manual (Feb. 2024) 14.6, p. 70, Inpatient Hospital Billing Guide, 11.6, p. 62 (Jan. 2024), Long-Term Care Billing Manual, 15.6, p. 53 (Sept. 2023) (Accessed Mar. 2024).

Excluded Services

The Program will not reimburse telemedicine providers for the following:

• Incomplete delivery of services via telemedicine, including technical interruptions that result in partial service delivery.
• When a provider is only assisting the beneficiary with technology and not delivering a clinical service.
• For a telemedicine transaction fee and/or facility fee.
• For store and forward and remote patient monitoring

SOURCE: Department of Health Care Finance – Telemedicine Provider Guidance, Jan. 2023, pg. 6, Physicians Billing Manual.  DC Medicaid.  (Jan. 2024) Sec. 15.8. P. 54, Clinic Billing Manual, DC Medicaid (Sept. 2023), Sec. 15.8, P. 52. FQHC Billing Manual, DC Medicaid 15.6.2, P. 54. (Oct. 2023), Behavioral Health Billing Manual (Feb. 2024) 14.8, p. 71, Outpatient Hospital Billing Guide, 15.8.6, p. 75 (Sept. 2023), Inpatient Hospital Billing Guide, 11.8, p. 63 (Jan. 2024), Long-Term Care Billing Manual, 15.8, p. 54 (Sept. 2023). (Accessed Mar. 2024).

Mental Health Rehabilitation Services Provider Certification Standards

Telemedicine/telehealth are included under reimbursable services. See rule for specific requirements.

SOURCE: DC Municipal Regulation, Title 22, Ch. 34, Sec. 3434. (Accessed Mar. 2024).

Mental Health Crisis/Emergency Services

A Crisis/Emergency Service is an immediate response face-to-face or via telehealth in accordance with 29 DCMR § 910 to an emergency situation involving a consumer with mental illness or emotional disturbance that is available twenty-four (24) hours per day, seven (7) days per week.

SOURCE: DC Municipal Regulation, Title 22, Ch. 34, Sec. 3422. (Accessed Mar. 2024).

Clinical Care Coordination (CCC)

CCC may be rendered by a qualified practitioner pursuant to § 3432.8 practicing within the scope of their license in person or through telehealth in accordance with 29 DCMR § 910.

Qualified practitioners providing CCC shall:

• Communicate treatment needs, assessments and treatment information to healthcare providers external to the consumer’s CSA or specialty provider;
• Facilitate appropriate linkages for the consumer with other healthcare professionals external to the consumer’s CSA or specialty provider; and
• Provide planning and Plan of Care implementation activities separate from the diagnostic assessment service when the clinician and consumer meet face-to-face or through telehealth pursuant to 29 DCMR § 910.

Providers must document CCC in an encounter note that meets the requirements of § 3413.19 and indicates the intended purpose of the service, the modality of communication, time spent reviewing or preparing records, the actions taken, and the result(s) achieved.

SOURCE: DC Municipal Regulation, Title 22, Ch. 34, Sec. 3432. (Accessed Mar. 2024).

Assertive Community Treatment (ACT)

During the calendar month billing cycle, the ACT provider must deliver at least five contacts face-to-face and may deliver up to three contacts via telehealth, including collateral contacts and the monthly MD/APRN contact. At least three contacts must be delivered by distinct qualified practitioners eligible to deliver ACT services pursuant to Title 22-A DCMR Chapter 34. See provider transmittals 23-39, 23-50, and 24-11 and rule for specific requirements.

SOURCE: Department of Health Care Finance, Notice of Final Rulemaking – Amending 29 DCMR Chapter 52 – Governing Assertive Community Treatment. Mar. 2024; Department of Behavioral Health – Notice of Final Rulemaking – Amending 22-A DCMR Ch. 34 and 37 – Assertive Community Treatment. Dec. 2023. (Accessed Mar. 2024).

ELIGIBLE PROVIDERS

Telemedicine providers must comply with the following:

• Be an enrolled Medicaid provider and comply with requirements including having a completed, signed Medicaid Provider Agreement
• Comply with technical, programmatic and reporting requirements
• Be licensed; and
• Appropriately document the beneficiary’s written or verbal consent.
• Comply with any other applicable consent requirements under District laws, including but not limited to Section 3026 of Title 5-E of the District of Columbia Municipal Regulations if providing telemedicine services at a District of Columbia Public School (DCPS) or District of Columbia Public Charter School (DCPCS).

SOURCE: DC Municipal Regulation. Title 29, Ch. 9, Sec. 910.6. (Accessed Mar. 2024)

D.C. Medicaid enrolled providers are eligible to deliver telemedicine services, using fee-for-service reimbursement, at the same rate as in-person consultations. All reimbursement rates for services delivered via telemedicine are consistent with the District’s Medical State Plan and implementing regulations.

The eligible distant site providers include but are not limited to the following:

• Hospital
• Nursing facility
• Federally Qualified Health Center
• Clinic
• Physician Group/Office
• Nurse Practitioner Group/Office
• DCPS
• DCPCS; and
• MHRS provider, ASARS provider and ASTEP provider certified by DBH and eligible to provide behavioral health services set forth under the State Plan

SOURCE: DC Municipal Regulation. Title 29, Ch. 9, Sec. 910.7 & Department of Health Care Finance – Telemedicine Provider Guidance, Jan. 2023, pg. 3-4. Physicians Billing Manual.  DC Medicaid.  (Jan. 2024) Sec. 15.3. P. 52, Clinic Billing Manual, DC Medicaid (Sept. 2023), Sec. 15.3, P. 50. FQHC Billing Manual, DC Medicaid 15.3, P. 52. (Oct. 2023), Behavioral Health Billing Manual (Feb. 2024) 14.3, p. 69, Outpatient Hospital Billing Guide, 15.8.3, p. 74-75 (Sept. 2023), Inpatient Hospital Billing Guide, 11.3, p. 61 (Jan. 2024), Long-Term Care Billing Manual, 15.3, p. 52 (Sept. 2023). (Accessed Mar. 2024).

At the discretion of the rendering provider, personnel delivering telemedicine services may work remotely, as long as all other requirements in the rule are met. See sections on technology, documentation in medical records, and confidentiality in guidance document for further specifications.

SOURCE: Department of Health Care Finance – Telemedicine Provider Guidance, Jan. 2023, pg. 3-4. Physicians Billing Manual.  DC Medicaid.  (Jan. 2024) Sec. 15.3. P. 52, Clinic Billing Manual, DC Medicaid (Sept. 2023), Sec. 15.3, P. 50. FQHC Billing Manual, DC Medicaid 15.3, P. 52. (Oct. 2023), Behavioral Health Billing Manual (Feb. 2024) 14.3, p. 69, Inpatient Hospital Billing Guide, 11.3, p. 61 (Jan. 2024), Long-Term Care Billing Manual, 15.3, p. 52 (Sept. 2023) (Accessed Mar. 2024).

When a beneficiary’s home is the originating site, the distant site provider shall ensure the technology in use meets the minimum requirements.

SOURCE: DC Municipal Regulation. Title 29, Ch. 9, Sec. 910.30. (Accessed Mar. 2024).

Federally Qualified Health Center (FQHC) Reimbursement

In accordance with the District’s Prospective Payment System (PPS) or alternative payment methodology (APM) for FQHCs, the following reimbursement parameters apply:

• Originating Site: An FQHC provider must deliver an FQHC-eligible service in order to be reimbursed the appropriate PPS, APM, or fee-for-service (FFS) rate at the originating site;
• Distant Site: An FQHC provider must deliver an FQHC-eligible service that is listed in Appendix A in order to be reimbursed the appropriate PPS, APM, or FFS rate; and
• Originating and Distant Site: If both the originating and the distant site are FQHCs, for both to receive reimbursement, each site must deliver a different PPS or APM service (e.g. medical or behavioral). If both sites submit a claim for the same PPS or APM service (e.g. medical), then only the distance site will be eligible to receive reimbursement.

SOURCE: Department of Health Care Finance – Telemedicine Provider Guidance, Jan. 2023, pg. 4-5.,Physicians Billing Manual.  DC Medicaid.  (Jan. 2024) Sec. 15.5. P. 53, Clinic Billing Manual, DC Medicaid (Sept. 2023), Sec. 15.5, P. 51. FQHC Billing Manual, DC Medicaid 15.5, P. 53. (Oct. 2023), Behavioral Health Billing Manual (Feb. 2024) 14.5, p. 70. Inpatient Hospital Billing Guide, 11.5, p. 62 (Jan. 2024), Long-Term Care Billing Manual, 15.5, p. 53 (Sept. 2023) (Accessed Mar. 2024).

ELIGIBLE SITES

Eligible services can be delivered via telemedicine when the beneficiary is at the originating site, while the eligible “distant” provider renders services via the audio/video or audio-only connection.

When clinically indicated, an originating site provider or its designee shall be in attendance during the patient’s medical encounter with the distant site professional. An originating site provider shall not be required to be in attendance when the beneficiary prefers to be unaccompanied because the beneficiary feels the subject is sensitive. An originating site provider shall note their attendance status in the patient’s medical record.

To receive reimbursement, originating site providers must deliver an eligible service, distinct from the service delivered at the distant site, in order to receive reimbursement.

Telemedicine providers will submit claims in the same manner the provider uses for in person services.

When billing for services delivered via video-audio telemedicine, distant site providers shall enter the “GT” procedure modifier on the claim. When billing for any audio-only telemedicine services, distant site providers shall enter the “93” procedure modifier on the claim.

Additionally, the distant site provider must appropriately specify the place of service (POS) using the following POS codes:

• In the event the beneficiary’s home is the originating site, the distant site provider must specify the place of service “10” which is defined as “telehealth provided in patient’s home”.
• In the event a DCPS or a DCPCS is the originating site, the distant site provider must specific the place of service “03” which is defined as “school”.
• In the event the beneficiary is at any other eligible originating site (see section IV above), the distant site provider must specify the place of service “02” which is defined as “telehealth provided other than in patient’s home”. When utilizing place of service “02”, the distant site provider must also report the National Provider Identifier (NPI) of the originating site provider in the “referring provider” portion of the claim.

Services billed where telemedicine is the mode of service delivery, but the claim form and/or service documentation do not indicate telemedicine (using the appropriate procedure modifiers and appropriate POS codes) are subject to disallowances in the course of an audit.

The Program will implement this telemedicine service for both providers and participants in the Medicaid fee-for-service, Medicaid managed care, Health Care Alliance, and Immigrant Children’s programs. All requirements stipulated in this provider guidance apply to all programs DHCF administers.

SOURCE: Department of Health Care Finance – Telemedicine Provider Guidance, Jan. 2023, pg. 1-4. Physicians Billing Manual.  DC Medicaid.  (Jan. 2024) Sec. 15.4. P. 52-53, Clinic Billing Manual, DC Medicaid (Sept. 2023), Sec. 15.4, P. 50-51. FQHC Billing Manual, DC Medicaid 15.4, P. 52-53. (Oct. 2023), Behavioral Health Billing Manual (Feb. 2024) 14.4, p. 69-70, Inpatient Hospital Billing Guide, 11.4, p. 61-62 (Jan. 2024), Long-Term Care Billing Manual, 15.4, p. 52-53 (Sept. 2023) (Accessed Mar. 2024).

Effective March 1st, 2023, District health care providers rendering services to beneficiaries in Medicaid fee-for-service, Medicaid managed care, Health Care Alliance, and Immigrant Children’s programs must comply with these revised billing requirements. Refer to Transmittal #23-11 for additional information.

SOURCE: Physicians Billing Manual.  DC Medicaid.  (Jan. 2024) Sec. 15.4. P. 52-53, Clinic Billing Manual, DC Medicaid (Sept. 2023), Sec. 15.4, P. 50-51. FQHC Billing Manual, DC Medicaid 15.4, P. 52-53. (Oct. 2023), Behavioral Health Billing Manual (Feb. 2024) 14.4, p. 69-70, Inpatient Hospital Billing Guide, 11.4, p. 61-62 (Jan. 2024), Long-Term Care Billing Manual, 15.4, p. 52-53 (Sept. 2023) (Accessed Mar. 2024).

The beneficiary’s home, or other settings authorized by DHCF, may serve as the originating site. When the originating site is the beneficiary’s home the distant site provider is responsible for ensuring that the technology in use meets the minimum requirements set forth in Subsection 910.13.

SOURCE: DC Municipal Regulation. Title 29, Ch. 9, Sec. 910.7 & 910.30. (Accessed Mar. 2024).

DHCF defines “the definition of “the beneficiary’s home or other settings” to include temporary lodging, such as hotels and homeless shelters. Additionally, for circumstances where the patient, for privacy or other personal reasons, chooses to travel a short distance from the exact home location during a telehealth service, the service is still considered to be furnished” in the home of an individual.

SOURCE: Department of Health Care Finance. Telemedicine Provider Guidance Clarification “Beneficiary’s Home or Other Settings”. March 2023. (Accessed Mar. 2024).

Must be an approved telemedicine provider.  The following providers are considered an eligible originating site:

• Hospital
• Nursing facility
• Federally Qualified Health Center
• Clinic
• Physician Group/Office
• Nurse Practitioner Group/Office
• District of Columbia Public Schools (DCPS)
• District of Columbia Public Charter Schools (DCPCS)
• Mental Health Rehabilitation Service (MHRS) provider, Adult Substance Abuse Rehabilitation Service (ASARS) provider, and Adolescent Substance Abuse Treatment Expansion Program (ASTEP) provider certified by the Department of Behavioral Health (DBH) and eligible to provide behavioral health services set forth under the District of Columbia Medicaid State Plan (State Plan).
• The beneficiary’s home or other settings identified in guidance published on the DHCF website.

SOURCE: DC Municipal Regulation. Title 29, Ch. 9, Sec. 910.7, Department of Health Care Finance – Telemedicine Provider Guidance, Jan. 2023, pg. 2-3. Physicians Billing Manual.  DC Medicaid.  (Jan. 2024) Sec. 15.3. P. 52, Clinic Billing Manual, DC Medicaid (Sept. 2023), Sec. 15.3, P. 50. FQHC Billing Manual, DC Medicaid 15.3, P. 52. (Oct. 2023), Behavioral Health Billing Manual (Feb. 2024) 14.3, p. 69. Outpatient Hospital Billing Guide, 15.8.3, p. 74 (Sept. 2023), Inpatient Hospital Billing Guide, 11.3, p. 61 (Jan. 2024), Long-Term Care Billing Manual, 15.3, p. 52 (Sept. 2023). (Accessed Mar. 2024).

When a beneficiary’s home is the originating site, the distant site provider shall ensure the technology in use meets the minimum requirements set forth in Subsection 910.13.

SOURCE: Department of Health Care Finance – Telemedicine Provider Guidance, Jan. 2023, pg. 7. (Accessed Mar. 2024).

When DCPS or DCPCS is the originating site provider, a primary support professional (an individual designated by the school) shall be in attendance during the patient’s medical encounter.

An originating site provider shall not be required to be in attendance when the beneficiary prefers to be unaccompanied because the beneficiary feels the subject is sensitive. Sensitive topics may include counseling related to abuse, or other psychiatric matters. An originating site provider shall note their attendance status in the patient’s medical record.

SOURCE: DC Municipal Regulation. Title 29, Ch. 9, Sec. 910.16-17. (Accessed Mar. 2024).

GEOGRAPHIC LIMITS

No Reference Found

FACILITY/TRANSMISSION FEE

No transaction or facility fee.

SOURCE: DC Municipal Regulation. Title 29, Ch. 9, Sec. 910.28, Department of Health Care Finance – Telemedicine Provider Guidance, Jan. 2023, pg. 6, Physicians Billing Manual.  DC Medicaid.  (Jan. 2024) Sec. 15.8. P. 54, Clinic Billing Manual, DC Medicaid (Sept. 2023), Sec. 15.8, P. 52. FQHC Billing Manual, DC Medicaid 15.6.2, P. 54. (Oct. 2023), Behavioral Health Billing Manual (Feb. 2024) 14.8, p. 71, Outpatient Hospital Billing Guide, 15.8.6, p. 75 (Sept. 2023), Inpatient Hospital Billing Guide, 11.8, p. 63 (Jan. 2024), Long-Term Care Billing Manual, 15.8, p. 54 (Sept. 2023). (Accessed Mar. 2024).

POLICY

During the federal PHE, the Agency provided expansive coverage for telemedicine services. Effective May 11, 2023, Florida Medicaid will cover telehealth services in accordance with the Agency’s promulgated Telemedicine rule and will no longer cover audio-only telehealth services. Florida Medicaid will continue to cover store-and-forward and remote patient monitoring services.

As a reminder, Statewide Medicaid Managed Care (SMMC) plans may provide more expansive coverage than what is in Agency rule, including telemedicine and waiving co-payments. However, SMMC plans may not be more restrictive than Agency rule.

SOURCE: FL Medicaid, Alert, Ending of Federal Public Health Emergency: Updated Co-Payment and Telemedicine Guidance for Medical and Behavioral Health Providers, May 4, 2023, (Accessed Feb. 2024).

FL Medicaid reimburses for real time, two-way, interactive telemedicine.

Providers must include the GT modifier.

SOURCE: FL Admin Code 59G-1.057. (Accessed Feb. 2024).

ELIGIBLE SERVICES/SPECIALTIES

List of eligible community behavioral health services is provided in Provider Alert.  See alert for procedure codes, modifiers and telemedicine modifiers.

SOURCE: FL Medicaid, Alert, Community Behavioral Health Telemedicine-Eligible Services, May 12, 2023, (Accessed Feb. 2024).

Florida Medicaid reimburses the practitioner who is providing the evaluation, diagnosis, or treatment recommendation located at a site other than where the recipient is located.

SOURCE: FL Admin Code 59G-1.057. (Accessed Feb. 2024).

Alcohol and/or drug screenings can be delivered with a telehealth place of service.

SOURCE: FL Medicaid Alert, Screening, Brief Intervention, and Referral to Treatment (SBIRT) Continuing Medical Education (CME) Opportunity for Providers, Apr. 13, 2023, (Accessed Feb. 2024).

ELIGIBLE PROVIDERS

Telemedicine is available for use by all providers of Florida Medicaid services that are enrolled in or registered with the Florida Medicaid program and who are licensed within their scope of practice to perform the service.

SOURCE: FL Admin Code 59G-1.057. (Accessed Feb. 2024).

ELIGIBLE SITES

Screening, Brief Intervention, and Referral to Treatment (SBIRT) Continuing Medical Education (CME) Opportunity for Providers

The place of service is open for office visits, telehealth, all hospital settings and clinics, and ambulatory surgical centers.

SOURCE: FL Medicaid, Alert, Screening, Brief Intervention, and Referral to Treatment (SBIRT) Continuing Medical Education (CME) Opportunity for Providers, July 7, 2023, (Accessed Feb. 2024).

GEOGRAPHIC LIMITS

No Reference Found

FACILITY/TRANSMISSION FEE

No Reference Found

POLICY

The use of a telecommunications system may substitute for an in-person encounter for professional office visits, pharmacologic management, limited office psychiatric services, limited radiological services and a limited number of other physician fee schedule services. See the telehealth guidelines for program specific policies.

SOURCE: GA Dept. of Community Health, Physician Services Manual, p. 170 (Jan. 1, 2024). (Accessed Jan. 2024).

Medicaid covered services are provided via telehealth for eligible members when the service is medically necessary, the procedure is individualized, specific, and consistent with symptoms or confirmed diagnosis of an illness or injury under treatment, and not in excess of the member’s needs.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 7 (Jan. 1, 2024). (Accessed Jan 2024).

ELIGIBLE SERVICES/SPECIALTIES

An interactive telecommunications system is required as a condition of payment. The originating site’s system, at a minimum, must have the capability of allowing the distant site provider to visually examine the patient’s entire body including body orifices (such as ear canals, nose and throat). The distant site provider should also have the capability to hear heart tones and lung sounds clearly (using a stethoscope) if medically necessary and currently within the provider’s scope of practice. The telecommunication system must be secure and adequate to protect the confidentiality and integrity of the information transmitted.

SOURCE: GA Dept. of Community Health, Physician Services Manual, p. 170 (Jan. 1, 2024). (Accessed Jan. 2024).

Claims for telehealth services must use the appropriate CPT or HCPCS code for the professional service. The GT modifier is required as applicable, and/or the use of either POS 02 or POS 10. POS 02 will indicate Telehealth services that were utilized at a location other than at the patient’s home. The GQ modifier is still required as applicable. By coding and billing with the covered telehealth procedure code, providers are certifying that the member was present at an eligible originating site when you furnished the telehealth service. CPT modifier ‘‘93’’ can be appended to claim lines, as appropriate, for services furnished using audio only communications technology. Interactive audio and video telecommunications must be used, permitting real time communications between the distant site provider or practitioner and the member.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 12, 16 (Jan. 1, 2024). (Accessed Jan. 2024).

The service must be medically necessary and the procedure individualized, specific, and consistent with symptoms or confirmed diagnosis of an illness or injury under treatment, and not in excess of the member’s needs.

Physician Services:  When an enrolled provider determines that medical care can be provided via electronic communication with no loss in the quality or efficacy of the member’s care, telehealth services can be performed.

See telehealth manual for list of eligible telehealth services and codes for specific programs.

An interactive telecommunications system is required as a condition of payment. The originating site’s system, at a minimum, must have the capability of allowing the distant site provider to visually examine the patient’s entire body including body orifices (such as ear canals, nose, and throat). Depending upon an enrolled provider’s specialty and scope of practice, the distant provider should also have the capability to hear heart tones and lung sounds clearly (using stethoscope) if medically necessary and currently within the provider’s scope of practice. The telecommunication system must be secure and adequate to protect the confidentiality and integrity of the information transmitted.

Non-Covered Service Modalities:

1. Telephone conversations.
2. Electronic mail messages.
3. Facsimile.
4. Services rendered via a webcam or internet-based technologies (i.e., Skype, Tango, etc.) that are not part of a secured network and do not meet HIPAA encryption compliance.
5. Video cell phone interactions.
6. The cost of telehealth equipment and transmission.
7. Failed or unsuccessful transmissions.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance, p. 6-7 & 17 (Jan. 1, 2024). (Accessed Jan 2024).

Nursing Facilities 

Those residents whose interest is best served by receiving mental health services in the nursing facility or in a nearby telemedicine site can receive services in either of those locations, with the practitioner using out-of-clinic or telehealth/telemedicine procedure codes. See manual for codes.

Though not available in all areas of the State, Medicare-funded mental health services are currently provided to nursing home residents via telemedicine, face-to-face visits by providers Rev. 04/12 in the nursing home, and nursing home resident visits to psychiatric/mental health clinics/offices for those individuals able to travel outside the nursing facility.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 45-46 (Jan. 1, 2024) & GA Dept. of Community Health, Division of Medical Assistance, Part II Policies and Procedures for Nursing Facility Services, p. H-1 , H-8 (p. 217, 223). (Jan. 1, 2024). (Accessed Jan 2024).

Teledentistry

See dental services manual for teledentistry codes.

SOURCE: GA Dept. of Community Health, Division of Medical Assistance, Part II Policies and Procedures for Dental Services, IX-21-22, p. 60-61 (Oct. 2023). GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 36 (Jan. 1, 2024). (Accessed Jan 2024).

Autism Spectrum Disorder Services

Practitioners of Autism Spectrum Disorder (ASD) services can use telehealth to assess, diagnose and provide therapies to patients. Prior authorization is required for all Medicaid-covered adaptive behavior services, behavioral assessment and treatment services (not telehealth specific). See manual for eligible codes.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 24-29 (Jan. 1, 2024). (Accessed Jan 2024).

Community Behavioral Health and Rehabilitation Services (CBHRS)

The Departments of Community Health and Behavioral Health and Developmental Disabilities have authorized telehealth to be used to provide some services in the CBHRS program.  See Behavioral Health and Development Disabilities manual for more detailed information.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 31-34 (Jan. 1, 2024). GA Department of Community Health for CBHRS, p. 98-99 (Jan. 1, 2024). GA Dept. of Behavioral Health & Developmental Disabilties, Provider Manual for Community Behavioral Health Providers (Dec. 2023).  (Accessed Jan 2024).

Those residents whose interest is best served by receiving mental health services in the nursing facility or in a nearby telemedicine site can receive services in either of those locations, with the practitioner using out-of-clinic or telehealth/telemedicine procedure codes.

SOURCE: GA Dept. of Community Health, Division of Medical Assistance, Part II Policies and Procedures for Community Behavioral Health Rehabilitation Services, p. 67, (Jan. 1, 2024). (Accessed Jan 2024).

Dialysis Services

The Centers for Medicaid and Medicare Services (CMS) has added Dialysis Services to the list of services that can be provided under Telehealth. See manual for list of eligible CPT codes.

SOURCE: GA Dept. of Community Health, GA Medicaid Telemedicine Guidance Handbook, p. 40-43 (Jan. 1, 2024). (Accessed Jan. 2024).

School Based Services

Telehealth benefits are allowed if all the following criteria are met:

• The provider is an authorized health-care provider enrolled in Georgia Medicaid
• The client is a child who is receiving the service in a primary or secondary school-based setting
• The parent or legal guardian of the client provides consent before the service is provided.

Certain speech language pathology, speech and audiology, and physical therapy services are reimbursable via telehealth in the school-based setting.  This includes time spent assisting the student with learning to use adaptive equipment and assistive technology.

See manual for eligible CPT/HCPCS speech, audiology and physical therapy codes.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 49-53 (Jan. 1, 2024). (Accessed Jan. 2024).

Durable Medical Equipment Services

A face-to-face encounter may be made through the use of telehealth technology by reporting the appropriate E&M code.

SOURCE: GA Dept. of Community Health, GA Medicaid Durable Medical Equipment Services Manual, p. 34  (Jan. 1, 2024). (Accessed Jan 2024).

Elderly and Disabled Waiver EDWP Traditional/Enhanced Case Management

Members must be seen by their PCP annually, either in the office of the PCP or via Telehealth with the SNS provider RN performing the call.

SOURCE: GA Dept of Community Health, Division of Medicaid, Policies and Procedures for Elderly and Disabled Waiver EDWP – (CCSP) Traditional/Enhanced Case Management (Jan. 1, 2024), p. 23.  (Accessed Jan 2024).

EDWP (CCSP and Source) Skilled Nursing Services by Private Home Care Providers

Registered Nurse Responsibilities include facilitating telehealth visits with the member and the member’s PCP.

SOURCE:  GA Dept of Community Health, Division of Medicaid, Policies and Procedures for EDWP (CCSP and SOURCE): General Services (Jan.1, 2024), p. 212-213; Skilled Nursing Services by Private Home Care Providers (Jan. 1, 2024), p. 7, 11-12.; (Accessed Jan 2024).

Department of Community Health

The Department of Community Health (DCH) will allow medically necessary services to be rendered via telehealth. Each billed procedure code must be submitted with the usual program modifier(s). Place of service code 02 must be added to the allowed procedure codes to indicate the services are related to telehealth services.

SOURCE: GA Dept of Community Health: Early Intervention Case Management Program, p. 28 (Jan. 1, 2024).  (Accessed Jan. 2024).

Children’s Intervention Services

The Department of Community Health will allow some speech therapy, therapy and audiology services to be rendered via telehealth.  See manual for appropriate codes.

SOURCE: GA Dept. of Community Health, Division of Medicaid, Children’s Intervention Services (Jan. 1, 2024), p. 47.  GA Dept. of CommunityHealth, Childrens Intervention School Services (Jan. 1, 2024). (Accessed Jan 2024).

Comprehensive Supports Waiver Program (COMP)

All components of Adult Occupational Therapy, Adult Physical Therapy, Speech and Language Therapy, Adult Nutrition Services,  Interpreter Services can be safely provided via telehealth modalities according to prevailing best practice standards published by the American Speech and Language Hearing (Occupational or Physical Therapy) Association and in accordance with the Georgia license requirements under O.C.G.A. § 43-44-7. Therapists are expected to use synchronous “in real time” audio/video technology for telehealth sessions. Telephone calls and store and forward (asynchronous) modalities are not allowed for billable therapy evaluation and services.

Some components of Behavior Supports Services can be provided via a telehealth modality to supplement in-person service delivery. The following components are the only components that are allowable for a telehealth option:

• Indirect assessment component for functional behavior assessment;
• Follow up or refresher staff training for behavior support plans;
• Additional fidelity monitoring of plan implementation and oversight;
• Distant site observations of the individual for the purposes of consultation, modeling, and recommendations for interventions to staff/caregivers in real time;
• Team meetings for the purpose of gathering feedback related to behavior support plans effectiveness; and
• Review of data analysis summaries and behavior graphing.

See manual for more details.

SOURCE: GA Dept. of Community Health, Comprehensive Supports Waivers Program (COMP) Chapters 1300-3700 (Jan. 1, 2024), GA Dept. of CommunityHealth, New Options Waiver Program (NOW) (Jan. 1, 2024).  (Accessed Jan 2024).

Independent Care Waiver Services

Counseling services are available to members needing treatment for personal, social or behavioral disorders to maintain and improve effective functioning. Counseling services can be provided via telehealth with or without a visual component.

SOURCE: GA Dept. of Community Health, Independent Care Waiver Services (Jan. 1, 2024), p. 78.  (Accessed Jan. 2024).

ELIGIBLE PROVIDERS

The consulting provider must be an enrolled provider in Medicaid in the state of Georgia and must document all findings and recommendations in writing, in the format normally used for recording services in the member’s medical records.  The provider at the distant site must obtain prior approval when services require prior approval.  Both the originating site and distant site must document and maintain the member’s medical records. The report from the distant site provider may be faxed to the originating provider.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 15 (Jan. 1, 2024). (Accessed Jan. 2024).

Autism Spectrum Disorder Services

Practitioners of ASD services can use telehealth to assess, diagnose and provide therapies to patients.  Providers must hold either a current and valid license to practice Medicine in Georgia, hold a current and valid license as a Psychologist as required under Georgia Code Chapter 39 as amended, or hold a current and valid Applied Behavior Analysis (ABA) Certification. In addition to licensed Medicaid enrolled Physicians and Psychologists, Georgia Medicaid will enroll Board Certified Behavioral Analysts (BCBAs) as Qualified Health Care Professionals (QHCPs) to provide ASD treatment services. The BCBA must have a graduate-level certification in behavior analysis. Providers who are certified at the BCBA level are independent practitioners who provide behavior-analytic services. In addition, BCBAs supervise the work of Board-Certified Assistant Behavior Analysts (BCaBAs), and Registered Behavior Technicians (RBTs) who implement behavior-analytic interventions.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 24 (Jan. 1, 2024). (Accessed Jan 2024).

Community Behavioral Health and Rehabilitation Services

See manual for eligible practitioner types and levels for CBHRS.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 33-34 (Jan. 1, 2024). (Accessed Jan 2024).

Teledentistry

Licensed dentists and dental hygienists are eligible providers.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 36 (Jan. 1, 2024). (Accessed Jan 2024).

Federally Qualified Health Center (FQHC)/Rural Health Center (RHC)

FQHCs and RHCs can serve as the originating or distant site. They cannot bill an originating site fee and distant site fee for telehealth services on the same encounter.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 38 (Jan. 1, 2024) & GA Dept. of Community Health, Policies and Procedures for Federally Qualified Health Center Services and Rural Health Clinic Services, p. 23, (Jan. 1, 2024). (Accessed Jan 2024).

Nursing Facility Specialized Services

See manual for eligible providers and levels.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 46 (Jan. 1, 2024). (Accessed Jan. 2024).

Advanced Nurse Practitioner & Nurse Midwifery Services

GT modifier must be used in conjunction with the appropriate codes for Telemedicine following full implementation of HIPAA compliance (see “Telemedicine Consultations.”).

SOURCE: GA Dept. of Community Health, GA Medicaid Division, Advanced Nurse Practitioner Services (Jan. 1, 2024), p. 23.  GA Dept. of Community Health, GA Medicaid Division, Nurse Midwifery Services, p. 36 (Jan. 1, 2024).  (Accessed Jan 2024).

School-Based Settings (Local Education Agencies)

Telehealth services are allowed in school-based settings upon enrollment into COS 600.  The following requirements must be met:

• The provider is an authorized health-care provider enrolled in Georgia Medicaid
• The client is a child who is receiving the service in a primary or secondary school-based setting
• The parent or legal guardian of the client provides consent before the service is provided

Telehealth services provided in a school-based setting are also a benefit if the referring provider delegates provision of services to a nurse practitioner, clinical nurse specialist, physician assistant, or other licensed specialist as long as the above-mentioned providers are working within the scope of their professional license and within the scope of their delegation agreement with the provider.

The school must enroll as a Health Check Provider in order to bill the telehealth originating site facility fee.

LEAs must submit an Attestation Form for the provision of telehealth services.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 50 (Jan. 1, 2024)., GA Dept. of CommunityHealth, Childrens Intervention School Services (Jan. 1, 2024), p. 9. (Accessed Jan 2024).

ELIGIBLE SITES

Originating sites are paid an originating site facility fee for telehealth services as described by HCPCS code Q3014 with a payment of $20.52. Hospitals are eligible to receive reimbursement for a facility fee for telehealth when operating as the originating site. Claims must be submitted with revenue code 780 (telehealth) and type of bill 131. There is no separate reimbursement for telehealth serves when performed during an inpatient stay, outpatient clinic or emergency room visit or outpatient surgery, as these are all-inclusive payments.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 12 (Jan. 1, 2024). (Accessed Jan 2024).

Ambulance Providers

They may serve as originating sites and the ambulance may bill a separate origination site fee. They are not authorized to provide distant site services.

Limitation (Emergency Ambulance Services Handbook): Emergency ambulance services are reimbursable only when medically necessary. The recipient’s physical condition must prohibit use of any method of transportation except emergency for a trip to be covered. See Emergency Ambulance Handbook for more specific information.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 21 (Jan. 1, 2024). & Emergency Ambulance Services Handbook, p. 18 (Jan. 1, 2024). (Accessed Jan 2024).

Community Behavioral Health and Rehabilitation Services

Member may be located at home, schools and other community-based settings or at traditional sites named in the Department of Community Health Telehealth Guidance.  See manual for detailed instructions explanation for when and which type of practitioner can bill for telehealth services.

Traditional sites include:

• Physician and Practitioner’s Offices;
• Hospitals;
• Rural Health Clinics;
• Federally Qualified Health Centers;
• Local Education Authorities and School Based Clinics;
• County Boards of Health;
• Emergency Medical Services Ambulances; and
• Pharmacies.

SOURCE: GA Dept. of Community Health, Community Behavioral Health Rehabilitation Services Handbook Appendix O, p.98 (Jan. 1, 2024). GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 31 (Jan. 1, 2024). (Accessed Jan 2024).

Teledentistry

Department of Public Health (DPH) Districts and Boards of Health Dental Hygienists shall only perform duties under this protocol at the facilities of the DPH District and Board of Health, at school-based prevention programs and other facilities approved by the Board of Dentistry and under the approval of the District Dentist or dentist approved by the District Dentist.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 36 (Jan. 1, 2024). (Accessed Jan 2024).

Services can now be provided in Federally Qualified Health Centers, volunteer community health settings, senior centers and family violence shelters.

SOURCE: GA Dept. of Community Health, Dental Services p. 60 (IX-21) (Oct. 2023). (Accessed Jan 2024).

Federally Qualified Health Center (FQHC)/Rural Health Center (RHC)

FQHCs and RHCs can serve as originating sites and are paid an originating site facility fee. They cannot bill an originating site fee and distant site fee for telehealth services on the same encounter.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 38 (Jan. 1, 2024). & GA Dept. of Community Health, Policies and Procedures for Federally Qualified Health Center Services and Rural Health Clinic Services, p. 23, (Jan. 1, 2024). (Accessed Jan 2024).

Dialysis Services

Dialysis facilities are eligible originating sites for dialysis services.

SOURCE: GA Dept. of Community Health, GA Medicaid Telemedicine Guidance Handbook, p. 40 (Jan. 1, 2024).  & GA Dept. of Community Health, GA Medicaid Dialysis Services Handbook, p. 17 (IX-10). (Jan. 1, 2024) (Accessed Jan  2024).

Nursing Facility Specialized Services

Nursing facilities can be eligible sites for nursing facility specialized services.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 45 (Jan. 1, 2024). & GA Dept. of Community Health, Nursing Facility Services, p. H-7 (p. 223). (Jan. 1, 2024). (Accessed Jan 2024).

School-Based Settings (Local Education Agencies)

Telehealth services are allowed in school-based settings upon enrollment into COS 600.  The following requirements must be met:

• The provider is an authorized health-care provider enrolled in Georgia Medicaid
• The client is a child who is receiving the service in a primary or secondary school-based setting
• The parent or legal guardian of the client provides consent before the service is provided

Telehealth services provided in a school-based setting are also a benefit if the referring provider delegates provision of services to a nurse practitioner, clinical nurse specialist, physician assistant, or other licensed specialist as long as the above-mentioned providers are working within the scope of their professional license and within the scope of their delegation agreement with the provider.

The school must enroll as a Health Check Provider in order to bill the telehealth originating site facility fee.

LEAs must submit an Attestation Form for the provision of telehealth services.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 50 (Jan. 1, 2024)., GA Dept. of CommunityHealth, Childrens Intervention School Services (Jan. 1, 2024), p. 9. (Accessed Jan 2024).

GEOGRAPHIC LIMITS

No Reference Found

FACILITY/TRANSMISSION FEE

Originating sites are paid an originating site facility fee.  Hospitals are eligible to receive reimbursement for a facility fee for telehealth when operating as the originating site. There is no separate reimbursement for telehealth serves when performed during an inpatient stay, outpatient clinic or emergency room visit or outpatient surgery, as these are all-inclusive payments.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 12 (Jan. 1, 2024). (Accessed Jan 2024).

Community Behavioral Health and Rehabilitation Services

Originating fees (as referenced in some of the other Georgia Medicaid programs) are not offered for telemedicine when utilized in the CBHRS category of service. Telemedicine costs are attributed to the services intervention rates.

SOURCE: GA Dept. of Community Health: Community Behavioral Health and Rehabilitation Services, p. 99 (Jan. 1, 2024),  GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 33 (Jan. 1, 2024). (Accessed Jan 2024).

School-Based Settings (Local Education Agencies)

LEAs that enroll as Health Check providers to serve as telehealth originating sites only will be allowed to bill the originating site facility fee. The telehealth originating facility fee is reimbursed at the current DEFAULT rate.

SOURCE: GA Dept. of Community Health, GA Medicaid Telemedicine Guidance Handbook, p. 50-1 (Jan. 1, 2024).  & GA Dept. of Community Health, Children’s Intervention Services, p. 46 (Jan. 1, 2024) GA Dept. of CommunityHealth, Childrens Intervention School Services (Jan. 1, 2024), p. 9. (Accessed Jan 2024).

Ambulance Providers

Ambulances may bill a separate origination site fee. The Telehealth originating fee (Q3014) cannot be billed in combination with other rendered EMS services.

SOURCE: GA Dept. of Community Health, GA Medicaid Telemedicine Guidance Handbook, p. 21 (Jan. 1, 2024). & Emergency Ambulance Services Handbook p. 17 (Jan. 1, 2024). (Accessed Jan 2024).

Dialysis Services

The originating facility/site (Dialysis Facility) will bill with the revenue code and procedure codes listed in the manual.

SOURCE: GA Dept. of Community Health, GA Medicaid Telemedicine Guidance Handbook, p. 40 (Jan. 1, 2024). & GA Dept. of Community Health, GA Medicaid Dialysis Services Handbook, p. IX-10 (17) (Jan. 1, 2024). (Accessed Jan 2024).

FQHC/RHC

FQHCs and RHCs that serve as an originating site for telehealth services are paid an originating site facility fee.

FQHCs and RHCs cannot bill an originating site fee and distant site fee for telehealth services on the same encounter.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 38 (Jan. 1, 2024).   GA Dept. of Community Health, GA Medicaid Federally Qualified Health Centers and Rural Health Clinics (Jan. 1, 2024), p. 23.  (Accessed Jan 2024).

EPSDT Services – Health Check Program

LEAs enrolled as Health Check providers to serve as telemedicine originating sites only will be allowed to bill the telemedicine originating site facility fee (procedure code Q3014).

SOURCE: GA Dept. of Community Health, EPSDT Services – Health Check Program, p. 70  (X-7). (Jan. 1, 2024). (Accessed Jan 2024).

Children’s Intervention Services

Originating sites are paid an originating site facility fee for telehealth services by billing procedure code Q3014.

SOURCE: GA Dept. of Community Health, Division of Medicaid, Children’s Intervention Services (Jan. 1, 2024), p. 46. (Accessed Jan. 2024).

POLICY

The State’s Medicaid managed care and fee-for-service programs shall not deny coverage for any service provided through telehealth that would be covered if the service were provided through in-person consultation between a patient and a health care provider.

(Repeal and reenactment on December 31, 2025) Reimbursement for services provided through telehealth via an interactive telecommunications system shall be equivalent to reimbursement for the same services provided via in-person contact between a health care provider and a patient; provided that reimbursement for the diagnosis, evaluation, or treatment of a mental health disorder delivered through an interactive telecommunications system using two-way, real-time audio-only communication technology shall meet the requirements of title 42 Code of Federal Regulations section 410.78.  Nothing in this section shall require a health care provider to be physically present with the patient at an originating site unless a health care provider at the distant site deems it necessary.

SOURCE: HI Revised Statutes § 346-59.1 (a & b).  Amended by HB 907 HD2 SD 2 (Repeal date of December 31, 2025).  (Accessed Feb. 2024).

Reimbursement for services provided through telehealth via an interactive telecommunications system shall be equivalent to reimbursement for the same services provided via in-person contact between a health care provider and a patient; provided that reimbursement for two-way, real-time audio-only communication technology for purposes of diagnosis, evaluation, or treatment of a mental health disorder to a patient in the patient’s home shall be equivalent to eighty per cent of the reimbursement for the same services provided via in-person contact between a health care provider and a patient.

To be reimbursed for telehealth via an interactive telecommunications system using two-way, real-time audio-only communication technology in accordance with this subsection, the health care provider shall first conduct an in-person visit or a telehealth visit that is not audio only, within six months prior to the initial audio-only visit, or within twelve months prior to any subsequent audio-only visit.  The telehealth visit required prior to the initial or subsequent audio-only visit in this subsection shall not be provided using audio-only communication.  Nothing in this section shall require a health care provider to be physically present with the patient at an originating site unless a health care provider at the distant site deems it necessary.

SOURCE: HI Revised Statutes § 431:10A-116.3(c).  Amended by HB 907 HD2 SD 2 (Repeal date of December 31, 2025).  (Accessed Feb. 2024).

Interactive audio and video telecommunication systems must be used. Interactive telecommunications systems must be multi-media communications that, at a minimum, include audio and video equipment, permitting real-time consultation among the patient, consulting practitioner, and referring practitioner. Telephones, facsimile machines, and electronic mail systems do not meet the requirements of interactive telecommunications system. As a condition of payment the patient must be present and participating in the telehealth visit.

SOURCE: Code of HI Rules 17-1737-51.1(c). (Accessed Feb. 2024). (NOTE: Recent legislation not yet reflected in Rules)

Eligible providers are health care providers who are eligible to bill Hawai’i Medicaid; practicing within their scope; and delivering services which can be appropriately and effectively administered through telehealth.

Services provided by telehealth must be appropriate for the telehealth modality, clinically appropriate for the patient, rendered in conformance with the full description of the procedure code, and performed by a health care provider eligible to bill Hawai’i Medicaid. Services provided shall be consistent with all federal and state privacy, security, and confidentiality laws.

SOURCE:  HI Dept of Human Services, Med-QUEST, Memo No. QIk-2338/FFS 23-22, CCS-2311. (Accessed Feb. 2024).

As noted in the Overview, due to the Maui fires, a public health emergency (PHE) was declared on August 8, 2023. Certain waivers were put into place for telehealth policies.  See Med-Quest Memo QI-2335A for more information.

ELIGIBLE SERVICES/SPECIALTIES

Services provided by telehealth must be appropriate for the telehealth modality, clinically appropriate for the patient, rendered in conformance with the full description of the procedure code, and performed by a health care provider eligible to bill Hawai’i Medicaid. Services provided shall be consistent with all federal and state privacy, security, and confidentiality laws.  See Attachment A in memo for list of suggested codes for live video.

SOURCE:  HI Dept of Human Services, Med-QUEST, Memo No. QI-2338/FFS 23-22, CCS-2311. (Accessed Feb. 2024).

Dentistry

The eligible codes for reimbursement will remain consistent with Memo QI-1702A (see Attachment A) with the addition of code D0145. All eligible codes are subject to the processing policies as defined in Chapter 14 of the Medicaid Dental Provider Manual.

CDT code D9999 must be used to identify the claim for PPS payment by FQHCs and RHCs.

SOURCE: HI Med-QUEST Medicaid Provider Manual: Dental, pg. 108 (Jan. 2023). CTR 19-01 Reimbursement for Procedures Related to FQHC Teledentistry Services (Under FFS-1901). HI Dept of Human Services, Med-QUEST, Memo No. QI-2338/FFS 23-22, CCS-2311. (Accessed Feb. 2024).

Applied Behavioral Analysis & Autism Spectrum Disorder

Applied behavioral analysis services (including family adaptive behavior treatment guidance) can be provided through telehealth.  MedQuest provides some areas of consideration when approving ABA services through telehealth (see memo). Memo QI 2301/FFS 23-01 Updates policy.

SOURCE: QI-2020 (Jun. 17, 2020), HI Med-Quest memo QI-2301/FFS 23-01.(January 13, 2023) (Accessed Feb. 2024).

Federally Qualified Health Centers

Providers who are eligible to bill for Hawaii Medicaid services are also eligible providers who can bill for telehealth.  Eligible services will be consistent with Memo QI-1702A and FFS 19-01.  See memo for specific billing scenarios.  Memo QI- 2139/FFS 21-15 replaces Memo QI-1702A.  See Attachment C in QI-2338/FFS 23-22, CCS-2311.

SOURCE: Med-QUEST Memo 20-07 (Mar. 16, 2020), QI-2139 Tele-Health Law (Act 226, SLH 2016) Implementation (Replaces QI-1702A) HI Dept of Human Services, Med-QUEST, Memo No. QI-2338/FFS 23-22, CCS-2311. (Accessed Feb. 2024).

QUEST Integration Health Plans & Community Case Management Agencies

Assessments and re-assessments may be conducted using telehealth and telecommunications technology only if an in-person interaction is not an option and should only be used on an exception basis. In-person interactions with members using appropriate safety precautions is the current expectation. Where possible, members at greatest risk and need should be prioritized to receive in-person interactions before members at lower risk and need.

The health plan must document the reason for conducting an interaction using a technology option.

SOURCE: Memo QI-2107A (April 29, 2021). (Accessed Feb. 2024).

Chronic Hepatitis C Infection

An in-person or telehealth/phone visit may be scheduled, if needed, for patient support, assessment of symptoms, and/or new medications.

SOURCE:  HI Med-Quest Memo QI-2227/FFS 22-08 (December 30, 2022). (Accessed Feb. 2024).

ELIGIBLE PROVIDERS

Eligible providers are health care providers who are eligible to bill Hawai’i Medicaid; practicing within their scope; and delivering services which can be appropriately and effectively administered through telehealth.

SOURCE:  HI Dept of Human Services, Med-QUEST, Memo No. QI-2338/FFS 23-22, CCS-2311. (Accessed Feb. 2024).

Dentistry

Dental providers who are eligible to bill Hawaii Medicaid are also eligible to bill for telehealth for specific services (see Dental Manual Attachment A for details).  The criteria for eligible dental providers are the same regardless whether or not telehealth is utilized (e.g., DDS or DMD).

SOURCE: HI Med-QUEST Medicaid Provider Manual: Dental, pg. 108-109 (Jan. 2023) & MedQuest Memo, Reimbursement for Procedures Related to Teledentistry Services, FFS No. 19-01, Mar. 13, 2019. (Accessed Feb. 2024).

Federally Qualified Health Centers

Providers who are eligible to bill for Hawaii Medicaid services are also eligible to bill for telehealth. Refer to HRS §346-53.64 (5) for the list of providers who may provide PPS services. See Attachment C in QI-2338/FFS 23-22, CCS-2311.

SOURCE: Med-QUEST FFS Memo 20-03 (Mar. 16, 2020), HI Med-QUEST Medicaid Provider Manual: Federally Qualified Health Centers, Chapter 21 (21.2.1),pg. 2 , HI Dept of Human Services, Med-QUEST, Memo No. QI-2338/FFS 23-22, CCS-2311. (Accessed Feb. 2024).

ELIGIBLE SITES

All providers prescribing controlled substances must be located in the State of Hawai’i. Until December 31, 2024, Federally Qualified Health Center (FQHC) behavioral health providers may be located at a non-HRSA approved site or satellite within the United States and the United States’ territories. If the FQHC provider is prescribing controlled substances, they must be located in the State of Hawai’i.

Originating/Spoke Site – The location where the patient is located, whether accompanied or not by a health care provider, at the time services are provided by a health care provider through telehealth, including but not limited to a health care provider’s office, hospital, critical access hospital, rural health clinic, federally qualified health center, a patient’s home, and other nonmedical environments such as schoolbased health centers, university-based health centers, or the work location of the patient. The originating site includes a patient’s residence. The U.S. Department of Health and Human Services Office for Civil Rights expects that patients should not receive telehealth services in public or semi-public settings, absent patient consent or exigent circumstances.

Distant/Hub Site – The location of the enrolled Hawai’i Medicaid provider delivering Medicaid eligible services through telehealth. The U.S. Department of Health and Human Services Office for Civil Rights expects health care providers will implement HIPAA safeguards and conduct telehealth in private settings, such as a doctor in a clinic or office connecting to a patient who is at home or at another clinic.

Non-FQHC Providers 

With one exception, the provider must be located within the United States and the United States’ territories is eligible to be a distant site for delivery and payment purposes. Exception: If prescribing controlled substances, the provider must be located in the State of Hawai’i.

FQHC Providers

With exceptions, the FQHC provider must be located at their contracted FQHC’s HRSA approved site or satellite.

Exceptions:

• Until December 31, 2024, FQHC behavioral health providers may be located at a non-HRSA approved site or satellite within the United States and the United States’ territories.
• If prescribing controlled substances, the provider must be located in the State of Hawai’i.

SOURCE:  HI Dept of Human Services, Med-QUEST, Memo No. QI-2338/FFS 23-22, CCS-2311. (Accessed Feb. 2024).

Eligible originating sites listed in the Administrative Rules:

• The office of a physician or practitioner
• Hospitals;
• Critical Access Hospitals;
• Rural Health Clinics;
• Federally Qualified Health Centers;
• Federal telehealth demonstration project sites.

SOURCE: Code of HI Rules 17-1737-51.1(d), p. 70  – Law passed & state plan amendment accepted prohibiting this limitation, however the prohibiting language is still present in regulation (Accessed Feb. 2024).

In statute, these locations are also included:

• A patient’s home;
• Other non-medical environments such as school-based health centers, university-based health centers, or the work location of a patient.

SOURCE: HI Revised Statutes § 346-59.1. (Accessed Feb. 2024).

Approved state plan amendment authorizes HI Medicaid to remove geographic and originating site requirements.

SOURCE: HI State Plan Amendment 16-0004. (Accessed Feb. 2024). 

Federally Qualified Health Centers:

The criteria for sites eligible to receive PPS payment is the same regardless whether or not tele-health is utilized. The services must be provided at an HRSA approved site or satellite. 5C (Other Activities/Locations) sites are not eligible to receive PPS reimbursement in Hawaii and therefore are not eligible to receive PPS for tele-health services.

The spoke (originating site) is the location where the patient is located whether accompanied or not by a health care provider through telehealth.  The originating site includes a patient’s residence.

SOURCE: HI Med-QUEST FFS Memo 20-03. (Accessed Feb. 2024).

GEOGRAPHIC LIMITS

All providers prescribing controlled substances must be located in the State of Hawai’i. Until December 31, 2024, Federally Qualified Health Center (FQHC) behavioral health providers may be located at a non-HRSA approved site or satellite within the United States and the United States’ territories. If the FQHC provider is prescribing controlled substances, they must be located in the State of Hawai’i.

Originating/Spoke Site – The location where the patient is located, whether accompanied or not by a health care provider, at the time services are provided by a health care provider through telehealth, including but not limited to a health care provider’s office, hospital, critical access hospital, rural health clinic, federally qualified health center, a patient’s home, and other nonmedical environments such as schoolbased health centers, university-based health centers, or the work location of the patient. The originating site includes a patient’s residence. The U.S. Department of Health and Human Services Office for Civil Rights expects that patients should not receive telehealth services in public or semi-public settings, absent patient consent or exigent circumstances.

Distant/Hub Site – The location of the enrolled Hawai’i Medicaid provider delivering Medicaid eligible services through telehealth. The U.S. Department of Health and Human Services Office for Civil Rights expects health care providers will implement HIPAA safeguards and conduct telehealth in private settings, such as a doctor in a clinic or office connecting to a patient who is at home or at another clinic.

Non-FQHC Providers 

With one exception, the provider must be located within the United States and the United States’ territories is eligible to be a distant site for delivery and payment purposes. Exception: If prescribing controlled substances, the provider must be located in the State of Hawai’i.

FQHC Providers

With exceptions, the FQHC provider must be located at their contracted FQHC’s HRSA approved site or satellite.

Exceptions:

• Until December 31, 2024, FQHC behavioral health providers may be located at a non-HRSA approved site or satellite within the United States and the United States’ territories.
• If prescribing controlled substances, the provider must be located in the State of Hawai’i.

SOURCE:  HI Dept of Human Services, Med-QUEST, Memo No. QI-2338/FFS 23-22, CCS-2311. (Accessed Feb. 2024).

Telehealth services may only be provided to patients if they are presented from an originating site located in either:

• A federally designated Rural Health Professional Shortage Area;
• A county outside of a Metropolitan Statistical Area;
• An entity that participates in a federal telemedicine demonstration project.

SOURCE: Code of HI Rules 17-1737.-51.1. (Accessed Feb. 2024). – Law passed (HI Statute Section 346-59.1(c) & state plan amendment accepted prohibiting this limitation, however the prohibiting language is still present in regulation.)

Approved state plan amendment authorizes HI Medicaid to remove geographic and originating site requirements.

SOURCE: HI State Plan Amendment 16-0004. (Accessed Feb. 2024). 

Teledentistry

The criteria for eligible dental sites are the same regardless whether or not telehealth is utilized.

SOURCE: HI Med-QUEST Medicaid Provider Manual: Dental, pg. 108 (Jan. 2023) (Accessed Feb. 2024).

FACILITY/TRANSMISSION FEE

No reference found.

POLICY

Services delivered through virtual care will be considered for reimbursement when rendered within the provider’s scope of practice and billed according to all applicable administrative rules, policy, federal and state regulations. Any covered service may be delivered via virtual care when:

• The service can be safely and effectively delivered via virtual care and the medium utilized;
• The service fully meets the code definition when provided via virtual care;
• The service is billed with the FQ or GT modifier; and
• All other existing coverage criteria are met.

Video must be provided in real-time with full motion video and audio that delivers high-quality video images that do not produce lags, choppy, blurry, or grainy images, or irregular pauses in communication. Transmission of voices must be clear and audible. Reimbursement is also not available for services that are interrupted and/or terminated early due to equipment difficulties.

SOURCE: Idaho Medicaid Provider Handbook.  General Information and Requirements for Providers.  (Jan. 30, 2024), Section 9.12 & 9.12.1 p. 133-134. Idaho MedicAide (May 2023).  (Accessed Feb. 2024).

Services delivered via virtual care as defined in Title 54, Chapter 57, Idaho Code, must be identified as such in accordance with billing requirements published in the Idaho Medicaid Provider Handbook. Virtual care  services billed without being identified as such are not covered. Virtual care services may be reimbursed within limitations defined by the Department in the Idaho Medicaid Provider Handbook. Fee-for-service reimbursement is not available for asynchronous services except remote monitoring.

SOURCE: ID Administrative Code 16.03.09 Sec. 210 (09), Pg. 25 (Accessed Feb. 2024).

For Home Health, the face-to-face encounter that initiates treatment may occur virtually.

SOURCE: ID Administrative Code 16.03.09 Sec. 723 (02)(b), Pg. 101, ID Medicaid Provider Handbook: Home Health and Hospice Services, 1.2.4.1, p. 6. (Mar. 2, 2021). (Accessed Feb. 2024).

ELIGIBLE SERVICES/SPECIALTIES

Any covered service may be delivered via virtual care when:

• The service can be safely and effectively delivered via virtual care and the medium utilized;
• The service fully meets the code definition when provided via virtual care;
• The service is billed with the FQ or GT modifier; and
• All other existing coverage criteria are met.

Reporting of test results only is not covered as a telehealth service.

Only one eligible provider may be reimbursed per service per participant per date of service. No reimbursement is available for the use of equipment at the originating or remote sites. Reimbursement is also not available for services that are interrupted and/or terminated early due to equipment difficulties. Claims for services delivered via virtual care will be reimbursed at the same rate as face-to-face services.

Idaho Medicaid uses places of service 02 (Telehealth provided other than in patient’s home) and 10 (Telehealth provided in patient’s home). Providers must use these places of service on claims for virtual care. Claims for virtual care must include one of the following modifiers:

• FQ – A telehealth service was furnished using real-time audio-only communication technology.
• GT – A telehealth service was furnished using real-time audio-visual communication technology.

Additionally, providers can also use the following modifier in conjunction with one of the above:

• FR – A supervising practitioner was present through a real-time two-way, audio/video communication technology.

SOURCE:  Idaho Medicaid Provider Handbook. General Information and Requirements for Providers.  (Jan. 30, 2024), Sections 9.12 & 9.12.3 p. 133-134, Idaho MedicAide May 2023.  (Accessed Feb. 2024).

Physician/Non-Physician Practitioner Services:

Stand-alone vaccine counseling is also reimbursable when delivered as virtual care services.

Services in the National Diabetes Prevention Program are eligible for telehealth.

Physicians and non-physician practitioners are eligible to receive reimbursement for telehealth services.

Physicians and psychiatric nurse practitioners may provide psychotherapy (CPT® 90839 and 90840) to participants in crisis via telehealth.  The medical record of the participant must support a crisis service was provided for the full duration billed and demonstrate that an urgent assessment of the participant’s mental state was necessary, and/or their health or safety was at risk. The participant must be in the room for the duration of the visit or a majority of the service, which is focused on the individual. 90839 is a stand-alone code not to be reported with psychotherapy or psychiatric diagnostic evaluation codes, the interactive complexity code, or any other psychiatry section code.

SOURCE: ID Medicaid Provider Handbook: Physician and Non-Physician Practitioner (Aug 8, 2023), p. 51, 57, 78, 85. (Accessed Feb. 2024).

Children with Developmental Disabilities

Children’s DD Telehealth services are reimbursable if provided and billed in accordance with the General Information and Requirements for Providers, Idaho Medicaid Provider Handbook.

SOURCE: ID Medicaid Provider Handbook Agency Professional (Feb. 22, 2023), p. 28. (Accessed Feb. 2024).

Therapy Services (Occupational, Physical Therapists & Speech Language Pathologists)

Covered telehealth services are real-time communication through interactive technology that enables a provider and a patient at two locations separated by distance to interact simultaneously through two-way video and audio transmission. Evaluations and reevaluations may be provided by virtual care. The therapist must certify that the services can safely and effectively be done with virtual care services and the physician or non-physician practitioner order must specifically allow the services to be provided by virtual care services. Therapists must adhere to all requirements of their licensing board for virtual care services.

Specific service codes found in manual.

SOURCE:  ID Medicaid Provider Handbook, Therapy Services (Jan. 30, 2024) pg 37 , (Accessed Feb. 2024).

Psychiatric Crisis

Physicians and psychiatric nurse practitioners may provide psychotherapy (CPT® 90839 and 90840) to participants in crisis via virtual care.  The medical record of the participant must support a crisis service was provided for the full duration billed and demonstrate that an urgent assessment of the participant’s mental state was necessary, and/or their health or safety was at risk. The participant must be in the room for the duration of the visit or a majority of the service, which is focused on the individual. 90839 is a stand-alone code not to be reported with psychotherapy or psychiatric diagnostic evaluation codes, the interactive complexity code, or any other psychiatry section code.

SOURCE: ID Medicaid Provider Handbook: Physician and Non-Physician Practitioner (Jan. 30, 2024), p. 78. (Accessed Feb. 2024).

Laboratory Services

To be reimbursable, drug tests must be ordered by a licensed or certified healthcare professional who has performed a face-to-face evaluation of the participant (this may include telehealth if the requirements of the telehealth policy are met).

SOURCE: ID Medicaid Provider Handbook: Laboratory Services (Aug 8, 2023), p. 22. (Accessed Feb. 2024).

Eye and Vision Services

Vision therapy is not covered for group therapy, telehealth or with home computer programs.

SOURCE: ID Medicaid Provider Handbook: Eye and Vision Services (Jan. 8, 2024), p. 54.  (Accessed Feb. 2024).

Early Intervention Services (IDEA)

Medicaid reimburses for early intervention services in accordance with Medicaid established rates and reimbursement methodology. The ITP must provide virtual care servcies in accodance with the Idahol Medicaid Provider Handbook.

SOURCE: SOURCE:  Idaho Medicaid Provider Handbook. General Information and Requirements for Providers. 9.9.7, p. 128 (Jan. 30, 2024), (Accessed Feb. 2024).

Interpretative Services

Idaho Medicaid will reimburse for interpretation, translation, Braille and sign language services provided to participants in person or through virtual care. Reimbursement is also available when interpretive services are provided to the parent or guardian of a child under 18. The service is only eligible for reimbursement if the provider has no alternative means of oral or written communication. No additional reimbursement is available for multilingual providers that share a language with the participant. Interpreters and translators must meet state and professional licensure requirements and be at least eighteen years of age. See the Virtual Care Services section for more information about reimbursement eligibility using virtual care services.

SOURCE: SOURCE:  Idaho Medicaid Provider Handbook. General Information and Requirements for Providers. 9.10.3, p. 129 (Jan. 30, 2024), (Accessed Feb. 2024).

ELIGIBLE PROVIDERS

Only one eligible provider may be reimbursed for the same service per participant per date of service.

SOURCE:  Idaho Medicaid Provider Handbook. General Information and Requirements for Providers. (Jan 30, 2024), Sections 9.12.3 p. 134, Idaho MedicAide (May 2023).  (Accessed Feb. 2024).

Idaho Medicaid therapy services, see manual for specific codes.

SOURCE: ID Medicaid Provider Handbook, Therapy Services (Jan. 30, 2024) pg 37  (Accessed Feb. 2024).

Physicians and psychiatric nurse practitioners may provide psychotherapy to participants in crisis via telehealth, using CPT 90839 and 90840.

Physicians and non-physician practitioners are eligible to receive reimbursement for telehealth services.

SOURCE: ID Medicaid Provider Handbook, Physician and Non-Physician Practitioner.  Sec. 4.34.3, Pg. 78, (4.38) 85. (Feb. 2, 2024), (Accessed Feb. 2024).

FQHCs, RHCs & IHS

Telehealth services provided as an encounter by a facility are reimbursable if the services are delivered in accordance with the Idaho Medicaid Telehealth Policy and applicable handbooks.

FQHC, RHC or IHS providers should not report the GT or FQ modifier with encounter code T1015 but should include it with each applicable supporting codes.

SOURCE:  ID Medicaid Provider Handbook: IHS, FQHC, and RHC Services, (Nov. 18, 2022), p. 30. Idaho Medicaid Provider Handbook. General Information and Requirements for Providers.  (Jan. 30, 2024), Sections 9.12.3 p. 134, Idaho MedicAide (May 2023).  (Accessed Feb. 2024).

ELIGIBLE SITES

Idaho Medicaid uses places of service 02 (Telehealth provided other than in patient’s home) and 10 (Telehealth provided in patient’s home). Providers must use these places of service on claims for virtual care. Claims for virtual care must include one of the following modifiers:

• FQ – A telehealth service was furnished using real-time audio-only communication technology.
• GT – A telehealth service was furnished using real-time audio-visual communication technology.

SOURCE:  Idaho Medicaid Provider Handbook. General Information and Requirements for Providers.  (Jan. 30, 2024), Sections 9.12.3 p. 134, Idaho MedicAide May 2023.  (Accessed Feb. 2024).

Idaho Medicaid reduces physician and non-physician practitioner reimbursement when certain procedures are provided in a facility setting. For these procedure codes there is a 30 percent reduction for physicians, and a 40 percent reduction for non-physician practitioners, of the Idaho Medicaid Numerical Fee Schedule in the following places of service (POS) including POS 02 Telehealth (Not recognized by Idaho Medicaid).

SOURCE: Idaho Medicaid Provider Handbook: Physician and Non-Physician Practitioner. 9.2, p. 129. (Feb. 2, 2024).  (Accessed Feb. 2024).

GEOGRAPHIC LIMITS

No Reference Found

FACILITY/TRANSMISSION FEE

Therapy Services

Therapy services covered via virtual care are listed in the table below. Reimbursement is according to the numerical fee schedule. There is no additional fee for either the originating or the distant site.

SOURCE:  ID Medicaid Provider Handbook, Therapy Services (Jan. 30, 2024) pg 37 (Accessed Feb. 2024).

POLICY

Recent Legislation Effective Jan. 1, 2024

The Department and any managed care plans under contract with the Department for the medical assistance program shall provide for coverage of mental health and substance use disorder treatment or services delivered as behavioral telehealth services as specified in this Section. The Department and any managed care plans under contract with the Department for the medical assistance program may also provide reimbursement to a behavioral health facility that serves as the originating site at the time a behavioral telehealth service is rendered.

SOURCE: SB 1913 (2023) & Illinois 305 ILCS 5/5-47 (Accessed Feb. 2024).

The Department of Healthcare and Family Services shall reimburse psychiatrists, federally qualified health centers as defined in Section 1905(l)(2)(B) of the federal Social Security Act, clinical psychologists, clinical social workers, advanced practice registered nurses certified in psychiatric and mental health nursing, and mental health professionals and clinicians authorized by Illinois law to provide behavioral health services to recipients via telehealth.  The Department shall reimburse epilepsy specialists, as defined by the Department by rule, who are authorized by Illinois law to provide epilepsy treatment services to persons with epilepsy or related disorders via telehealth. The Department, by rule, shall establish: (i) criteria for such services to be reimbursed, including appropriate facilities and equipment to be used at both sites and requirements for a physician or other licensed health care professional to be present at the site where the patient is located; however, the Department shall not require that a physician or other licensed health care professional be physically present in the same room as the patient for the entire time during which the patient is receiving telehealth services; (ii) a method to reimburse providers for mental health services provided by telehealth; and (iii) a method to reimburse providers for epilepsy treatment services provided by telehealth.

SOURCE: 305 ILCS 5/5-5.25.(b) (Accessed Feb. 2024).

Health insurance providers must include coverage for licensed dietitians, nutritionists, and diabetes educators who counsel diabetes patients, via telehealth, in the patients’ homes to remove the hurdle of transportation for patients to receive treatment.

SOURCE: 215 ILCS 5/356z.22.(g) (Accessed Feb. 2024).

Illinois Medicaid will reimburse for live video under the following conditions:

• A physician or other licensed health care professional or other licensed clinician, mental health professional or qualified mental health professional must be present with the patient at all times with the patient at the originating site;
• The distant site provider must be a physician, physician assistant, podiatrist or advanced practice nurse who is licensed by Illinois or the state where the patient is located.  For telepsychiatry, it must be a physician who has completed an accredited general psychiatry residency program or an accredited child and adolescent psychiatry residency program;
• The originating and distant site provider must not be terminated, suspended or barred from the Department’s medical programs;
• Telepsychiatry: The distant site provider must personally render the telepsychiatry service;
• Medical data may be exchanged through a telecommunication system.  For telepsychiatry it must be an interactive telecommunication system;
• The interactive telecommunication system must, at a minimum, have the capability of allowing the consulting distant site provider to examine the patient sufficiently to allow proper diagnosis of the involved body system.  The system must also be capable of transmitting clearly audible heart tones and lung sounds, as well as clear video images of the patient and any diagnostic tools, such as radiographs;
• Telepsychiatry:  Group psychotherapy is not a covered telepsychiatry service.

SOURCE: IL Admin. Code Title 89, 140.403(b). (Accessed Feb. 2024). 

For telemedicine services, a physician or other licensed health care professional must be present at all times with the patient at the originating site.

For telepsychiatry services, a staff member meeting the minimum qualifications of a mental health professional (MHP) must be present at all times with the patient at the originating site.

When medically appropriate, more than one Distant Site provider may bill for services rendered during the telehealth visit.

Enrolled distant site providers may not seek reimbursement from the Department for their services when the originating site is an encounter clinic. The originating site encounter clinic is responsible for reimbursement to the distant site provider.

SOURCE: IL Dept. of Healthcare and Family Svcs., Handbook for Practitioners. Ch. A-200 Policy and Procedures, 220.5.7 p. 26-27, (June 2021). (Accessed Feb. 2024).

See regulations for requirements during a public health emergency.

SOURCE: IL Admin. Code, Title 89,140.403. (Accessed Feb. 2024). 

ELIGIBLE SERVICES/SPECIALTIES

Appropriate CPT codes must be billed with the GT modifier for telemedicine and telepsychiatry services and the appropriate Place of Service code, 02, telehealth. Enrolled distant site providers may not seek reimbursement from the Department for their services when the originating site is an encounter clinic. The originating site encounter clinic is responsible for reimbursement to the distant site provider. Non-enrolled providers rendering services as a distant site provider shall not be eligible for reimbursement from the Department, but may be reimbursed by the originating site provider from their facility fee payment.

SOURCE: IL Dept. of Healthcare and Family Svcs., Handbook for Practitioners. Ch. A-200 Policy and Procedures, 220.5.7 p. 26, (June 2021),  IL Dept. of Healthcare and Family Svcs, Handbook for Podiatric Services, Ch F-200 Policy and Procedures 220.6.2, p. 27. (Oct. 2016). (Accessed Feb. 2024).

See Encounter Clinic Services Appendices and Handbook Supplement (Sept. 2020) for billing examples.

SOURCE: Handbook for Encounter Clinic Services, Chapter D-200, Sept. 23, 2020 (Accessed Feb. 2024).

There is no reimbursement for group psychotherapy as a telepsychiatry service.

SOURCE: IL Admin. Code Title 89, 140.403. (Accessed Feb. 2024).

Modifier GT – identifies telehealth interactions using both audio and video telecommunications systems.

Modifier 93 (Effective with dates of service beginning July 1, 2022) – identifies telehealth interactions using an audio-only telecommunications system.

The system updates allow providers to bill a service with modifier “GT” or “93” and a service without modifier “GT” or “93” for the same customer, same date of service, and same procedure code and get reimbursed for both services.

SOURCE: Provider Notice Rate Adjustment and Telehealth Billing Guidance (Jan. 9, 2023). (Accessed Feb. 2024).

Interprofessional Consultation for Psychiatric Services

Certain procedure codes for interprofessional consultation is allowed for the delivery of psychiatric services. See memo for codes.

SOURCE: IL HFS Provider Notice (Feb. 3, 2023).  (Accessed Feb. 2024).

Recent Legislation Effective Jan. 1, 2024

Mental Health and Substance Use Disorder

For purposes of reimbursement, the Department and any managed care plans under contract with the Department for the medical assistance program shall reimburse a behavioral health care professional or behavioral health facility for behavioral telehealth services on the same basis, in the same manner, and at the same reimbursement rate that would apply to the services if the services had been delivered via an in-person encounter by a behavioral health care professional or behavioral health facility. This subsection applies only to those services provided by behavioral telehealth that may otherwise be billed as an in-person service.

SOURCE: SB 1913 (2023) & Illinois 305 ILCS 5/5-47 (Accessed Feb. 2024).

Podiatry

Codes and billing examples for podiatry services.

SOURCE: Handbook for Podiatric Services (Appendices), Appendix F-6 (p. 35). (Accessed Feb. 2024).

Home Health Services

A face-to-face encounter may occur through telehealth.

SOURCE: IL Dept. of Healthcare and Family Svcs., Handbook for Home Health Services. Ch. R-200 Policy and Procedures, R-205.1 p. 19, (May 2016). IL Dept. of Healthcare and Family Svcs., Handbook for Care Coordination and Support Organization Provider (Oct. 5, 2022), p. 31.  (Accessed Feb. 2024).

POS 10 is a new place of service code that specifies a distant site telehealth service rendered to a patient who is located in their home. It does not replace POS 02. The description for POS 02 has been changed to, “Telehealth Provided Other than in Patient’s Home” and it is still a valid distant site telehealth service POS code. POS 10, when applicable, should be submitted for claims with dates of service beginning April 1, 2022.

SOURCE: Provider Notice Issued 3/21/22: Modifier 93 and Place of Service Code 10 Implementation. (Accessed Feb. 2024).

Community Based Behavioral Services

Effective with dates of service beginning October 1, 2021, providers delivering services via audio or video communication must utilize the appropriate telehealth POS code, consistent with Section 207.3.7, when billing for services.  Providers submitting claims for ‘on-site’ services that include services rendered both by telehealth and face-to-face must exclude the telehealth services from the “roll up” combination of on-site units. Rather, services delivered via telehealth must be billed with the appropriate telehealth modifier (GT or 93) and POS (02 or 10) on a service line separate from other ‘rolled up’ on-site services rendered face-to-face to the same recipient for the same procedure code and modifier combination.

Providers billing a service that was performed via audio or video communication must append the procedure code with appropriate modifier and POS to indicate telehealth as the mode of service delivery.  This coding is needed for HFS to track the mode of service delivery. The modifier and place of service codes are for reporting purposes only and do not affect current payment methodology.  Additional telehealth modifiers and POS have been adopted effective with dates of service beginning July 1, 2022. The table below provides guidance to providers utilizing telehealth on the appropriate telehealth modifiers and POS based upon the date of service. (See manual for additional information).

The new billing instructions apply to any service being billed as a telehealth service, whether it is:

• A code identified in the Community Based Behavioral Services Handbook that historically could be provided via phone and/or video delivery modes independent of the current public health emergency, or
• A behavioral health service allowed via telehealth per the current public health emergency telehealth policy stated in the March 20, 2020 provider notice. This list of codes includes the following services from the CBS Fee Schedule: 96110, 96112, 96127 and H1000.

SOURCE: Medicaid Provider Notice “Use of Modifier GT and Place of Service Code 02 to Specify Telehealth Delivery Mode for Behavioral Health Services” & IL Dept. of Healthcare and Family Svcs., Handbook for Community-Based Behavioral Services Providers, 208.3.1 pg. 23-26 (June 6, 2022). (Accessed Feb. 2024).

The Department shall reimburse epilepsy specialists, as defined by the Department by rule, who are authorized by Illinois law to provide epilepsy treatment services to persons with epilepsy or related disorders via telehealth.

SOURCE: ILCS 5/5.25, (Accessed Feb. 2024).

Department provides coverage for epilepsy treatment services via telehealth as required under Public Act 102-0207. Coverage is provided under both Medicaid fee-for-service and the managed care plans.

SOURCE: Medicaid Provider Notice “Confirmation of Reimbursement for Epilepsy Specialists via Telehealth (9/24/21)” (Accessed Feb. 2024).

Newly Passed Legislation (2023)

Telehealth services for persons with intellectual and developmental disabilities. The Department shall file an amendment to the Home and Community-Based Services Waiver Program for Adults with Developmental Disabilities authorized under Section 1915(c) of the Social Security Act to incorporate telehealth services administered by a provider of telehealth services that demonstrates knowledge and experience in providing medical and emergency services for persons with intellectual and developmental disabilities. The Department shall pay administrative fees associated with implementing telehealth services for all persons with intellectual and developmental disabilities who are receiving services under the Home and Community-Based Services Waiver Program for Adults with Developmental Disabilities.

SOURCE: SB 1298 (Passed in 2023). (Accessed Feb. 2024).

Diabetes Prevention Program (DPP) & Diabetes Self-Management Education and Support (DSMES)

DPP services are provided in-person or via telehealth/virtually during sessions that occur at regular, periodic intervals over the course of one year.

DSMES services may be provided in the home, clinic, hospital outpatient facility, via telehealth, or any other setting as authorized and include: counseling related to long-term dietary change, increased physical activity, and behavior change strategies for weight control; counseling and skill building to facilitate the knowledge, skill and ability necessary for diabetes self-care; and nutritional counseling services.

SOURCE: Medicaid Provider Notice “Billing Update for Diabetes Prevention and Management Programs (7/29/22)” (Accessed Feb. 2024).

Care Coordination and Support Organization (CCSO)

Care Coordination and Support (CCS) services are reimbursed if certain requirements met, including completing two oral communications with family within the calendar month via telephonic, video or in-person.

SOURCE:  IL Dept. of Healthcare and Family Services, Care Coordination and Support Organization Provider Handbook (Oct. 5, 2022), p. 56-57.  (Accessed Feb. 2024).

ELIGIBLE PROVIDERS

The Department of Healthcare and Family Services required to reimburse psychiatrists, federally qualified health centers, clinical psychologists, clinical social workers, advanced practice registered nurses certified in psychiatric and mental health nursing and mental health professionals and clinicians authorized by Illinois law to provide behavioral health services via telehealth.  The Department shall reimburse epilepsy specialists, as defined by the Department by rule, who are authorized by Illinois law to provide epilepsy treatment services to persons with epilepsy or related disorders via telehealth.

SOURCE: 305 ILCS 5/5.25, (Accessed Feb. 2024).

For telemedicine services, the distant site provider must be a physician, physician assistant, podiatrist, or advanced practice nurse who is licensed by the State of Illinois or by the state where the patient is located.

• Practitioner Handbook:  When medically appropriate, more than one Distant Site provider may bill for services rendered during the telehealth visit.  Enrolled distant site providers may not seek reimbursement from the Department for their services when the originating site is an encounter clinic. The originating site encounter clinic is responsible for reimbursement to the distant site provider. Non-enrolled providers rendering services as a distant site provider shall not be eligible for reimbursement from the Department, but may be reimbursed by the originating site provider from their facility fee payment.
• Podiatry Handbook:  Services rendered by an APN can be billed under the collaborating physician’s NPI, or if the APN is enrolled, under the APN’s NPI. When medically appropriate, more than one Distant Site provider may bill for services rendered during the telehealth visit.

For telepsychiatry, the distant site provider must be a physician who is licensed by the State of Illinois or by the state where the patient is located who has completed an accredited general psychiatry residency program or an accredited child and adolescent psychiatry residency program.

• Practitioner Handbook: To be eligible for reimbursement for telepsychiatry services, physicians must enroll in the correct specialty/sub-specialty in IMPACT.
• Encounter Clinic Handbook:  Telepsychiatry is not a covered service when rendered by an APN or PA.  Group psychotherapy is not a covered telepsychiatry service.

SOURCE: IL Admin. Code Title 89, 140.403(b); IL Dept. of Healthcare and Family Svcs., Handbook for Podiatrists (physician services only), F-200, F-220.6.2 p. 28 (Oct. 2016); IL Dept Of Healthcare and Family Svcs, Handbook for Providers of Podiatric Services (Oct 2016), p. 27, & Handbook for Practitioner Services. Ch. 200, 220.5.7 p. 26 (June 2021) & Handbook for Encounter Clinic Services. Ch. 200, 210.2.2 pg. 17. (Aug. 2016). (Accessed Feb. 2024).

An encounter clinic serving as the distant site shall be reimbursed as follows:

• If the originating site is another encounter clinic, the distant site encounter clinic shall receive no reimbursement from the Department.  The originating site encounter clinic is responsible for reimbursement to the distant site encounter clinic; and
• If the originating site is not an encounter clinic, the distant site encounter clinic shall be reimbursed for its medical encounter.  The originating site provider will receive a facility fee.

See Encounter Clinic Services Appendices supplement for telehealth billing examples for encounter clinics.

SOURCE: IL Admin. Code Title 89, 140.403; IL Dept. of Healthcare and Family Svcs., Expansion of Telehealth Services, Informational Notice, Jan. 1, 2010; Handbook for Encounter Clinic Services. Ch. 200, pg. 17.  Aug. 2016 & IL All Providers Handbook Supplement (Sept. 2020), pg. 43-45. (Accessed Feb. 2024).

Effective with dates of service beginning October 1, 2021, providers billing a service from the Community Based Behavioral  Services Fee Schedule that was performed via audio or video communication must append the procedure code with modifier GT and use Place of Service Code 02. This coding is needed for HFS to track the mode of service delivery. The GT modifier and Place of Service Code 02 are for reporting purposes only and do not affect current payment methodology.

The new billing instructions apply to any service being billed as a telehealth service, whether it is:

• A code identified in the Community Based Behavioral Services Handbook that historically could be provided via phone and/or video delivery modes independent of the current public health emergency, or
• A behavioral health service allowed via telehealth per the current public health emergency telehealth policy stated in the March 20, 2020 provider notice. This list of codes includes the following services from the CBS Fee Schedule: 96110, 96112, 96127 and H1000.

The following providers billing from the Community Based Behavioral Services Fee Schedule are impacted:

• Community Mental Health Centers
• Behavioral Health Clinics
• Physicians
• Licensed Clinical Psychologists
• Licensed Clinical Social Workers

SOURCE: Medicaid Provider Notice “Use of Modifier GT and Place of Service Code 02 to Specify Telehealth Delivery Mode for Behavioral Health Services” (Accessed Feb. 2024)

Local education agencies may submit telehealth services as a certified expenditure.

SOURCE: IL Admin. Code Title 89, 140.403(c)(1)(B). (Accessed Feb. 2024).

ELIGIBLE SITES

The Department shall reimburse any Medicaid certified eligible facility or provider organization that acts as the location of the patient at the time a telehealth service is rendered, including substance abuse centers licensed by the Department of Human Services’ Division of Alcoholism and Substance Abuse.

SOURCE: ILCS 5/5.25(c), (Accessed Feb. 2024).  

POS 10 is a new place of service code that specifies a distant site telehealth service rendered to a patient who is located in their home. It does not replace POS 02. The description for POS 02 has been changed to, “Telehealth Provided Other than in Patient’s Home” and it is still a valid distant site telehealth service POS code. POS 10, when applicable, should be submitted for claims with dates of service beginning April 1, 2022.

SOURCE: Provider Notice Issued 3/21/22: Modifier 93 and Place of Service Code 10 Implementation. (Accessed Feb. 2024).

For telemedicine services, a physician or other licensed health care professional must be present at all times with the patient at the originating site.

For telepsychiatry services, A physician, licensed health care professional or other licensed clinician, mental health professional (MHP), or qualified mental health professional (QMHP), must be present at all times with the patient at the originating site.

SOURCE: IL Admin. Code Title 89, 140.403(b) &  IL Dept. of Healthcare and Family Svcs., Handbook for Practitioners. Ch. A-200 Policy and Procedures, 220.5.7  p. 25, (June 2021). (Accessed Feb. 2024).

IL Healthcare and Family Services recognizes the following as valid originating sites: physician’s office, podiatrist’s office, local health department, Community Mental Health Center, Encounter Rate Clinics, and outpatient hospital.

For telepsychiatry services, a staff member meeting the minimum qualifications of a mental health professional (MHP) must be present at all times with the patient at the originating site.

SOURCE:  IL Dept. of Healthcare and Family Svcs., Handbook for Practitioners. Ch. A-200 Policy and Procedures, 220.5.7  p. 25, (June 2021). (Accessed Feb. 2024).

See handbook supplement for telehealth billing examples.

SOURCE: All Providers Handbook Supplement (Sept. 2020), pg. 43-45. (Accessed Feb. 2024). 

An encounter clinic is eligible as an originating site and is responsible for ensuring and documenting that the distant site provider meets the department’s requirements for telehealth and telepsychiatry services since the clinic is responsible for reimbursement to the distant site provider.

Enrolled distant site providers may not seek reimbursement from the Department for their services when the originating site is an encounter clinic. The originating site encounter clinic is responsible for reimbursement to the distant site provider.

See Encounter Clinic Services Appendices supplement for telehealth billing examples for encounter clinics.

SOURCE: IL Dept. of Healthcare and Family Svcs., Expansion of Telehealth Services, Informational Notice, Jan. 1, 2010; IL Dept. of Healthcare and Family Svcs., Handbook for Practitioners. (June 2021) Ch. 200, p. 25; Handbook for Podiatrists, F-200, p. 27 (Oct. 2016); & Handbook for Encounter Clinic Services. Ch. D-200, pg. 17.  Aug. 2016. (Accessed Feb. 2024).

Recent Legislation Effective Jan. 1, 2024

Mental Health and Substance Use Disorder

There shall be no restrictions on originating site requirements for behavioral telehealth coverage or reimbursement to the distant site under this Section other than requiring the behavioral telehealth services to be medically necessary and clinically appropriate.

SOURCE: SB 1913 (2023) & Illinois 305 ILCS 5/5-47 (Accessed Feb. 2024).

GEOGRAPHIC LIMITS

No Reference Found

FACILITY/TRANSMISSION FEE

Originating site providers may submit claims for a facility fee for each telehealth service encounter using HCPCS Code Q3014/Telehealth Originating Site Facility Fee.

Eligible facilities include:

• Physician’s office;
• Podiatrist’s office
• Local health departments
• Community mental health centers
• Outpatient hospitals

SOURCE: IL Handbook for Practitioners Rendering Medical Services, Ch. 200, p. 26 (June 2021) & Handbook for Podiatrists, F-200, p. 27 (Oct. 2016). (Accessed Feb. 2024).

Hospitals Billing with Revenue Code 0780 and HCPCS Code Q3014

HCPCS code Q3014 must be identified on the same revenue line with Revenue Code 0780. If any other procedure code is billed with Revenue Code 0780, the claim will be rejected with error code T55 – Missing/Invalid HCPCS for Revenue Code 0780.

Other services may be billed as necessary on the same outpatient claim with a telehealth facility fee, but the telehealth service must be identified as described in this provider notice. No modifier is required for the telehealth service.

SOURCE: Medicaid Provider Notice “Hospitals Billing as the Telehealth Originating Site”  (Mar. 2, 2021). (Accessed Feb. 2024)

Sites approved as valid originating facility sites were expanded. The March 20, 2020 notice contained a list of sites that included “providers who receive reimbursement for a patient’s room and board, including nursing facilities and Intermediate Care Facilities for the Developmentally Disabled.” For further clarification, this category would also include Family Support Program residential providers, Medically Complex Facilities for Persons with Developmental Disabilities, and Specialized Mental Health Rehabilitation Facilities.

Facility Fee Billing Instructions for Hospice Agencies:

In situations where a hospice patient in a long term care facility is in need of a telehealth service, the hospice may submit charges for the facility fee as an originating telehealth site.

Use Revenue Code 0657 in conjunction with HCPCS code Q3014 and identify the number of Service Units (telehealth occurrences) provided in the billing period.

The telehealth facility fee service cannot be billed separately and must be included on a claim containing the hospice’s usual charges.

Facility Fee Billing Instructions for Hospitals:

Hospitals are already able to bill as a non-institutional provider originating site, as stated in the Handbook for Practitioner Services, topic 202.1.4 – Allowable Fee-for-Service Charges by Hospitals.

All Other Originating Facility Sites – The Department is currently working to implement a facility fee payment system for these sites and additional information will be forthcoming.

SOURCE: Provider Notice Telehealth Expansion Billing Instructions (March 30, 2020). (Accessed Feb. 2024).

POLICY

The Indiana Health Coverage Programs (IHCP) covers select medical, dental and remote patient monitoring services delivered via telehealth. IHCP coverage is also available for the virtual delivery of certain nonhealthcare services (such as case management) for members who are eligible to receive such services. For applicable procedure codes, see Telehealth and Virtual Services Codes, accessible from the Code Sets page at in.gov/medicaid/providers.  Most telehealth services must be provided via video and audio, although a few designated telehealth services can be provided via audio only. Audio-only delivery is allowable for all nonhealthcare virtual services.

SOURCE: Indiana Health Coverage Programs, Telehealth and Virtual Services, Provider Reference Module (Nov. 1, 2023), p. 1.  (Accessed Mar. 2024).

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

SOURCE: IN Code, 12-15-5-11 (Accessed Mar. 2024).

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

SOURCE: Indiana Health Coverage Programs (IHCP) Bulletin, BT202142, June 8, 2021, (Accessed Mar. 2024).

In any telemedicine encounter, there will be the following:

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

SOURCE: IN Admin. Code, “Article 5,” Title 405, 5-38-3 & 4., p. 199 (Accessed Mar. 2024).

ELIGIBLE SERVICES/SPECIALTIES

Providers are allowed to use telehealth for the medical, dental and remote patient monitoring services listed in Telehealth and Virtual Services Codes, accessible from the Code Sets page at in.gov/medicaid/providers. The following services may not be provided using telehealth:

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

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

SOURCE: Indiana Health Coverage Programs, Telehealth and Virtual Services, Provider Reference Module (Nov. 1, 2023), p. 2-3.  Indiana Health Coverage Programs (IHCP) Bulletin, BT202142, p. 2 June 8, 2021, (Accessed Mar. 2024).

Group psychotherapy services and 2024 Annual HCPCS Codes Update – new codes added.

SOURCE: Indiana Health Coverage Programs (IHCP) Bulletin, BT202425 (Feb. 29, 2024). (Accessed Mar. 2024).

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

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

The procedure code billed must appear on the telehealth code set (Tables 1–3 of Telehealth and Virtual Services Codes, accessible from the Code Sets page at in.gov/medicaid/providers). IIn addition, an appropriate telehealth modifier may be required, depending on the type of service:

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

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

SOURCE: Indiana Health Coverage Programs, Telehealth and Virtual Services, Provider Reference Module (Nov. 1, 2023), p. 3-4  Indiana Health Coverage Programs ICHP Bulletin BT202249 (June 30, 2022). (Accessed Mar. 2024).

In December 2022, IHCP expanded and clarified telehealth coverage and note it will be effective December 9, 2022.  The updated coverage applies to all IHCP programs that offer such services – including but not limited to Healthy Indiana Plan (HIP), Hoosier Care Connect, Hoosier Healthwise and Traditional Medicaid. The telehealth and virtual services code set is used by both fee-for-service (FFS) and managed care delivery systems. This updated code set will remain in place for the remainder of 2022 and 2023, and will be reevaluated by the Office of Medicaid Policy and Planning (OMPP) at the end of 2023.

Updated Code Set as of Dec. 2022, February 2023.

Added codes found in BT202425 (Feb. 29, 2024).

SOURCE: Indiana Health Coverage Programs (IHCP) Bulletin, BT202425 (Feb. 29, 2024). IN Health Coverage Programs (IHCP) Bulletin BT 202297 (Nov 8, 2022). Past bulletins:  Indiana Health Coverage Programs (IHCP) Bulletin, BT202142, p. 2 June 8, 2021, ICHP BT2020106 Indiana Health Coverage Programs ICHP Bulletin BT 202239 (May 19, 2022).  (Accessed Mar. 2024).

As published in IHCP Bulletin BT202239, for a practitioner to receive reimbursement for telehealth services, the procedure code must be listed in the telehealth and virtual services code set, and must be a service for which the member is eligible. Additionally, the claim detail must have:

One of the following place of service (POS) codes:

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

One of the following modifiers:

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

Modifier 93 (audio-only) is allowable only for certain, designated telehealth services. Effective Dec. 9, 2022, the IHCP will allow reimbursement for the telehealth services specified in Table 1 when billed with the appropriate POS code and the audio-only modifier (93).

SOURCE: Indiana Health Coverage Programs ICHP Bulletin BT202297 (Nov 8, 2022), p. 1.  (Accessed Mar. 2024).

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

SOURCE: Medicaid Federally Qualified Health Centers and Rural Health Clinics Module, (Jan 2022 edition, published May 19, 2022), p. 4-5, (Accessed Mar. 2024).

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

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

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

SOURCE:  Indiana Health Coverage Programs, Telehealth and Virtual Services, Provider Reference Module (Nov. 1, 2023), p. 6   (Accessed Mar. 2024).

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

SOURCE: IN Code, 12-15-5-11(f) IHCP Division of Mental Health and Addiction, Adult Mental Health Habilitation Services (Oct. 1, 2023), p. 20; IHCP Division of Mental Health and Addiction, Behavioral and Primary Healthcare Coordination Service (July 1, 2023), p. 26. (Accessed Mar. 2024).

Behavioral and Primary Healthcare Coordination (BPHC) Services

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

SOURCE: Indiana Health Coverage Programs, Provider Reference Module, Behavioral and Primary Healthcare Coordination Services (October 26, 2023), p. 33, 41, 46. 71  (Accessed Mar. 2024).

Nonhealthcare Virtual Services

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

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

SOURCE: Indiana Health Coverage Programs, Telehealth and Virtual Services, Provider Reference Module (Nov. 1, 2022), p. 5 (Accessed Mar. 2024).

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

SOURCE: Indiana Health Coverage Programs IHCP Bulletin BT 202239 (May 19, 2022). (Accessed Mar. 2024).

Telehealth Dental Services

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

SOURCE: Indiana Health Coverage Programs, Telehealth and Virtual Services, Provider Reference Module (Nov. 1, 2023), p. 4, Indiana Health Coverage Programs IHCP Bulletin BT 202239 (May 19, 2022).  (Accessed Mar. 2024).

Intensive Outpatient Treatment via Telehealth

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

SOURCE: Indiana Health Coverage Programs, Telehealth and Virtual Services, Provider Reference Module (Nov. 1, 2023), p. 7 (Accessed Mar. 2024).

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

SOURCE: Indiana Health Coverage Programs IHCP Bulletin BT 202239 (May 19, 2022).  (Accessed Mar. 2024).

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

SOURCE: Indiana Health Coverage Programs, Telehealth and Virtual Services, Provider Reference Module (Nov. 1, 2023), p. 3,  (Accessed Mar. 2024).

Skills Training and Development Rendered Via Telehealth

As published in BT202249, the IHCP reimburses for H2014 – Skills training and development, per 15 minutes when the service is rendered through an audiovisual telehealth modality. Skills training and development is covered only for members who have access to Medicaid Rehabilitation Option (MRO) services. The OMPP, in partnership with the Division of Mental Health and Addiction (DMHA), developed the following service parameters for when telehealth delivery satisfies the “face-to-face” contact required for this service. Providers are expected to have these service parameters in place by Dec. 9, 2022, when rendering skills training and development via telehealth. See bulletin for additional information.

SOURCE: IHCP Expands and Clarifies Telehealth Coverage BT 202297 (Nov. 8, 2022), p. 2-3.  (Accessed Mar. 2024).

Home and Community-Based Services Waivers

Caregiver Coaching and Behavior Management provided in the home of the participant, virtually or telephonically and through Health Insurance Portability and Accountability Act (HIPAA) secure communication platforms that allow for real time and asynchronous communication between caregivers and caregiver coaches and collaboration with waiver care managers.

SOURCE: ICHP Dept of Aging Home and Community-Based Services Waivers (Jan. 1, 2023), p. 55.  (Accessed Mar. 2024).

Mobile Crisis Intervention Services

Follow-up stabilization services: Follow up contacts in-person, via phone, or telehealth up to 14 days following initial crisis intervention and can be billable up to 90 days.

SOURCE: IHCP Adding Coverage for Mobile Crisis Intervention Services BT 202364 (Jun. 15, 2023) & IHCP Bulletin ICHP Covers Mobile Intervention Services Retroactive to July 1, 2023 (Dec. 12, 2023).  (Accessed Mar. 2024).

Home Health Services

The IHCP covers telehealth services provided by home health agencies.

SOURCE: IHCP Home Health Services Module (Oct. 3, 2023), p. 8.  (Accessed Mar. 2024).

Opioid Treatment Program

POS codes 02 – Telehealth provided other than in patient’s home and 10 – Telehealth provided in patient’s home can be used when billing OTP services. It should be noted that by end of 2023, the Office of Medicaid Policy and Planning will be reevaluating the telehealth service codes. If any changes to these POS codes occur, it will be noted in a future bulletin.

SOURCE:  IHCP Bulleting BT 2023151 (Nov. 2, 2023), p. 2.  (Accessed Mar. 2024).

Behavioral and Primary Healthcare Coordination Service

Evaluations and meetings with patient maybe conducted face-to-face or with telehealth.

SOURCE: Division of Mental Health and Addiction Behavioral and Primary Healthcare Coordination Service (Oct. 26, 2023), p. 33, 46. (Accessed Mar. 2024).

Adult Mental Health Habilitation Services

Evaluations and reassessments may be conducted face-to-face or via telehealth. Certain information must be included and in some cases specific requirements must be met.  See manual for more information.

All clients being considered for telehealth services must be given the option of in-person services prior to telehealth being selected as modality.

The use of telehealth should protect against isolating participants by offering services that are in person and shall be invoked to prioritize and facilitate community integration.

Telehealth services shall consider and respond to all accessibility needs, including whether hands-on or physical assistance is needed to render the service.

Telehealth services must ensure the health and safety of the individual receiving services by adhering to all abuse, neglect and exploitation prevention practices that apply to in-person treatment, as well as by providing participants with resources on how to report incidences of abuse, neglect and exploitation.

Habilitation and support is not permissible via audio-only telehealth modalities. The IHCP reimburses for H2014 – Skills training and development, per 15 minutes (see Table 2) when the service is rendered through an audiovisual telehealth modality.

These services (specific HPCCS Codes listed on pages 70, 74, 87) cannot be delivered via audio-only telehealth per IHCP policy, but can be delivered via audiovisual telehealth. If a member has eligibility to receive these services in person through the IHCP, then they are eligible to receive these services via telehealth. For more information, see Telehealth and Virtual Services Codes, accessible from the Code Sets page at in.gov/medicaid/providers.

Adult Mental Health Habilitation (AMHH) Addiction Counseling services consist of a series of planned and organized face-to-face or telehealth, according to Indiana Administrative Code, services in which addiction professionals and other clinicians provide counseling interventions that work toward the member’s recovery goals identified in the Individualized Integrated Care Plan (IICP), as they pertain to substance use-related disorders.

T1016 – Care Coordination – If a member has eligibility to receive these services in person through the IHCP, then they are eligible to receive these services via telehealth. For more information, see Telehealth and Virtual Services Codes, accessible from the Code Sets page at in.gov/medicaid/providers. (See manual for more detail).

Adult Mental Health Habilitation (AMHH) Medication Training and Support services involve face-to-face or telehealth according to Indiana Administrative Code, services provided to the member, in an individual or group setting, for the purpose of:

• Monitoring medication compliance
• Providing education and training about medications
• Monitoring medication side effects
• Providing other nursing or medical assessment

SOURCE: Division of Mental Health and Addiction, Adult Mental Health Habilitation Services Module (Oct. 3, 2023), p. 20, 41, 56, 63-64, 70, 73, 91, 93, 95. (Accessed Mar. 2024).

Outpatient Institutional Claims for Telehealth Services

For providers that use the outpatient institutional claim (UB-04 claim form, IHCP Provider Healthcare Portal institutional claim or 837I electronic transaction), services delivered via telehealth should be billed as follows:

• If the service can be billed with a procedure code, providers should enter the procedure code and, if applicable, use the appropriate modifier (93 or 95) to indicate that the service was delivered via telehealth. POS codes are not used on outpatient claims.
• If the service cannot be billed with a procedure code (for example, procedure codes cannot be used with revenue codes 905 or 906), the service should be billed as it normally would if delivered in person. Procedure code, modifier and POS code requirements do not apply in this case. Providers are advised to mark in their patient records that the service was delivered via telehealth.

In either case, the service provided must be a one that is allowable for telehealth delivery, as indicated on the telehealth code set (Tables 1–3 of Telehealth and Virtual Services Codes, accessible from the Code Sets page at in.gov/medicaid/providers).

SOURCE: Indiana Health Coverage Programs, Telehealth and Virtual Services, Provider Reference Module (Nov. 1, 2023), p. 4-5,  (Accessed Mar. 2024).

Applied Behaviora Analysis Therapy Services via Telehealth

The IHCP provides coverage for applied behavior analysis (ABA) therapy when medically necessary for the treatment of autism spectrum disorder (ASD). All ABA therapy services require prior authorization. Besides the PA criteria outlined in the Behavioral Health Services module, procedure codes 97155 and 97156 are subject to the following additional requirements when rendered via telehealth:

• Credentialed registered behavior technicians (RBTs) may not deliver any ABA service via telehealth. Only a health service provider in psychology (HSPP) or a licensed or board-certified behavior analyst (BCBA) are eligible for using telehealth when supervising the delivery of ABA services remotely.
• Procedure code 97155 is reimbursable via telehealth only when an HSPP or BCBA is providing guidance/supervision to an RBT remotely, and the RBT is rendering adaptive behavioral treatment in person to the member.
• All ABA services must include synchronous audiovisual interaction. No ABA services are reimbursable when delivered via audio-only telehealth.

The complete list of procedure codes for applied behavior analysis therapy can be found in Behavioral Health Services Codes, accessible from the Code Sets page at in.gov/medicaid/providers. Procedure codes 97155 and 97156 are the only two ABA services that are allowable as telehealth.

For dates of service on and after Jan. 1, 2024, all ABA services must be billed with an appropriate modifier to indicate the credentials of the practitioner delivering the service. When ABA services are delivered via telehealth, modifier 95 must also be included.

SOURCE: Indiana Health Coverage Programs, Telehealth and Virtual Services, Provider Reference Module (Nov. 1, 2023), p. 8,  (Accessed Mar. 2024).

Addiction Counseling, Behavioral Health Counseling & Therapy, Medication Training and Support

Addiction Counseling may be delivered via an audiovisual telehealth modality. This service is not permissible via audio-only telehealth modalities. If behavioral health assistance needs to be rendered via audio-only telehealth modalities, the following procedure codes are reimbursable via audio-only telehealth per IHCP policy, and may be used in place of Addiction Counseling services:

H0038 – Self-help/peer service, per 15 minutes

H2011 – Crisis intervention service, per 15 minutes

See the Behavioral Health Services module for more information on the peer recovery and crisis intervention services. See the Telehealth and Virtual Services module for more information about rendering and billing for telehealth services.

Skills Training and Development may be delivered via an audiovisual telehealth modality when the following service parameters are met: • All members being considered for telehealth services must be given the option of in-person services prior to telehealth being selected as the modality. • The member must indicate that telehealth is their preferred method for receiving services. • The member must have documented acknowledgement of receipt of informed consent about risks and benefits of the telehealth modality. • Within 30 days of the first telehealth session occurring, a licensed behavioral health practitioner, HSPP or overseeing psychiatric medical professional must document verification that telehealth is thought to be an effective modality for the member based on symptoms, severity and access to services. • Use of the telehealth modality must be formally reviewed with the member every 90 days and adjusted based on need or efficacy. • If the member is not progressing or stabilizing, evaluation of how treatment will be adjusted must be documented. This adjustment may include increasing in-person sessions. • All Skills Training and Development sessions should have clearly documented connection to diagnosis and/or treatment goals. • At minimum, the member must have an in-person session with a member of the treatment team every 90 days. This session may be in the home, community or office setting. Skills Training and Development is not permissible via audio-only telehealth modalities. If behavioral health assistance needs to be rendered via audio-only telehealth modalities, the following procedure codes are reimbursable via audio-only telehealth per IHCP policy, and may be used in place of Skills Training and Development services:

• H0038 – Self-help/peer service, per 15 minutes
• H2011 – Crisis intervention service, per 15 minutes

See the Behavioral Health Services module for more information on the peer recovery and crisis intervention services. See the Telehealth and Virtual Services module for more information about rendering and billing for telehealth services.

SOURCE: IHCP Medicaid Rehabilitation Option Services, p. 10, 14, 22, 29. (Sept. 1, 2023). (Accessed Mar. 2024).

ELIGIBLE PROVIDERS

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

SOURCE: IN Code, 12-15-5-11 (Accessed Mar. 2024).

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

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

SOURCE: Indiana Health Coverage Programs, Telehealth and Virtual Services, Provider Reference Module (Nov. 1, 2023), p. 6,  (Accessed Mar. 2024).

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

SOURCE: Medicaid Federally Qualified Health Centers and Rural Health Clinics Module, Jan. 1, 2022 (published May 19, 2022), p. 4, (Accessed Mar. 2024).

Non-Eligible Providers

IHCP does not reimburse the following provider types for telemedicine:

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

SOURCE: IN Admin. Code, “Article 5” Title 405, 5-38-4, p. 200 (Accessed Mar. 2024).

ELIGIBLE SITES

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

SOURCE: Indiana Health Coverage Programs, Telehealth and Virtual Services, Provider Reference Module (Nov. 1 2022), p.1 ,  (Accessed Mar. 2024).

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

SOURCE: IN Code, 12-15-5-11 (Accessed Mar. 2024).

Per Indiana Code IC 25-1-9.5-3, “originating site” means any site at which a patient is located at the time healthcare services through telehealth are provided to the individual. Accordingly, eligible providers may be reimbursed for procedure code Q3014 when the provider location is acting as an originating site for telehealth services.

SOURCE: ICHP Expands Procedure Code Q3014 to Additional Providers BT 202332 (Apr. 25, 2023). (Accessed Mar. 2024).

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

SOURCE: IN Admin. Code, “Article 5” Title 405, 5-38-4, p. 199 (Accessed Mar. 2024).

GEOGRAPHIC LIMITS

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

SOURCE: IN Code 12-15-5-11 (Accessed Mar. 2024)

Medicaid may not require:

• A provider that is licensed, certified, registered, or authorized with the appropriate state agency or board and exclusively offers telehealth services (as defined in IC 12-15-5-11(a)) to maintain a physical address or site in Indiana to be eligible for enrollment as a Medicaid provider.
• A telehealth provider group with providers that are licensed, certified, registered, or authorized with the appropriate state agency or board to have an in-state service address to be eligible to enroll as a Medicaid vendor or Medicaid provider group.

SOURCE: IN Code 12-15-11-10 (Accessed Mar. 2024).

FACILITY/TRANSMISSION FEE

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

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

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

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

SOURCE: Indiana Health Coverage Programs, Telehealth and Virtual Services, Provider Reference Module (Nov. 1, 2023), p. 5.  (Accessed Mar. 2024).

Effective immediately, and retroactive to dates of services (DOS) on or after July 21, 2022, the following specialties under provider type 11 – Behavioral Health Provider will be able to receive reimbursement for procedure code Q3014 when their offices or facilities are acting as an originating telehealth site for members:

• 616 – Licensed Psychologist
• 617 – Licensed Independent Practice School Psychologist
• 618 – Licensed Clinical Social Worker (LCSW)
• 619 – Licensed Marriage and Family Therapist (LMFT)
• 620 – Licensed Mental Health Counselor (LMHC)
• 621 – Licensed Clinical Addiction Counselor (LCAC)

SOURCE: ICHP Expands Procedure Code Q3014 to Additional Providers BT 202332 (Apr. 25, 2023). (Accessed Mar. 2024).

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

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

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

SOURCE: Indiana Health Coverage Programs IHCP Bulletin BT 202239 (May 19, 2022). IHCP Bulletin BT 202253 (July 14, 2022). (Accessed Mar. 2024).

POLICY

An in-person contact between a health care professional and a patient is not required as a prerequisite for payment for otherwise-covered services appropriately provided through telehealth in accordance with generally accepted health care practices and standards prevailing in the applicable professional community at the time the services are provided, as well as being in accordance with provisions under rule 653—13.11(147,148,272C). Health care services provided through in-person consultations or through telehealth shall be treated as equivalent services for the purposes of reimbursement

SOURCE: IA Admin Code Sec. 441, 78.55 (249A). (Accessed Apr. 2024).

Based on this rule [see above], there is no additional payment for the telehealth components of service, associated with the underlying service being rendered. Payment for a service rendered via telehealth is the same as payment made for that service when rendered in a face-to-face (i.e., in-person) setting.

SOURCE: IA Dep. of Human Services. Informational Letter No. 1815-MC-FFS, Aug. 10, 2017, (Accessed Apr. 2024).

Crisis Response Services and Subacute Mental Health Services.

Payment shall be made for time spent in face-to-face services with the member.  “Face-to-face” means services in-person or using telehealth in conformance with the federal Health Insurance Portability and Accountability Act (HIPAA) privacy rules.

SOURCE:  Iowa Dep. of Human Services.  Provider Manual.  Ch. III Provider Specific Policies.  Crisis Response Services, p. 19, May 1, 2018; Subacute Mental Health Services.  May 1, 2018, p. 9. (Accessed Apr. 2024).

ELIGIBLE SERVICES/SPECIALTIES

See approved procedure code list.

SOURCE: IA Medicaid. New Telehealth Approved Codes [see quarterly codes dropdown], 2/7/24, (Accessed Apr. 2024).

Please visit the Iowa Medicaid PHE unwind webpage for telehealth service codes continuing post-PHE. The effective date for the discontinued telehealth service codes is December 31, 2023. After this date, claims submitted with discontinued service codes, when billed as telehealth (place of service 02 or 10), will be denied.

SOURCE: IA Dep. of Human Services. Informational Letter No. 2457-MC-FFS, Jun. 2, 2023 (Effective Dec. 31, 2023), (Accessed Apr. 2024).

IA Medicaid covers teledentistry synchronous real time encounter.

SOURCE: IA Dep. of Human Services. Informational Letter No. 2124-MC-FFS, April 6, 2020, (Accessed Apr. 2024).

Please be aware that while some services such as teledentistry will continue after the PHE, billing requirements for some other services provided via telehealth may change when the PHE is lifted.

SOURCE: IA Dep. of Human Services. Informational Letter No. 2323-MC-FFS, Mar. 11, 2022 (Effective April 1, 2023), (Accessed Apr. 2023).

ELIGIBLE PROVIDERS

The following providers may serve as the distant site provider:

• Physicians
• Nurse Practitioners
• Physician Assistants
• Nurse-Midwives
• Clinical Nurse Specialists
• Certified Registered Nurse Anesthetists
• Clinical Psychologists
• Clinical Social Workers
• Federally Qualified Health Centers
• Behavioral Health Service Providers
  • Licensed Independent Social Workers
  • Licensed Master Social Workers
  • Licensed Marital and Family Therapists
  • Licensed Mental Health Counselors
  • Certified Alcohol and Drug Counselors

SOURCE:  Iowa Dep. of Human Services.  Informational Letter No. 2103-MC-FFS. (Feb. 20, 2020). (Accessed Apr. 2024).

ELIGIBLE SITES

All services delivered via telehealth must be billed with one of the following POS codes:

• 02 – telehealth provided other than in the patient’s home
  • The location where health services and health-related services are provided or received, through telecommunication technology. The patient is not located in their home when receiving health services or health-related services through telecommunication technology.
• 10 – telehealth provided in the patient’s home
  • The location where health services and health-related services are provided or received through telecommunication technology. The patient is in their home (which is a location other than a hospital or other facility where the patient receives care) when receiving health services or health related services through telecommunication technology.

As announced in IL 24573, claims submitted with service codes not included in the telehealth approved list continuing post-Public Health Emergency (PHE) and billed as telehealth (Place of service 02 or 10) after December 31, 2023 will be denied.

SOURCE:  Iowa Dep. of Human Services.  Informational Letter No. 2472-MC-FFS. (Sept. 11, 2023). (Accessed Apr. 2024).

The following locations may serve as the originating site:

• The offices of physicians and other practitioners (psychologists, social workers, behavioral health providers, habilitation services providers, and advanced registered nurse practitioners (ARNPs)).
• Hospitals
• Critical Access Hospitals
• Community Mental Health Centers
• Federally Qualified Health Centers
• Rural Health Clinics
• Area Education Agencies (AEAs) and Local Education Agencies

SOURCE:  Iowa Dep. of Human Services.  Informational Letter No. 2103-MC-FFS. (Feb. 20, 2020). (Accessed Apr. 2024).

The Centers for Medicare and Medicaid (CMS) has added a new POS for telehealth to identify when individuals are receiving services via telehealth in their homes. Iowa Medicaid will adopt this POS effective April 1, 2022. The provider will bill the applicable Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) codes with POS code 02 (telehealth) if the member is receiving services anywhere other than home. The provider will bill the applicable HCPCS/CPT codes with POS code 10 (telehealth patient in home) if the member is in their home. An originating site charge will not be applicable with a POS code 10. However, a distant site charge may be applicable.

• POS 02: Telehealth Provided Other than in Patient’s Home Descriptor: The location where health services and health-related services are provided or received, through telecommunication technology. The patient is not located in their home when receiving health services or health-related services through telecommunication technology.
• POS 10: Telehealth Provided in Patient’s Home Descriptor: The location where health services and health-related services are provided or received through telecommunication technology. The patient is located in their home (which is a location other than a hospital or other facility where the patient receives care) when receiving health services or health related services through telecommunication technology.

SOURCE: IA Dep. of Human Services. Informational Letter No. 2323-MC-FFS, Mar. 11, 2022 (Effective April 1, 2023), (Accessed Apr. 2024).

Effective March 13, 2020, the site of service differential was removed from place of service 02 (please refer to Informational Letter 1815-MC-FFS2 [see below). As discussed during the April 27, 2023, provider town hall event, the site of service differential with the place of service 02 and 10 will not be applied to telehealth claims.

SOURCE: IA Dep. of Human Services. Informational Letter No. 2457-MC-FFS, Jun. 2, 2023 (Effective Dec. 31, 2023), (Accessed Apr. 2024).

POS code 02 is defined as, “the location where health services and health related services are provided or received, through a telecommunication system”. POS code 02 is used to report that a billed service was furnished as a telehealth service from a distant site. The only portion that is considered telehealth services is when the patient was present and interacting with the distant site physician or practitioner.

An originating site is the location of a Medicaid member at the time the telehealth service is furnished. CMHCs can be an originating site. Other originating sites can include: physician offices, hospitals, and critical access hospitals (CAHs). The “telehealth” POS code (i.e., “02”) would not be used by an originating site that can bill a facility fee (i.e., Q3014), instead the originating site would continue to use the POS code that applies to the type of facility where the patient is located. Under these circumstances, a CMHC would bill POS 53 (CMHC).

CMHCs billing for services under the CMHC provider category will not have payments cut back for the SoS differential, in cases where the service is provided at POS 02 (Telehealth). Consistent with the immediately preceding paragraph, the “distant” provider would bill POS 02 for the telehealth service and the CMHC would bill POS 53. In these cases, under Medicaid, there is no separate facility bill to account for the overhead, and therefore no SoS cut would be taken, consistent with the intent of this policy.

SOURCE: IA Dep. of Human Services. Informational Letter No. 1815-MC-FFS, Aug. 10, 2017, (Accessed Apr. 2024).

GEOGRAPHIC LIMITS

No Reference Found

FACILITY/TRANSMISSION FEE

Originating sites are paid a facility fee for telehealth services. FQHCs and RHCs would not bill Q3014 as a separate service because reimbursement for the related costs would occur through the annual cost settlement process.

SOURCE:  Iowa Dep. of Human Services.  Informational Letter No. 2103-MC-FFS. (Feb. 20, 2020). (Accessed Apr. 2024).

POLICY

Insurers (including Medicaid) cannot exclude from coverage a service solely because the service is provided through telemedicine, rather than in-person contact or based upon the lack of a commercial office for the practice of medicine, when such service is delivered by a healthcare provider.

SOURCE: KS Statute Ann. § 40-2,213(b).  (Accessed Mar. 2024).

Services provided through telemedicine must be medically necessary and are subject to the terms and conditions of the individual’s health benefits plan.

Payment or reimbursement of covered healthcare services delivered through telemedicine is the payment or reimbursement for covered services that are delivered through personal contact.

SOURCE: KS Dept. of Health and Environment, Kansas Medical Assistance Program, Provider Manual, General Benefits, p.  2-32 & 33 (Jan. 2024). (Accessed Mar. 2024).

ELIGIBLE SERVICES/SPECIALTIES

Eligible services:

• Office visits;
• Individual psychotherapy;
• Pharmacological management services.

The consulting or expert provider at the distant site must bill with the 02 place of service code and will be reimbursed at the same rate as face-to-face services. The GT modifier is not required when billing for telemedicine services.

See manual for list of acceptable CPT codes as well as codes KMAP does not recognize for payment.

SOURCE: KS Dept. of Health and Environment, Kansas Medical Assistance Program, Provider Manual, General Benefits, p. 2-32 (Jan. 2024) & FQHC/RHC, 8-14 (Dec. 2023), (Accessed Mar. 2024).

Mobile Crisis Intervention (MCI):  Preference is for MCI to be provided in person, at the preferred location of the individual or family (home, school, or another community-based setting) by a LMHP. In situations where a face-to-face service by an LMHP is not viable, the medical record should reflect the reason that an LMHP was unable to respond to the crisis. If face-to-face by a clinician is not viable, the MCI in person contact could made by a peer, case manager, or other professional that would provide telemedicine access to an LMHP.

SOURCE: KS Dept. of Health and Environment, Kansas Medical Assistance Program, Provider Manual, Mental Health, p. 8-29 (Jan. 2024). (Accessed Mar. 2024).

The speech-language pathologist and audiologist may furnish appropriate and medically necessary services within their scope of practice via telemedicine.  See manual for list of codes that are deemed appropriate to be furnished via telemedicine by the American Speech-Language and Hearing Association. Codes not appearing on the tables below are not covered via telemedicine.

SOURCE: KS Dept. of Health and Environment, Kansas Medical Assistance Program, Provider Manual, General Benefits, p. 2-29 (Jan. 2024), & Rehabilitative Therapy Services, p. 8-4, (Jan. 2024). (Accessed Mar. 2024).

Kansas Medicaid does not authorize the use of telemedicine in the delivery of any abortion procedure.

SOURCE: KS Dept. of Health and Environment, Kansas Medical Assistance Program, Provider Manual, General Benefits, p. 2-33 (Jan. 2024). (Accessed Mar. 2024).

Autism Service

Parent support and training as well as Family Adjustment Counseling can be provided via telemedicine, telehealth, or other modes of video distance monitoring methods that adhere to all required HIPPA guidelines and meet the state standards for telemedicine delivery methods.  This service delivery model is subject to state program manager approval. A request submitted for this exception must include, at a minimum, three written statements from service providers in at least a 50-mile radius declining to provide services because the participant resides in a location that is so remote or far away that the provider does not have the staff to meet with the child on a continual and/or intermittent basis as needed.

SOURCE: KS Dept. of Health and Environment, Kansas Medical Assistance Program, Provider Manual, Autism Services, p. 8-5 & 8-9 (Aug. 2023). (Accessed Mar. 2024).

Intellectual/Developmentally Disabled Services

All functional assessments must be conducted in-person at a location of the individual’s choosing, or, if available, through the use of real-time interactive telecommunications equipment that includes, at a minimum, audio and video equipment. Those responsible for conducting the assessment will be flexible in accommodating the individual’s preference for the meeting location and time of assessment.

SOURCE: KS Dept. of Health and Environment, Provider Manual, HCBS Intellectual/Developmentally Disabled, p. I-1 (Mar. 2023). (Accessed Mar. 2024).

Substance Use Disorder directs providers to General Benefits manual telemedicine section.

SOURCE: KS Dept. of Health and Environment, Provider Manual, Substance Use Disorder, p. 8-10, (Mar. 2023), (Accessed Mar. 2024).

Stand-alone vaccine counseling may also be covered when provided via telehealth.

The face-to-face encounter [for home health] may occur through telehealth, as implemented by the State.

Telehealth and transportation codes are covered codes for OTP services. Please refer to the Kansas Medicaid Telehealth and Non-Emergency Medical Transportation (NEMT) policies.

SOURCE: KS Dept. of Health and Environment, Provider Manual, Professional, (Jan. 2024). (Accessed Mar. 2024).

Stand-alone vaccine counseling may also be covered when provided via telehealth.

SOURCE: KS Dept. of Health and Environment, Provider Manual, KAN Be Health EPSDT, (Dec. 2023), (Accessed Mar. 2024).

Prenatal Care At Risk Enhanced Care Coordination

Effective with dates of service on and after May 1, 2023, procedure code H1002 will be covered for telemedicine for video and audio transmissions. Existing provisions for the delivery of this service will remain in effect. Place of service (POS) code 10 (telehealth services provided in patient’s home) will be covered for code H1002.

SOURCE: KS Department of Health and Environment, KMAP Bulletin 23051, Prenatal Care At Risk Enhanced Care Coordination, Mar. 2023, (Accessed Mar. 2024).

Lactation Counseling

Effective with dates of service on or after April 1, 2023, lactation counseling services (utilizing procedure code S9443) for nonphysician lactation counselors will be additionally covered via telemedicine. Both video and audio transmissions will be covered. The home setting is allowed for this service delivery. Existing provisions for the delivery of this service will remain in effect until specifically rescinded.

Telemedicine Place of Service (POS) codes include:

• 02 – Telehealth
• 10 – Telehealth in patient home

SOURCE: KS Department of Health and Environment, KMAP Bulletin 23042, Lactation Counseling Via Telemedicine, Feb. 2023 & KS Dept. of Health and Environment, Provider Manual, Professional, (Jan. 2024). (Accessed Mar. 2024).

HCBS Appendix K

The service delivery options that will continue after November 11 include the following: …

A Remote Option for Receiving Services:

• Members will be able to receive some in-home services through tele-video. The State is currently working to receive approval from the federal government for this. Managed Care Organization (MCO) Care Coordinators will provide members more information when this option is approved.

SOURCE: KMAP General Bulletin 23302 HCBS Appendix K – COVID Measure Rescinding (PHE Changes Ending), Nov. 2023, (Accessed Mar. 2024).

Non-Waiver Mental Health Attendant Care Service

Telehealth services are excluded from the EVV process for Non-Waiver Mental Health Attendant Care. Centers will continue to submit claims for Non-Waiver Mental Health Attendant Care until otherwise instructed.

SOURCE: KMAP General Bulletin 23326 Non-Waiver Mental Health Attendant Care Service Code – EVV Implementation Resuming, Dec. 2023, (Accessed Mar. 2024).

ELIGIBLE PROVIDERS

Telemedicine services may be delivered by a healthcare provider, which includes:

• Physicians
• Licensed Physician Assistants
• Licensed Advanced Practice Registered Nurses
• Or person licensed, registered, certified, or otherwise authorized to practice by the behavioral sciences regulatory board.

SOURCE: KS Dept. of Health and Environment, Kansas Medical Assistance Program, Provider Manual, General Benefits, p. 2-31 (Jan. 2024), (Accessed Mar. 2024).

The speech-language pathologist and audiologist may furnish appropriate and medically necessary  services within their scope of practice via telemedicine. As documented in related telemedicine policies, telemedicine claims at the distant site must contain place of service 02 (Telehealth distant site).

• Distant site means a site at which the healthcare provider is located while providing healthcare services by means of telemedicine.

SOURCE: KS Dept. of Health and Environment, Kansas Medical Assistance Program, Provider Manual, General Benefits, p. 2-29 (Jan. 2024),; Early Childhood Intervention Fee-for-Service Provider Manual, p. 8-5 (Feb. 2023); Local Education Agency Services, p. 8-7 (Feb 2023); & Rehabilitative Therapy Services, p. 8-4, (Jan. 2024). (Accessed Mar. 2024).

Providers who are not RHC or FQHC providers and are acting as the distant site will be reimbursed in accordance with a percentage of the Physician Fee Schedule and not an encounter rate.

SOURCE: KS Dept. of Health and Environment, Kansas Medical Assistance Program, Provider Manual, FQHC/RHC, 8-14, (Dec. 2023), (Accessed Mar. 2024).

ELIGIBLE SITES

The speech-language pathologist and audiologist may furnish appropriate and medically necessary services within their scope of practice via telemedicine.  Providers at the originating site may submit claims using code Q3014 (Telehealth originating site facility fee).

• Originating site means a site at which a patient is located at the time healthcare services are provided by means of telemedicine. The facilitator at the originating site must have the appropriate skill set to safely assist the speech-language pathologist or audiologist to provide safe, effective, and medically necessary services via telemedicine.

SOURCE: KS Dept. of Health and Environment, Kansas Medical Assistance Program, Provider Manual, General Benefits, p. 2-29 (Jan. 2024), & Rehabilitative Therapy Services, p. 8-5, (Jan. 2024). (Accessed Mar. 2024).

Adding Place of Service Code 10 to Home Telehealth Nursing Services

Effective with dates of processing on and after January 1, 2022, licensed practical nurses (LPNs) or registered nurses (RNs) that provide home telehealth services must use Place of Service (POS) code 10 for codes T1030 and T1031 on all claims.

SOURCE: KS Department of Health and Environment, KMAP Bulletin 23033, Adding Place of Service Code 10 to Home Telehealth Nursing Services, Feb. 2023, (Accessed Mar. 2024).

Intensive Individual Support (IIS) Providers

Intensive Individual Support (IIS) providers may now bill under the following POS codes:…

• 02 – Telehealth Provided Other Than in Patients Home
• 10 – Telehealth Provided in Patients Home

See bulletin for other POS codes.

SOURCE: KS KMAP General Medicaid Bulletin 23211, Aug. 2023, (Accessed Mar. 2024).

CCBHC

The allowable Place of Service (POS) codes for HCPCS code H0040 are defined to provide clarity on coverage:

• 02 – Telehealth Provided Other Than in Patients Home
• 10 – Telehealth Provided in Patients Home

SOURCE: KS KMAP General Medicaid Bulletin 24005, Jan. 2024, (Accessed Mar. 2024).

GEOGRAPHIC LIMITS

No Reference Found

FACILITY/TRANSMISSION FEE

The originating site, with the member present, may bill code Q3014 with the appropriate POS code.  Providers at the originating site are required to submit claims using code Q3014 (Telehealth originating site facility fee).

Speech-Language Pathology

Originating site means a site at which a patient is located at the time healthcare services are provided by means of telemedicine. The facilitator at the originating site must have the appropriate skill set to safely assist the speech-language pathologist or audiologist to provide safe, effective, and medically necessary services via telemedicine.

SOURCE: KS Dept. of Health and Environment, Kansas Medical Assistance Program, Provider Manual, General Benefits, p. 2-29 (Jan. 2024), & Rehabilitative Therapy Services, p. 8-5, (Jan. 2024). (Accessed Mar. 2024).

RHC/FQHC

The originating site, with the member present, may bill code Q3014 with POS code 50 or 72 under the originating site provider ID and location number.

SOURCE: KS Dept. of Health and Environment, Kansas Medical Assistance Program, RHC/FQHC Fee-for-Service Provider Manual, Benefits & Limitations, p. 8-14 (Dec. 2023), (Accessed Mar. 2024).

Certified Community Behavioral Health Clinic (CCBHC) Services

The originating site, with the member present, may bill code Q3014 with the appropriate POS code. No payment will be made for Q3014 if the originating telemedicine site is place of service “home” (POS code 12) without the physical presence of a provider.

SOURCE:  KS Dept. of Health and Environment, Kansas Medical Assistance Program, FFS Provider Manual, Certified Community Behavioral Health Clinic (CCBHC) Services, (Jan. 2024). (Accessed Mar. 2024).

POLICY

The department must reimburse an eligible telehealth care provider for a telehealth service in an amount that is at least 100 percent of the amount for a comparable in-person service. A managed care plan may establish a different rate for telehealth reimbursement via contract.

Any recipient, upon being offered the option of an asynchronous or audio-only telehealth visit, shall have the opportunity or option to request to be accommodated by that provider in an in-person encounter or synchronous telehealth encounter.

SOURCE: KY Admin. Regs. Title, 907, 3:170. (Accessed Mar. 2024).

A request for reimbursement shall not be denied solely because:

• An in-person consultation between a Medicaid-participating practitioner and a patient did not occur; or
• A Medicaid-participating provider employed by a rural health clinic, federally qualified health center, or federally qualified health center look-alike was not physically located on the premises of the clinic or health center when the telehealth service or telehealth consultation was provided.

SOURCE: KY Revised Statute Sec. 205.559. (Accessed Mar. 2024).

The Department for Medicaid Services and any managed care organization with whom the department contracts for the delivery of Medicaid services shall not:

• Require a Medicaid provider to be physically present with a Medicaid recipient, unless the provider determines that it is medically necessary to perform those services in person;
• Require prior authorization, medical review, or administrative clearance for telehealth that would not be required if a service were provided in person;
• Require a Medicaid provider to be employed by another provider or agency in order to provide telehealth services that would not be required if that service were provided in person;
• Require demonstration that it is necessary to provide services to a Medicaid recipient through telehealth;
• Restrict or deny coverage of telehealth based solely on the communication technology or application used to deliver the telehealth services; or
• Require a Medicaid provider to be part of a telehealth network.

Nothing in this section shall be construed to require the Medicaid program or a Medicaid managed care organization to:

• Provide coverage for telehealth services that are not medically necessary; or
• Reimburse any fees charged by a telehealth facility for transmission of a telehealth encounter.

The cabinet, in implementing Sections 2 and 3 of this Act, shall maintain telehealth policies and guidelines to providing care that ensure that Medicaid-eligible citizens will have safe, adequate, and efficient medical care, and that prevent waste, fraud, and abuse of the Medicaid program.

SOURCE: KY Revised Statute Sec. 205.5591, (Accessed Mar. 2024).

As appropriate for the service, provider, and recipient, utilize the following modalities of communication delivered over a secure communications connection that complies with the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA).

• Live or real-time audio and video synchronous telehealth technology;
• Asynchronous store-and-forward telehealth technology;
• Remote patient monitoring using wireless devices, wearable sensors, or implanted health monitors;
• Audio-only telecommunications systems; or
• Clinical text chat technology when:
  • Utilized within a secure, HIPAA compliant application or electronic health record system; and

• • Meeting:
    • The scope of the provider’s professional licensure; and
    • The scope of practice of the provider; and
    • Comply with the following federal laws to prevent waste, fraud, and abuse relating to telehealth:
      • False Claims Act, 31 U.S.C. § 3729-3733;
      • Anti-Kickback Statute, 42 U.S.C. § 1320a-7b(b); and
      • Physician Self-Referral, Section 1877 of the Social Security Act

SOURCE:  KY 900 KAR 12:005 (Accessed Mar. 2024).

ELIGIBLE SERVICES/SPECIALTIES

The Cabinet for Health and Family Services and any managed care organization with whom the Department for Medicaid Services contracts for the delivery of Medicaid services shall provide Medicaid reimbursement for covered telehealth services and telehealth consultations, if the telehealth service or telehealth consultation:

• Is provided by a Medicaid-participating practitioner, including those employed by a home health agency licensed pursuant to KRS Chapter 216, to a Medicaid recipient or another Medicaid-participating practitioner at a different physical location; and
• Meets all clinical, technology, and medical coding guidelines for recipient safety and appropriate delivery of services established by the Department for Medicaid Services or the provider’s professional licensure board.

SOURCE: KY Revised Statute Sec. 205.559.  (Accessed Mar. 2024).

Telehealth service means any service that is provided by telehealth that is one of the following:

• Event
• Encounter
• Consultation, including a telehealth consultation
• Visit
• Store-and-forward transfer, as limited by Section 6
• Remote patient monitoring
• Referral
• Treatment

A telehealth service shall not be reimbursed by the department if:

• It is not medically necessary;
• The equivalent service is not covered by the department if provided in an in-person setting; or
• The telehealth care provider of the telehealth service is:
  • Not currently enrolled in the Medicaid Program pursuant to 907 KAR 1:672;
  • Not currently participating in the Medicaid Program pursuant to 907 KAR 1:671;
  • Not in good standing with the Medicaid Program;
  • Currently listed on the Kentucky DMS Provider Terminated and Excluded Provider List, which is available at https://chfs.ky.gov/agencies/dms/dpi/pe/Pages/terminated.aspx;
  • Currently listed on the United States Department of Health and Human Services, Office of Inspector General List of Excluded Individuals and Entities, which is available at https://oig.hhs.gov/exclusions/;
  • Otherwise prohibited from participating in the Medicaid program in accordance with 42 C.F.R. Part 455; or
  • Not physically located within the United States or a United States territory at the time of service.

A telehealth service shall be subject to utilization review for:

• Medical necessity;
• Compliance with this administrative regulation; and
• Compliance with applicable state and federal law.

The department shall not reimburse for a telehealth service if the department determines that a telehealth service is not:

• Medically necessary:
• Compliant with this administrative regulation;
• Applicable to this administrative regulation; or
• Compliant with applicable state or federal law.

The department shall recover the paid amount of a reimbursement for a previously reimbursed telehealth service if the department determines that a telehealth service was not:

• Medically necessary;
• Compliant with this administrative regulation;
• Applicable to this administrative regulation; or
• Compliant with applicable state or federal law.

SOURCE: KY Admin. Regs. Title, 907, 3:170. (Accessed Mar. 2024).

Dental  

“Direct practitioner interaction” means the billing dentist or oral surgeon is physically present with and evaluates, examines, treats, or diagnoses the recipient, unless the service can be appropriately performed via telehealth pursuant to 907 KAR 3:170.

SOURCE: KY Admin Regs. Title 907 KAR 1:126, (Accessed Mar. 2024).

Specialized Children’s Services Clinics

Certain services, such as crisis intervention, intensive outpatient program services, behavioral health therapeutic intervention, group outpatient therapy, family outpatient therapy, and peer support services consist of a one-on-one encounter between the provider and recipient conducted in-person or via telehealth as appropriate pursuant to 907 KAR 3:170.

SOURCE: KY Admin Regs. Title 907 KAR 3:160, (Accessed Mar. 2024).

If, after reviewing the allegations contained in the petition and examining the petitioner under oath, it appears to the court that there is probable cause to believe the respondent should be ordered to undergo treatment, then the court shall: …

• Cause the respondent to be examined no later than twenty-four (24) hours before the hearing date by two (2) qualified health professionals, at least one (1) of whom is a physician. The qualified health professionals: …
  • May conduct the examination required by this paragraph via telehealth as defined in KRS 211.332.

SOURCE: KY Statute Sec. 222.433, (Accessed Dec. 2023).

Rural Health Clinic

Psychological testing, crisis intervention, service planning, individual outpatient therapy, family outpatient therapy, group outpatient therapy, collateral outpatient therapy, screening, brief intervention and refers to treatment for a substance use disorder, partial hospitalization, withdrawal management services, shall:…

• Be in-person or via telehealth as appropriate pursuant to 907 KAR 3:170

Medication assisted treatment supporting behavioral health services shall be co-located within the same practicing  site as the practitioner who maintains a current waiver, as necessary, under 21 USC 823(g)(2) to prescribe buprenorphine products or via telehealth as appropriate pursuant to 907 KAR 3:170.

SOURCE: KY Admin Regs. Title 907 KAR 1:082, (Accessed Mar. 2024).

ELIGIBLE PROVIDERS

For rural health clinics, federally qualified health centers, and federally qualified health center look-alikes, reimbursement for covered telehealth services and telehealth consultations shall:

• To the extent permitted under federal law, include an originating site fee in an amount equal to that which is permitted under 42 U.S.C. sec. 1395m for Medicare-participating providers if the Medicaid beneficiary who received the telehealth service or telehealth consultation was physically located at the rural health clinic, federally qualified health center, or federally qualified health center look-alike at the time of service or consultation delivery and the provider of the telehealth service or telehealth consultation is not employed by the rural health clinic, federally qualified health center, or federally qualified health center look-alike; or
• If the telehealth service or telehealth consultation provider is employed by the rural health clinic, federally qualified health center, or federally qualified health center look-alike, include a supplemental reimbursement paid by the Department for Medicaid Services in an amount equal to the difference between the actual reimbursement amount paid by a Medicaid managed care organization and the amount that would have been paid if reimbursement had been made directly by the department.

SOURCE: KY Revised Statute Sec. 205.559. (Accessed Mar. 2024).

A “telehealth care provider” is a Medicaid provider who is:

• Currently enrolled as a Medicaid provider;
• Currently participating as a Medicaid provider;
• Operating within the scope of the provider’s professional licensure; and
• Operating within the provider’s scope of practice.

Also includes a community mental health center (CMHC) that is participating in the Medicaid program in compliance with 907 KAR 1:045, or 907 KAR 1:047.

SOURCE: KY Admin. Regs. Title, 907, 3:170. (Accessed Mar. 2024).

ELIGIBLE SITES

Place of service is anywhere the patient is located at the time a telehealth service is provided, and includes telehealth services provided to a patient at home or office, or a clinic, school or workplace.

SOURCE: KY Admin. Regs. Title, 907, 3:170. (Accessed Mar. 2024).

For rural health clinics, federally qualified health centers, and federally qualified health center look-alikes, reimbursement for covered telehealth services and telehealth consultations shall:

• To the extent permitted under federal law, include an originating site fee in an amount equal to that which is permitted under 42 U.S.C. sec. 1395m for Medicare-participating providers if the Medicaid beneficiary who received the telehealth service or telehealth consultation was physically located at the rural health clinic, federally qualified health center, or federally qualified health center look-alike at the time of service or consultation delivery and the provider of the telehealth service or telehealth consultation is not employed by the rural health clinic, federally qualified health center, or federally qualified health center look-alike; or
• If the telehealth service or telehealth consultation provider is employed by the rural health clinic, federally qualified health center, or federally qualified health center look-alike, include a supplemental reimbursement paid by the Department for Medicaid Services in an amount equal to the difference between the actual reimbursement amount paid by a Medicaid managed care organization and the amount that would have been paid if reimbursement had been made directly by the department.

Notwithstanding any provision of law to the contrary, neither the Department for Medicaid Services nor a Medicaid managed care organization with whom the department has contracted for the delivery of Medicaid services shall require that a health professional, as defined in KRS 205.510, or medical group maintain a physical location or address in this state to be eligible for enrollment as a Medicaid provider if the provider or group exclusively offers services via telehealth as defined in KRS 211.332.

SOURCE: KY Revised Statute Sec. 205.559. (Accessed Mar. 2024).

GEOGRAPHIC LIMITS

No Reference Found

FACILITY/TRANSMISSION FEE

For rural health clinics, federally qualified health centers, and federally qualified health center look-alikes, reimbursement for covered telehealth services and telehealth consultations shall to the extent permitted under federal law, include an originating site fee in an amount equal to that which is permitted under 42 U.S.C. sec. 1395m for Medicare-participating providers if the Medicaid beneficiary who received the telehealth service or telehealth consultation was physically located at the rural health clinic, federally qualified health center, or federally qualified health center look-alike at the time of service or consultation delivery and the provider of the telehealth service or telehealth consultation is not employed by the rural health clinic, federally qualified health center, or federally qualified health center look-alike.

SOURCE: KY Revised Statute Sec. 205.559. (Accessed Mar. 2024).

POLICY

Louisiana Medicaid only reimburses the distant site for services provided via telemedicine. Reimbursement for services provided by telemedicine/telehealth is at the same level as services provided in person.

The beneficiary’s clinical record must include documentation that the service was provided through the use of telemedicine/telehealth. NOTE: The distant site provider must be enrolled as a Louisiana Medicaid provider to receive reimbursement for covered services rendered to Louisiana Medicaid beneficiaries.

Medicaid covered services provided using telemedicine must be identified on claim submissions by appending the modifier “95” to the applicable procedure code and indicating the correct place of service, either POS 02 (other than home) or 10 (home). Both the correct POS and the -95 modifier must be present on the claim to receive reimbursement

SOURCE: LA Dept. of Health, Professional Svcs. Provider Manual, Chapter Five of the Medicaid Svcs. Manual, Section 5.1, p. 165-166 (as issued 6/27/22). (Accessed Feb. 2024).

Telemedicine/telehealth is the use of an interactive audio and video telecommunications system to permit real time communication between a distant site health care practitioner and the beneficiary. There is no restriction on the originating site (i.e., where the beneficiary is located) and it can include, but is not limited to, a healthcare facility,  school, or the beneficiary’s home.

Medicaid covered services provided via telehealth/telemedicine shall be identified on claim submissions by appending the Health Insurance Portability and Accountability Act (HIPAA) of 1996 compliant place of service (POS) or modifier to the appropriate procedure code, in line with current policy

SOURCE: LA Admin. Code 50: Sec. 501 & 503, p. 36 (Accessed Feb. 2024).

The MCO shall reimburse the distant site provider for services provided via telemedicine/telehealth. Reimbursement for services provided by telemedicine/telehealth is at the same level as services provided in person.

The MCO shall require the provider to include in the enrollee’s clinical record documentation that the service was provided through the use of telemedicine/telehealth.

The distant site provider must be enrolled as a Louisiana Medicaid provider to receive reimbursement for covered services rendered to Louisiana Medicaid enrollees.

SOURCE: MCO Manual (updated 2/2/24), pg. 176, (Accessed Feb. 2024).

ELIGIBLE SERVICES/SPECIALTIES

The department shall periodically review policies regarding Medicaid reimbursement for telehealth services to identify variations between permissible reimbursement under that program and reimbursement available to healthcare providers under the Medicare program.

The department may modify its administrative rules, policies, and procedures applicable to Medicaid reimbursement for telehealth services as necessary to provide for a reimbursement system that is comparable to that of the Medicare program for those services.

SOURCE: LA Statute RS 40:1255.2 (Accessed Feb. 2024). 

When otherwise covered, services located in the Telemedicine appendix of the CPT manual, or its successor, may be reimbursed when provided by telemedicine/telehealth. In addition, other specified services may be reimbursed when provided by telemedicine/telehealth and these services are explicitly noted in this manual.

SOURCE: LA Dept. of Health, Professional Svcs. Provider Manual, Chapter Five of the Medicaid Svcs. Manual, Section 5.1, p. 165. (as issued 6/27/22). (Accessed Feb. 2024).

In the event that the federal or state government declares an emergency or disaster, the Medicaid Program may temporarily cover services provided through the use of an interactive audio telecommunications system, without the requirement of video, if such action is deemed necessary to ensure sufficient services are available to meet beneficiaries’ needs.

SOURCE: LA Admin Code, Sec. 50:I.505, (Accessed Feb. 2024).

When otherwise covered, the MCO shall cover services located in the Telemedicine appendix of the CPT manual, or its successor, when provided by telemedicine/telehealth. In addition, the MCO shall cover other services provided by telemedicine/telehealth when indicated as covered via telemedicine/telehealth in Medicaid program policy. The MCO shall ensure adequate availability of telemedicine/telehealth during declared emergencies, disasters, and pandemics. Physicians and other licensed practitioners must continue to adhere to all existing clinical policy for all services rendered. Providing services through telemedicine/telehealth does not remove or add any medical necessity requirements.

SOURCE: MCO Manual (revised 2/2/24, pg. 175, (Accessed Feb. 2024).

Treatment-in-place ambulance services

Effective for dates of service on or after May 12, 2023, the Louisiana Medicaid Program provides coverage for initiation and facilitation of telehealth services by qualified Louisiana Medicaid enrolled ambulance providers.

SOURCE:  LA Admin Code, Title 50, Part IX, Subpart 1, Ch. 13, Sec. 1301, p. 336 (Accessed Feb. 2024).

A physician directed treatment-in-place service is the facilitation of a telehealth visit by an ambulance provider.

Each paid treatment-in-place ambulance claim must have a separate and corresponding paid treatment-in-place telehealth claim, and each paid treatment-in-place telehealth claim must have a separate and corresponding paid treatment-in-place ambulance claim or a separate and corresponding paid ambulance transportation claim. Reimbursement for both an emergency transport to a hospital and an ambulance treatment-in-place service for the same incident is not permitted.

SOURCE: LA Dept. of Health, Medical Transportation, Sec. 10.8, (As issued on 9/25/23), (Accessed Feb. 2024).

Payment of treatment-in-place ambulance services is restricted to those identified on the Physician Directed Ambulance Treatment-in-Place Fee Schedule and edit claims for non-payable procedure codes as follows:

• If a treatment-in-place ambulance claim is billed with mileage, the entire claim document shall be denied;
• If an unpayable procedure code, that is not mileage, is billed on a treatment-in-place ambulance claim, only the line with the unpayable code will be denied;
• Claims for allowable telehealth procedure codes must be billed with procedure code G2021. The G2021 code shall be accepted, paid at $0.00, and used by the transportation provider to identify treatment-in-place telehealth services; and
• As with all telehealth claims, providers must include POS identifier “02” or “10” and modifier “95” with their claim to identify the claim as a telehealth service. Providers must follow CPT guidance relative to the definition of a new patient versus an established patient.

See valid treatment in place ambulance claim modifier list.

If an enrollee being treated-in-place has a real-time deterioration in their clinical condition necessitating immediate transport to an emergency department, as determined by the ambulance provider (i.e., EMT or paramedic), telehealth provider, or enrollee, the MCO may not reimburse for both the treatment-in-place ambulance service and the transport to the emergency department. In this situation, the MCO shall reimburse for the emergency department transport only. The MCO shall require ambulance providers to submit pre-hospital care summary reports when ambulance treatment-in-place and ambulance transportation claims are billed for the same enrollee with the same date of service.

If an enrollee is offered treatment-in-place services but declines the services, ambulance providers should include procedure code G2022 on claims for ambulance transportation to an emergency department. Use of this informational procedure code is optional and does not affect the establishment of medical necessity of the service or reimbursement of the ambulance transportation claim. The G2022 code shall be accepted, paid at $0.00, and used by the MCO to identify enrollee refusal of treatment-in-place services.

The MCO shall restrict payment of treatment-in-place telehealth services to those identified on the Treatment-in-Place Telehealth Services Fee Schedule.

SOURCE: MCO Manual (revised 2/2/24), pg. 88-89, & LA Dept. of Health, Medical Transportation, Sec. 10.8, (As issued on 9/25/23), (Accessed Feb. 2024).

Behavioral Health Services

Assessments, evaluations, individual psychotherapy, family psychotherapy, and medication management services [CPST allowed in Rehabilitation Services section and services allowed within intensive outpatient or outpatient treatment may be provided in Addiction Services section] may be reimbursed when provided via telecommunication technology when the following criteria is met:

1. The telecommunication system used by physicians and LMHPs must be secure, ensure member confidentiality, and be compliant with the requirements of the Health Insurance Portability and Accountability Act (HIPAA);
2. The services provided are within the practitioner’s telehealth scope of practice as dictated by the respective professional licensing board and accepted standards of clinical practice;
3. The member’s record includes informed consent for services provided through the use of telehealth;
4. Services provided using telehealth must be identified on claims submission using by appending the modifier “95” to the applicable procedure code and indicating the correct place of service, either POS 02 (other than home) or 10 (home). Both the correct POS and the 95 modifier must be present on the claim to receive reimbursement;
5. Assessments and evaluations conducted by an LMHP through telehealth should include synchronous, interactive, real-time electronic communication comprising both audio and visual elements unless clinically appropriate and based on member consent; and
6. Providers must deliver in-person services when telehealth is not clinically appropriate or when the member requests in-person services.

LMHP’s providing assessments, evaluations, individual psychotherapy, family psychotherapy, and medication management services offered within Opioid treatment programs may be reimbursed when conducted via telecommunication technology. The LMHP is responsible for acting within the telehealth scope of practice as decided by the respective licensing board. The provider must bill the procedure code (CPT codes) with modifier “95”, as well as the correct place of service, either POS 02 (other than home) or 10 (home). Reimbursement will be at the same rate as a face-to-face service. Exclusions: Methadone admission visits conducted by the admitting physician within OTPs are not allowed via telecommunication technology.

SOURCE: LA Dept. of Health and Hospitals, Behavioral Health Services, Chapter Two of the Medicaid Svcs. Manual, Section 2.3, p. 112, 198 & 269 (As issued 1/12/24). (Accessed Feb. 2024).

Parent-Child Interaction Therapy

Fidelity is then directly assessed via the following requirement: Applicants must have their treatment sessions observed by a certified PCIT Trainer. Observations may be conducted in real time (e.g., live or online/telehealth) or through video recording

Dialectical Behavioral Therapy

As an outpatient therapy service delivered by licensed practitioners, allowed modes of delivery include individual, family, group, on-site, off-site, and tele-video. Telehealth delivery is allowed if it includes synchronous, interactive, real-time electronic communication comprising both audio and visual elements.

A comprehensive DBT program is typically provided in an outpatient setting. Telehealth is an allowed modality, and use of telehealth for DBT skills training groups in particular may support continued and consistent client engagement, especially when travel or transportation is a barrier to client engagement.

Components of DBT may be delivered, with some adaptation, in a residential or inpatient setting; however, this would not be billed as a separate service, instead would be part of the active treatment plan reimbursed as part of the comprehensive inpatient or psychiatric residential treatment facility (PRTF) rate

SOURCE: LA Dept. of Health and Hospitals, Behavioral Health Services, Chapter Two of the Medicaid Svcs. Manual, Section 2.3, 460 (As issued 1/12/24). (Accessed Feb. 2024).

Ambulance Providers – Managed Care Organizations

Physician directed treatment-in-place service is the facilitation of a telehealth visit by an ambulance provider.  Each paid treatment-in-place ambulance claim must have a separate and corresponding paid treatment-in-place telehealth claim, and each paid treatment-in-place telehealth claim must have a separate and corresponding paid treatment-in-place ambulance claim or a separate and corresponding paid ambulance transportation claim. The MCO may not reimburse for both an emergency transport to a hospital and an ambulance treatment-in-place service for the same incident.

SOURCE: LA Medicaid Managed Care Organization (MCO) Manual, p. 88 (Updated 2/2/24), & LA Dept. of Health, Medical Transportation, Sec. 10.8, (As issued on 9/25/23), (Accessed Feb. 2024).

Early and Periodic Screening, Diagnostics and Treatment Health Services (EPSDT)

Permissible Telecommunications Systems:

• All services eligible for telemedicine/telehealth may be delivered via an interactive audio/video telecommunications system;
• A secure, HIPAA-compliant platform is preferred, if available. However, for the duration of the COVID-19 event, if a HIPAA-compliant system is not immediately available at the time it is needed, providers may use everyday communications technologies such as cellular phones with widely available audio/video communication platforms;
• Providers should follow guidance from the Office for Civil Rights at the Department of Health and Human Services for software deemed appropriate for use during this event;
• For the duration of the COVID-19 event, in cases where an interactive audio/video system is not immediately available at the time it is needed, an interactive audio-only system (e.g., telephone) without the requirement of video may be employed, unless noted otherwise;
• For use of an audio-only system, the same standard of care must be met, and the need and rationale for employing an audio-only system must be documented in the clinical record; and
• Please note, some telemedicine/telehealth services described below require delivery through an audio/video system due to the clinical nature of these services. Where applicable, this requirement is noted explicitly.

Reimbursement for services delivered through telemedicine/telehealth is at the same level as reimbursement for in-person services.

Providers must indicate place of service 02 and must append modifier -95.

SOURCE: LA Dept. of Health, Provider Manual, Chapter Twenty of the Medicaid Svcs. Manual, Section 20.1, p. 19-20 (As issued 9/7/23). (Accessed Feb. 2024).

Consultations are to be face-to-face contact in one-on-one sessions. These are services for which a parent would otherwise seek medical attention at a physician or health care provider’s office. Telemedicine/telehealth is not a covered service, but is an applicable service delivery method. When otherwise covered by Louisiana Medicaid, telemedicine/telehealth is allowed for all CPT codes located in Appendix P of the CPT manual. This service is available to all Medicaid individuals eligible for EPSDT.

SOURCE:  LA Admin Code, Title 50, Part XV, Subpart 5, Ch. 95, Sec. 9503, p. 390 (Accessed Feb. 2024).

The department shall include in its Medicaid policies and procedures all of the following information relating to telehealth:

• An exhaustive listing of the covered healthcare services which may be furnished through telehealth.
• Processes by which providers may submit claims for reimbursement for healthcare services furnished through telehealth.
• The conditions under which a managed care organization may reimburse a provider or facility that is not physically located in this state for healthcare services furnished to an enrollee through telehealth.

ELIGIBLE PROVIDERS

Distant site means the site at which the physician or other licensed practitioner is located at the time the services are provided.

The distant site provider must be enrolled as a Louisiana Medicaid provider to receive reimbursement for covered services rendered to Louisiana Medicaid beneficiaries.

SOURCE: LA Dept. of Health, Professional Svcs. Provider Manual, Chapter Five of the Medicaid Svcs. Manual, Section 5.1, p. 165 (As issued on 6/27/22) (Accessed Feb. 2024).

Distant site means the site at which the physician or other licensed practitioner is located at the time the telehealth services are provided.

SOURCE:  Behavioral Health Services, Chapter Two of the Medicaid Svcs. Manual, Section 2.3, p. 112, 171, & 198 (As issued 1/12/24). (Accessed Feb. 2024).

Rural health clinics (RHC) and federally qualified health clinics (FQHC): Reimbursement for these services will be at the all-inclusive prospective payment rate on file for the date of service (DOS).

SOURCE: LA Dept. of Health, Informational Bulletin 20-1. (May 20, 2022). (Accessed Feb. 2024).

FQHC manual refers to provider manual for billing instructions for telemedicine services.

SOURCE: LA Dept. of Health, Federally Qualified Health Centers Provider Manual, Chapter 22, Sec. 22.4, pg. 33, (As issued on Jun. 30, 2022) & Rural Health Clinic Manual, Chapter 40, Sec. 40.4, pg. 33 (As issued on Jun. 30, 2022). (Accessed Feb. 2024).

Distant Site: The distant site refers to where the provider is located. The preferred location of a distant site provider is in a healthcare facility. However, if there is disruption to a healthcare facility or a risk to the personal health and safety of a provider, there is no formal limitation as to where the distant site provider can be located, as long as the same standard of care can be met.

SOURCE: LA Dept. of Health, EPSDT Health and IDEA Related Services, Ch. 20, Sec. 20.1, (As issued on 9/7/23), (Accessed Feb. 2024).

Treatment-in-place ambulance services

Ambulance providers interested in offering physician directed treatment-in-place telehealth services must complete the following:

• enroll as a CMS ET3 model participant;
• enter into a partnership with a qualified, Louisiana Medicaid enrolled healthcare provider to furnish treatment-in-place telehealth services to Louisiana Medicaid beneficiaries; and
• notify the Department of Health of its partnerships with each telehealth provider.
• Reimbursement for initiation and facilitation of telehealth services shall be made according to the established physician directed treatment-in-place telehealth service fee schedule or billed charges, whichever is the lesser amount.

Initiation and facilitation of physician directed treatment-in-place telehealth services are performed by Louisiana Medicaid enrolled ambulance providers on site, with no transport, using audio and video telecommunications systems that permit real-time communication between a qualified, Medicaid enrolled, licensed medical practitioner and the beneficiary.

All services provided by ambulance providers during the initiation and facilitation of the physician directed treatment-in-place intervention are covered by the associated BLS-E, emergency base rate, or the ALS1-E, Level 1 emergency base rate.

Ambulance providers are not eligible to submit a claim for reimbursement or receive payment for other services (except for supplies) at the scene.

If a beneficiary must be transported to an emergency department (ED) due to poor internet connection, which resulted in a failed physician directed treatment-in-place encounter, or the beneficiary’s condition deteriorates, the ambulance provider may submit a claim for reimbursement and receive compensation for the transport to the ED, but not for initiation and facilitation of the telehealth service.

The entity seeking reimbursement for the corresponding physician directed treatment-in-place telehealth service must be an enrolled Louisiana Medicaid provider.

Reimbursement to the ambulance providers for initiation and facilitation of the physician directed treatmentin-place telehealth service requires a corresponding treatment-in-place telehealth service. The corresponding treatment-in-place telehealth service is demonstrated via a Louisiana Medicaid paid treatment-in-place telehealth service claim.

SOURCE:  LA Admin Code, Title 50, Part IX, Subpart 1, Ch. 13, Sec. 1301-1305, p. 336 (AccessedFeb. 2024).

Valid rendering providers are licensed physicians, advanced practice registered nurses, and physician assistants.

SOURCE: MCO Manual (revised 2/2/24), pg. 89, & LA Dept. of Health and Hospitals, Medical Transportation, Sec. 10.8, (As issued on 9/25/23), (Accessed Feb. 2024).

School Based Health Centers provide convenient access to preventive and acute care services for students who might otherwise have limited or no access to health care. This care may be provided onsite or through telehealth.

SOURCE: LA Admin Code, Title 50, Park XV, Subpart 5, Ch. 91, pg. 388 (Accessed Feb. 2024).

ELIGIBLE SITES

Originating site means the location of the Medicaid beneficiary [enrollee] at the time the services are provided. There is no restriction on the originating site and it can include, but is not limited to, a healthcare facility, school, or the beneficiary’s [enrollee’s] home.

SOURCE: LA Dept. of Health, Professional Svcs. Provider Manual, Chapter Five of the Medicaid Svcs. Manual, Section 5.1, p. 165. (As issued 6/27/22), & MCO Manual (revised 2/2/24), pg. 175, & Behavioral Health Services, Chapter Two of the Medicaid Svcs. Manual, Section 2.3, p. 171 (As issued 1/12/24). (Accessed Feb. 2024).

The Centers for Medicare and Medicaid Services (CMS) added a new place of service (POS) for telehealth services provided in the patient’s home effective for dates of service on and after January 1, 2022. Providers are required to use the appropriate POS, either 02 (other than home) or 10 (home) with modifier 95 for the billing of telemedicine/telehealth services based on the beneficiary’s location at the time of service.

SOURCE: LA Dept. of Health, Informational Bulletin 19-11. (May 18, 2022). (Accessed Feb. 2024).

Rural health clinics (RHC) and federally qualified health clinics (FQHC) are required to indicate the appropriate place of service, either 02 (other than home) or 10 (home), based on the beneficiary’s location at the time of and append modifier 95 for the billing of telemedicine/telehealth services. Services delivered via an audio/video system and via an audio-only system are to be coded the same way.

SOURCE: LA Dept. of Health, Informational Bulletin 20-1. (May 20, 2022). (Accessed Feb. 2024).

Originating Site: The originating site refers to where the patient is located. There is currently no formal limitation on the originating site and this can include, but is not limited to, the patient’s home.

SOURCE: LA Dept. of Health, EPSDT Health and IDEA Related Services, Ch. 20, Sec. 20.1, (As issued on 9/7/23), (Accessed Feb. 2024).

GEOGRAPHIC LIMITS

A BHS provider that is not a licensed mental health professional or a provisionally licensed mental health professional acting within his/her scope of practice may not provide telehealth services outside of its geographic service area.

SOURCE: LA Admin Code 48:I Sec. 5605, (Accessed Feb. 2024).

FACILITY/TRANSMISSION FEE

Louisiana Medicaid only reimburses the distant site provider.

SOURCE: LA Dept. of Health, Professional Svcs. Provider Manual, Chapter Five of the Medicaid Svcs. Manual, Section 5.1, p. 165 (As issued on 6/27/22). (Accessed Feb. 2024).

POLICY

If a Member is eligible for the underlying Covered Service to be delivered, and if delivery of the Covered Service via Telehealth Services is medically appropriate, as determined by the Health Care Provider, the Member is eligible for Telehealth Services.

Except as set forth herein, reimbursement will not be provided for communications between Health Care Providers when the Member is not participating.

Except as set forth herein, reimbursement will not be provided for communications solely between Health Care Providers and Members when such communications would not otherwise be billable.

Reimbursement

Services are to be billed in accordance with applicable Sections of the MBM. Providers must submit claims in accordance with Department billing instructions.

Telehealth Services are subject to all conditions and restrictions described in Chapter I, Section 1, of the MBM.

Telehealth Services are subject to co-payment requirements for the underlying Covered Service, if applicable, as established in Chapter I, Section 1, of the MBM. However, there shall be no separate co-payment for telehealth services.

Specific reimbursement rates for other telehealth services can be found in the appropriate Sections of the MBM or the MaineCare Provider fee schedules on the MaineCare Health PAS Portal.

SOURCE: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4., (Nov. 6, 2023). (Accessed Feb. 2024).

“Synchronous encounters” means a real-time interaction conducted with interactive audio or video connection between a patient and the patient’s provider or between providers regarding the patient.

SOURCE: ME Statute Sec. 22:855.3173-H, Sub. Sec. 1 (Accessed Feb. 2024).

ELIGIBLE SERVICES/SPECIALTIES

Any medically necessary MaineCare Covered Service may be delivered via Telehealth Services, provided the following requirements are met:

• The Member is otherwise eligible for the Covered Service, as described in the appropriate Section of the MBM; and
• The Covered Service delivered by Telehealth Services is of comparable quality to what it would be were it delivered in person.

Prior authorization is required for Telehealth Services only if prior authorization is required for the underlying Covered Service. In these cases, the prior authorization is the usual prior authorization for the underlying Covered Service, rather than a prior authorization for the mode of delivery. Unless otherwise required by law, a face-to-face encounter is not required prior to delivering Telehealth Services.

Non-Covered Services and Limitations

Except as set forth herein, services not otherwise covered by MaineCare are not covered when delivered via Telehealth Services.

Services covered under other MaineCare Sections but specifically excluded from Telehealth coverage include, but are not limited to the following:

• Services that require direct physical contact with a Member by a Health Care Provider and that cannot be delegated to another Health Care Provider at the site where the Member is located are not covered;
• Any service medically inappropriate for delivery through Telehealth Services – e.g. services that include providing medical procedures or administration of medications that must be conducted in person.
• Except as set forth herein, reimbursement will not be provided for communications between Health Care Providers when the Member is not participating.
• Except as set forth herein, reimbursement will not be provided for communications solely between Health Care Providers and Members when such communications would not otherwise be billable.
• The Originating Site Fee may be paid only to a Health Care Provider.

Virtual Check-In

Virtual Check-in is a brief communication where an established patient checks in with a Health Care Provider using a telephone or other telecommunications device for 5-10 minutes to determine the status of a chronic clinical condition(s) and to determine whether an office visit is needed. Modalities permitted for Virtual Check-Ins include Telephonic Services or Interactive Services to deliver clinical services at a distance for the purpose of diagnosis, disease monitoring, or treatment.

Communications exclusively by email, text, or voicemail are not reimbursable.

The Health Care Provider must document a Virtual Check-In in the Member’s record, including the length of the Virtual Check-In, an overview and outcome of the conversation, and the modality of the interaction.

If the Virtual Check-In takes place within seven (7) days after an in-person visit or triggers an in-person office visit within 24 hours (or the soonest available appointment), the Virtual Check-In is not billable under this Section.

SOURCE: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4., (Nov. 6, 2023). (Accessed Feb. 2024).

Rules adopted by the department:

• May not include any requirement that a patient have a certain number of emergency room visits or hospitalizations related to the patient’s diagnosis in the criteria for a patient’s eligibility for telemonitoring services;
• Except as provided in paragraph E, must include qualifying criteria for a patient’s eligibility for telemonitoring services that include documentation in a patient’s medical record that the patient is at risk of hospitalization or admission to an emergency room;
• Must provide that group therapy for behavioral health or addiction services covered by the MaineCare program may be delivered through telehealth;
• Must include requirements for providers providing telehealth and telemonitoring services; and
• Must allow at least some portion of case management services covered by the MaineCare program to be delivered through telehealth, without requiring qualifying criteria regarding a patient’s risk of hospitalization or admission to an emergency room.

SOURCE:  ME Revised Statute Sec. 3173,-H, (Accessed Feb. 2024)

A multitude of services are listed as being allowed either face-to-face or through telehealth in the behavioral health services manual.

SOURCE:  MaineCare Benefits Manual, Behavioral Health Services, 10-44 Ch. II, Sec. 65, (Nov. 9, 2022). (Accessed Feb .2024).

Rehabilitative and Community Support Services for Children with Cognitive Impairments and Functional Limitations

Telemedicine may be utilized as clinically appropriate, according to the standards described in Chapter I, Section 4 of the MaineCare Benefits Manual.

SOURCE: MaineCare Benefits Manual, Rehabilitative and Community Support Services for Children with Cognitive Impairments and Functional Limitations, 28.08, Ch. 101, Ch. II, Sec. 28, p. 12, (9/23/19), (Accessed Feb. 2024).

Durable Medical Equipment

A face-to-face encounter is a mandatory encounter (including encounters through telehealth (as described in Chapter I, Section 4) and other than encounters incidental to services involved) between the member and a  Qualified Provider that takes place within the six (6) months prior to the date of a written order for DME. The written order may be, but does not have to be, prescribed by the provider who performed the face-to-face encounter.

SOURCE: MaineCare Benefits Manual, Durable Medical Equipment, 60.06, Ch. 101, Ch. II, Sec. 60, p. 4, (10/31/23), (Accessed Feb. 2024).

Children’s Residential Care Facilities (CRCFs)

The nurse may provide in-person, telehealth, and/or telephonic support outside of normal business hours as needed. The nurse must be either a psychiatric mental health nurse practitioner (APRN-PMH-NP), or a registered nurse (RN) with experience in the treatment of children with serious behavioral health conditions or requisite training to treat children with serious behavioral health conditions.

SOURCE: MaineCare Benefits Manual, Private Non-Medical Institution, 97.07, Ch. 101, Ch. II, Sec. 97, (11/1/21), (Accessed Feb. 2024).

Teledentistry

Providers may deliver diagnostic services via telehealth in accordance with Chapter I, Section 4, of the MaineCare Benefits Manual (MBM) and current Board rules and guidance. When delivering services via telehealth, providers shall bill for the underlying service and include, for tracking purposes only, the appropriate teledentistry CDT code that indicates a synchronous real-time encounter or an asynchronous encounter in which information is stored and forwarded to the dentist for subsequent review.

SOURCE: ME Benefits Manual, Dental Services and Reimbursement Methodology, 10-144, Ch. II, Sec. 25, pg. 1, (Sept. 28, 2022), (Accessed Feb. 2024).

Primary Care Plus (PCP)

In PCP Tier II Services, providers must offer telehealth as an alternative to traditional office visits in accordance with MBM, Ch. I, Sec. 4, Telehealth Services, and/or for non-office visit supports and outreach to increase access to the care team and clinicians in a way that best meets the needs of Members.

SOURCE: MaineCare Benefits Manual, Primary Care Plus, 10-144, Ch. VI,  Sec. 3.03, pg. 6, June 21, 2022, (Accessed Feb. 2024).

Home Health Services – Community Care Teams

A comprehensive biopsychosocial assessment, conducted face-to-face or via telehealth.

SOURCE: Maine Care Benefits Manual Home Health Services – Community Care Teams, 10-144, Chapter II, Section 91 (June 21, 2022), p. 15, (Accessed Feb. 2024).

Support Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder

AT-Assessment:  Evaluation of the assistive technology needs of a member, including a functional evaluation of the impact of the provision of appropriate assistive technology and appropriate services to the member in the customary environment of the member.

Evaluation of the assistive technology needs of a Member may be delivered via telehealth when the provider ensures that the assessment via telehealth meets the requirements of the scope of the service.

SOURCE: Maine Care Benefits Manual Support Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder, 10-144, Chapter II, Section 29 (Jan. 24, 2024), p. 15, (Accessed Feb. 2024).

Diabetes Prevention Program

Providers shall bill 0403T for each in-person session and bill 0403T with the GT modifier for sessions delivered through telehealth, e.g. online and distance learning sessions, as defined in the DPRP Standards.

SOURCE: Maine Care Benefits Manual National Diabetes Prevention Program Services, 10-144, Chapter II, Section 71 (Nov. 8, 2023), p. 5, (Accessed Feb. 2024).

MaineMOM Services and Reimbursement

The MaineMOM provider shall offer telehealth as an alternative to traditional office visits in accordance with the MBM, Chapter I, Section 4, and/or for non-office visit supports and outreach to increase access to the care team and clinicians in a way that best meets the needs of members.

SOURCE:  MaineCare Benefits Manual, MaineMOM Services and Reimbursement, 10-44 Ch. II, Sec. 89, p. 22 (Dec. 6, 2023). (Accessed Feb. 2024).

Ongoing Telehealth Medicaid Flexibilities [End Date Not Specified]

The Department, under Bright Futures Health Assessment Visits under Ch. II, Section 94.06-1, will allow for one additional health assessment visit per member within a year following an initial assessment via Telehealth for each age shown on the MaineCare Bright Futures periodic health assessment schedule (MBM, Ch. II, Section 96, Appendix 1).

SOURCE: Maine Department of Health and Human Services Office of MaineCare Services, Flexibilities Continuing: End of the Public Health Emergency (PHE), May 16, 2023, (Accessed Feb. 2024).

ELIGIBLE PROVIDERS

A health care provider is an individual or entity licensed or certified to provide medical, behavioral health, and related services to MaineCare Members. Health Care Providers must be enrolled as MaineCare Providers to receive reimbursement for services.

In order to be eligible for reimbursement for Telehealth Services, a Health Care Provider must

• Act within the scope of their license;
• B. Be enrolled as a MaineCare provider;
• Be otherwise eligible to deliver the underlying Covered Service according to the requirements of the applicable Section of the MBM; and
• Be appropriately licensed, accredited, certified, and/or registered in the State where the Member is located during the provision of the Telehealth Service.

Reimbursement – Receiving (Provider) Site

• Except as described below, only the Health Care Provider at the Receiving (Provider) Site may receive payment for Telehealth Services.
• When billing for Telehealth Services, Health Care Providers at the Receiving (Provider) Site must bill for the underlying Covered Service using the same claims they would if it were delivered face-to-face and must add the GT modifier for Interactive Telehealth Services and the 93 modifier for Telephonic Services.
• When billing for Telephone Evaluation and Management Services, Health Care Providers at the Receiving (Provider) Site must use the appropriate E&M code. The GT and 93 modifier should not be used.
• No separate transmission fees will be paid for Telehealth Services. The only services that may be billed by the Health Care Provider at the Receiving (Provider) Site are the fees for the underlying Covered Service delivered with the GT or 93 modifier.

The Health Care Providers at the Receiving and Originating Sites may be part of the same organization. A Health Care Provider at the Originating (Member) Site may bill MaineCare and receive payment for Telehealth Services if the service is provided by a Treating Provider who is under a contractual arrangement with the Originating (Member) Site.

SOURCE: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4.03., (Nov. 6, 2023). (Accessed Feb. 2024). 

Telehealth Services may be included in a Federally Qualified Health Center (FQHC), Rural Health Clinic (RHC), or Indian Health Center (IHC) scope of practice, as approved by the State. If approved, these facilities may serve as the provider site and bill under the encounter rate. When an FQHC or RHC serves as the Originating (Member) Site, the Originating Facility Fee is paid separately from the center or clinic all-inclusive rate.

SOURCE: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4., p. 12. (Nov. 6, 2023). (Accessed Feb. 2024).

Interprofessional Codes for Medication Management Providers

Medication management providers and other treating providers of Section 65 of the MaineCare Benefits Manual (MBM) may deliver and bill MaineCare for interprofessional consultations in alignment with MBM Chapter 1, Section 4.04-2(B). As described in CMS state health official letter #23-001, interprofessional consultations are assessments and management services in which a patient’s treating provider requests the opinion and/or treatment advice of a consultant with specific specialty expertise to assist the treating provider in the diagnosis and/or management of the patient’s condition without the need for the patient’s face-to-face contact with the consultant.

The consulting provider and the provider requesting the consultation must be able to independently bill for evaluation and management services. Examples of these provider types include physicians, nurse practitioners, clinical nurse specialists, physician assistants, and licensed clinical social workers. A registered nurse, for example, is not an eligible provider type.

The following examples illustrate when medication management providers may deliver and bill for interprofessional consultations:

• A medication management provider provides consultation to a primary care provider (PCP) on cross-tapering a patient from one antidepressant to another due to concerning side-effects.
• A medication management provider provides consultation to a PCP regarding antipsychotic medications because the PCP has a symptomatic patient who has been off of medications, and the PCP has never prescribed antipsychotic medication before.
• The PCP has been treating a behavioral health patient who was previously stabilized and who is now reporting increased symptoms with active substance use. The PCP is not sure of what to do about medications in the context of active substance use and consults a medication management provider.

Providers must bill for interprofessional consultations using common procedural terminology (CPT) codes 99446-99449, 99451, and 99452. However, CPT code 99452 is different. Interprofessional consultation code 99452 applies when the patient’s PCP or other qualified health professional interacts with a consultant via telephone, the Internet, or an electronic health record to provide the consultant with the patient’s clinical data so that the consultant can form an opinion regarding further management of the patient’s condition. For example, a PCP would bill CPT code 99452 if they send a patient to a medication management provider and the PCP provided background information.

SOURCE: State of Maine Department of Health and Human Services, Bulletin:  Interprofessional Codes for Medication Management Providers, Nov. 13, 2024, (Accessed Feb. 2024).

Electronic Visit Verification (EVV) Place of Service Providers

Telehealth Personal Care Services (PCS) claims are excluded from Electronic Visit Verification (EVV) record requirements. When billing telehealth claims on the CMS 1500 Claim Form, you must use the POS code 02 or 10 and include the GT modifier, as this indicates you are providing services via telehealth and not in-person.

See the table below for affected codes. UB04 claim lines submitted with telemedicine revenue code 078x are exempt from EVV editing.

SOURCE: ME Department of Health and Human Services, Office of MaineCare Services, Electronic Visit Verification (EVV) Place of Service Reminders, Sept. 26. 2022. (Accessed Feb. 2024).

ELIGIBLE SITES

Originating (Member) Site:  The site at which the Member is located at the time of Telehealth Service delivery. The site must be physically located in the United States.

When an FQHC or RHC serves as the Originating (Member) Site, the Originating Facility Fee is paid separately from the center or clinic all-inclusive rate.

The Health Care Providers at the Receiving and Originating Sites may be part of the same organization. A Health Care Provider at the Originating (Member) Site may bill MaineCare and receive payment for Telehealth Services if the service is provided by a Treating Provider who is under a contractual arrangement with the Originating (Member) Site.

Reimbursement – Originating (Member Site)

• If the Health Care Provider at the Originating (Member) Site supports the Member’s access to Telehealth Services the Health Care Provider at the Originating (Member) Site may bill MaineCare for an Originating Facility Fee using code Q3014 for the service of supporting access to the Telehealth Service. Supporting access to telehealth services means providing a room and/or telecommunications equipment and/or helping a Member use audio or video conferencing software or equipment to enable the Member to utilize telehealth.
• The Health Care Provider at the Originating (Member) Site may not bill for assisting the Health Care Provider at the Receiving (Provider) Site with an examination.
• No separate transmission fees will be paid for Telehealth Services.
• The Health Care Provider at the Originating (Member) Site may bill for any clinical services provided on-site on the same day that a Telehealth Service claim is made, except as specifically excluded elsewhere in this Section.
• Telehealth Services may be included in a Federally Qualified Health Center (FQHC), Rural Health Clinic (RHC), or Indian Health Center (IHC) scope of practice, as approved by the State. If approved, these facilities may serve as the provider site and bill under the encounter rate. When an FQHC or RHC serves as the Originating (Member) Site, the Originating Facility Fee is paid separately from the center or clinic all-inclusive rate.
• In the event an interpreter is required, the Health Care Provider at either the Originating (Member) Site or the Receiving (Provider) site must provide and may bill for interpreter services in accordance with the provisions of Chapter I, Section 1, of the MBM. Members may not bill or be reimbursed by the Department for interpreter services utilized during a telehealth encounter.
• If the technical component of an X-ray, ultrasound, or electrocardiogram is performed at the Originating (Member) Site during a Telehealth Service, the technical component and the Originating Facility Fee are billed by the Health Care Provider at the Originating (Member) Site. The professional component of the procedure and the appropriate visit code are billed by the Receiving (Provider) Site.  The professional component of the procedure and the appropriate visit code are billed by the Receiving (Provider) Site.

The Health Care Providers at the Receiving and Originating Sites may be part of the same organization. A Health Care Provider at the Originating (Member) Site may bill MaineCare and receive payment for Telehealth Services if the service is provided by a Treating Provider who is under a contractual arrangement with the Originating (Member) Site.

SOURCE: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4., (Nov. 6, 2023). (Accessed Feb. 2024).

Electronic Visit Verification (EVV) Place of Service Reminders

Personal Care Services (PCS) claims are included or excluded from EVV record requirements based on the POS code and EVV service codes that are submitted on the CMS 1500 claim form.

Claims for services delivered in the following locations are not subject to EVV and do not require a verified EVV visit record:

• POS 02: Telehealth provided other than in a patient’s home
  • Use this POS for Home Support-Remote Support: Monitor Only and Interactive services (including MaineCare policy Sections 18, 19, 20, 21, and 29).
  • Please refer to our additional telehealth billing guidance for PCS.
• POS 10: Telehealth provided in patient’s home

SOURCE: ME Department of Health and Human Services, Office of MaineCare Services, Electronic Visit Verification (EVV) Place of Service Reminders, Sept. 26. 2022. (Accessed Feb. 2024).

GEOGRAPHIC LIMITS

No Reference Found

FACILITY/TRANSMISSION FEE

Originating Facility Fee: Fee paid to the Health Care Provider at the Originating (Member) Site for the service of
coordinating Telehealth Services.

If the Health Care Provider at the Originating (Member) Site supports the Member’s access to Telehealth Services the Health Care Provider at the Originating (Member) Site may bill MaineCare for an Originating Facility Fee using code Q3014 for the service of supporting access to the Telehealth Service. Supporting access to telehealth services means providing a room and/or telecommunications equipment and/or helping a Member use audio or video conferencing software or equipment to enable the Member to utilize telehealth.

The Health Care Provider at the Originating (Member) Site may not bill for assisting the Health Care Provider at the Receiving (Provider) Site with an examination.

No separate transmission fees will be paid for Telehealth Services.

When an FQHC or RHC serves as the Originating (Member) Site, the Originating Facility Fee is paid separately from the center or clinic all-inclusive rate.

If the technical component of an X-ray, ultrasound, or electrocardiogram is performed at the Originating (Member) Site during a Telehealth Service, the technical component and the Originating Facility Fee are billed by the Health Care Provider at the Originating (Member) Site.

The professional component of the procedure and the appropriate visit code are billed by the Receiving (Provider) Site.

The Department will not separately reimburse Health Care Providers for any charge related to the purchase, installation, or maintenance of telehealth equipment or technology, nor any transmission fees. Health Care Providers shall not bill Members for such costs or fees.

The rate for Telehealth Originating Facility Fee, per visit, code Q3014, is listed on the MaineCare Provider fee schedule, which is posted on the Department’s website in accordance with 22 MRSA Section 3173-J(7) at https://mainecare.maine.gov/Provider%20Fee%20Schedules/Forms/Publication.aspx.

SOURCE: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4. (Nov. 6, 2023). (Accessed Feb. 2024).

POLICY

Reimbursement for telehealth is required for services appropriately delivered through telehealth regardless of the location of the patient and may not exclude from coverage a health care service or behavioral health service solely because it is through telehealth.

SOURCE: MD Health General Code 15-141.2 (Accessed Feb. 2024).

SOURCE: MD Medicaid Synchronous Telehealth Policy Guide, p. 1. Updated Aug. 2023. (Accessed Feb. 2024).

Mental Health

The Department shall grant approval to a telemental health provider to be eligible to receive State or federal funds for providing interactive telemental health services if the provider meets requirements of this chapter and for outpatient mental health centers; or if the telemental heath provider is an individual psychiatrist.

SOURCE: Code of Maryland Admin. Regs. Sec. 10.21.30.03. (Accessed Feb. 2024).

Managed Care

MCOs shall provide coverage for medically necessary telemedicine services.

SOURCE: Code of Maryland Admin. Regs. Sec. 10.67.06.31. (Accessed Feb. 2024).

ELIGIBLE SERVICES/SPECIALTIES

SOURCE: MD Medicaid Synchronous Telehealth Policy Guide, p. 1-3. Updated Aug. 2023. (Accessed Feb. 2024).

Mental Health Eligible Services:

• Diagnostic interview;
• Individual therapy
• Family therapy
• Group therapy, up to 8 individuals
• Outpatient evaluation and management
• Outpatient office consultation
• Initial inpatient consultation
• Emergency department services

SOURCE: Code of Maryland Admin. Regs. Sec. 10.21.30.09. (Accessed Feb. 2024).

Services required to be provided shall include counseling and treatment for substance use disorders and mental health conditions. The Program may not exclude from coverage a behavioral health care service provided to a Program recipient in person solely because the service may also be provided through telehealth.

The Program may undertake utilization review, including preauthorization, to determine the appropriateness of any health care service whether the service is delivered through an in–person consultation or through telehealth if the appropriateness of the health care service is determined in the same manner.

For the purpose of reimbursement and any fidelity standards established by the Department, a health care service provided through telehealth is equivalent to the same health care service when provided through an in–person consultation.

SOURCE: MD General Health Code 15-141.2(c-e, h). (Accessed Feb. 2024).

Doula Services

Prenatal and postpartum services may be delivered in the home, at the provider’s office or doctor’s office and other community-based settings. Doula services for prenatal and postpartum visits may be delivered in-person or as a telehealth service. The labor and delivery service must be provided in-person and can only be delivered at a hospital or freestanding birthing center.

The Maryland Medical Assistance Program will not cover Doula services rendered during labor and delivery as a telehealth visit.

SOURCE: MD Medicaid Doula Services Program Manual, p. 3, 5. Updated Jun. 30, 2023. (Accessed Feb. 2024).

Effective January 1, 2022, the Program covers doula services as defined in Regulation .01 of this chapter when the services:

1. Are medically necessary;
2. Are rendered during a birthing parent’s prenatal period, labor and delivery, and postpartum period; and
3. If rendered via telehealth, comply with the requirements established in COMAR 10.09.49 and any other subregulatory guidance.

B. The Program shall cover up to:

1. Eight prenatal or postpartum visits; and
2. One labor and delivery service.

SOURCE: Code of Maryland Admin Regs. 10.09.39.04 (Accessed Feb. 2024).

Individualized Education Program (IEP) and Individualized Family Service Plan (IFSP) Services

MDH Will reimburse IEP and IFSP providers for certain procedure codes via telehealth. Providers must identify telehealth services on the child’s IEP/IFSP and bill using the appropriate modifier (GT or UB). Service coordination procedures (T1023, T1023-TG, T2022, W9322, W9323, and W9324) and individual psychotherapy services (90791, 90832 and 90834) may continue with an audio-only component. In addition to IEP/IFSP services, MDH will continue to reimburse Autism Waiver service coordination when provided via telehealth. See Provider Transmittal for approved Maryland Medicaid Fee-for-Service approved IEP/IFSP Telehealth Services.

SOURCE: MD Medical Assistance Program. Early Intervention and School Health Service Providers Transmittal No. 3. Sept. 23, 2021. (Accessed Feb. 2024).

GT Modifier required for telehealth delivered services.

SOURCE: MD Dept of Health, Medicaid Policy & Procedure Manual For Services Delivered through the IEP/IFSP (July 1, 2022). p. 25.  (Accessed Feb. 2024).

Therapy Services (Physical Therapists, Occupational Therapists, Speech Therapists, Therapy Groups, EPSDT Providers, Managed Care Organizations)

MDH will reimburse providers for certain procedure codes when provided via audio-visual telehealth. Services must be identified and billed using the GT modifier to indicate a telehealth delivery model. MDH will not reimburse for services provided via an audio-only delivery model or for codes not included on the Provider Transmittal regarding approved therapy telehealth services when provided via any method of telehealth.

SOURCE: MD Medical Assistance Program. Guidance on the Continuation of Telehealth for Therapy Services. PT 09-22. Oct. 7, 2021. MD Dept of Health, Audiology, Physical Therapy, and Early Periodic, Screening, Diagnosis, and Treatment (EPSDT) Provider Manual (Jan. 2023). (Accessed Feb. 2024).

Applied Behavior Analysis (ABA) Services

Maryland Medicaid reimburses for certain procedure codes via audio-visual telehealth for ABA providers. ABA providers may continue to render up to 100% of supervision services (97155) via telehealth. When billing for services that are rendered via two-way HIPAA compliant audio-visual telehealth, providers must bill using the GT modifier and Place of Service 11 to indicate a telehealth delivery model.

SOURCE: MD Medical Assistance Program. Guidance on the Continuation of Telehealth for ABA Services. PT 11-22. Oct. 26 2021. (Accessed Feb. 2024).

ELIGIBLE PROVIDERS

“Health care provider” means:

• A person who is licensed, certified, or otherwise authorized under the Health Occupations Article to provide health care in the ordinary course of business or practice of a profession or in an approved education or training program;
• A mental health and substance use disorder program licensed in accordance with § 7.5–401 of this article;
• A person licensed under Title 7, Subtitle 9 of this article to provide services to an individual with developmental disability or a recipient of individual support services; or
• A provider as defined under § 16–201.4 of this article to provide services to an individual receiving long–term care services.

SOURCE: MD General Health Code 15-141.2(a)(4). (Accessed Feb. 2024).

The Program shall reimburse a health care provider for the diagnosis, consultation, and treatment of a Program recipient for a health care service covered by the Program that can be appropriately provided through telehealth. This subsection does not require the Program to reimburse a health care provider for a health care service delivered in person or through telehealth that is:

• Not a covered health care service under the Program; or
• Delivered by an out–of–network provider unless the health care service is a self–referred service authorized under the Program.

From July 1, 2021, to June 30, 2025, both inclusive, when appropriately provided through telehealth, the Program shall provide reimbursement on the same basis and the same rate as if the health care service were delivered by the health care provider in person. Reimbursement does not include:

• Clinic facility fees unless the health care service is provided by a health care provider not authorized to bill a professional fee separately for the health care service; or
• Any room and board fees.

The Department may specify in regulation the types of health care providers eligible to receive reimbursement for health care services provided to Program recipients under this section. If the Department specifies by regulation the types of health care providers eligible to receive reimbursement for health care services provided to Program recipients under this subsection, the regulations shall include all types of health care providers that appropriately provide telehealth services.

The Program or a managed care organization that participates in the Program may not impose as a condition of reimbursement of a covered health care service delivered through telehealth that the health care service be provided by a third–party vendor designated by the Program.

The Department may adopt regulations to carry out this section. The Department shall obtain any federal authority necessary to implement the requirements of this section, including applying to the Centers for Medicare and Medicaid Services for an amendment to any of the State’s § 1115 waivers or the State plan. This section may not be construed to supersede the authority of the Health Services Cost Review Commission to set the appropriate rates for hospitals, including setting the hospital facility fee for hospital–provided telehealth.

SOURCE: MD General Health Code 15-141.2(g-l), as amended by HB 1148/SB 582/SB 534 (2023 Session). (Accessed Feb. 2024).

SOURCE: MD Medicaid Synchronous Telehealth Policy Guide, p. 2-3. Updated Aug. 2023. (Accessed Feb. 2024).

Distant Site Providers may render services via telehealth within the provider’s scope of practice.

SOURCE: Code of Maryland Admin. Regs. Sec. 10.09.49.04(E). (Accessed Feb. 2024).

Mental Health

Eligible Providers:

• Outpatient mental health centers
• Telemental health providers who are individual psychiatrists.

Telemental health providers may be private practice, part of a hospital, academic, health or mental health care system.  Public Mental Health System (PMHS) approved community-based providers or individual practitioners may engage in agreements with TMH providers for services.  Fee-for-service reimbursement shall be at an enhanced rate, as stipulated by the Department, provided all applicable provisions of this chapter are met and funds are available.

SOURCE: Code of Maryland Admin. Regs. Sec. 10.21.30.03 & Sec. 10.21.30.04. (Accessed Feb. 2024).

ELIGIBLE SITES

The Program shall provide health care services appropriately delivered through telehealth to Program recipients regardless of the location of the Program recipient at the time telehealth services are provided and allow a distant site provider to provide health care services to a Program recipient from any location at which the health care services may be appropriately delivered through telehealth.

SOURCE: MD General Health Code 15-141.2(b). (Accessed Feb. 2024).

SOURCE: MD Medicaid Synchronous Telehealth Policy Guide, p. 2. Updated Aug. 2023. (Accessed Feb. 2024).

• Critical Access Hospital;
• Federally Qualified Health Center;
• Hospital;
• Outpatient mental health center;
• Physician’s office;
• Rural Health Clinic;
• Elementary, middle, high, or technical school with a supported nursing, counseling or medical office; or
• College or university student health or counseling office.

Distant Site Location Eligibility – An approved distant TMH location shall be within the State.

SOURCE: Code of Maryland Admin. Regs. Sec. 10.21.30.05. (Accessed Feb. 2024).

Providers should use the place of service code that would be appropriate as if it were a non-telehealth claim. The distant site should use the location of the doctor. If a distant site provider is rendering services at an off-site office, use place of service office (11). Place of Service Code 02 (Telehealth) is not recognized for Maryland Medicaid participants except for use on Medicare crossover claims to specify services rendered through a telecommunication system for dual eligible participants. Allowable place of service codes should remain unchanged for Medicaid-only claims.

The Program recognizes specific modifiers for certain services rendered via telehealth delivery models; providers may bill using -GT and -UB. Providers should submit claims in the same manner as for in-person services and include the “-GT” modifier to identify that services were rendered via two-way audio-visual telehealth. To bill for audio-only telephonic services, providers must bill for the appropriate service code and use the “-UB” modifier to identify the claim as a telephonically delivered service. Billing with these modifiers will not affect Medicaid reimbursement rates.

SOURCE: MD Medical Assistance Program. Professional Services Provider Manual, p. 24-25, 78. Updated Jan. 2023. (Accessed Feb. 2024).

GEOGRAPHIC LIMITS

The Program may not distinguish between Program recipients in rural or urban locations in providing coverage under the Program for health care services delivered through telehealth.

SOURCE: MD General Health Code 15-141.2(f). (Accessed Feb. 2024).

SOURCE: MD Medicaid Synchronous Telehealth Policy Guide, p. 1. Updated Aug. 2023. (Accessed Feb. 2024).

Mental Health

To be eligible a beneficiary must reside in one of the designated rural geographic areas or whose situation makes person-to-person psychiatric services unavailable.

SOURCE: Code of Maryland Admin. Regs. Sec. 10.21.30.05(A)(3). (Accessed Feb. 2024).

FACILITY/TRANSMISSION FEE

From July 1, 2021, to June 30, 2025, when appropriately provided through telehealth, the Program shall provide reimbursement in accordance on the same basis and the same rate as if the health care service were delivered by the health care provider in person. Reimbursement does not include:

• Clinic facility fees unless the health care service is provided by a health care provider not authorized to bill a professional fee separately for the health care service; or
• Any room and board fees.

The Department may adopt regulations to carry out this section.

SOURCE: MD Health General Code 15-141.2 (g)(3),(h), as amended by HB 1148/SB 582/SB 534 (2023 Session). (Accessed Feb. 2024).

A provider eligible to bill a professional fee for a health care service shall bill a professional fee for the health care service instead of a clinic facility fee.​

SOURCE: Code of Maryland Admin. 10.09.49.07 (Accessed Feb. 2024).

Hospital Billing Instructions

Facility charges related to the use of telemedicine services. This revenue code is listed as not payable.

SOURCE: Maryland Dept. of Health Medical Assistance, UB04 Hospital Billing Instructions, 6/2023, p. 96 (Accessed Feb. 2024).

POLICY

The division and its contracted health insurers, health plans, health maintenance organizations, behavioral health management firms and third-party administrators under contract to a Medicaid managed care organization, accountable care organization or primary care clinician plan shall provide coverage for health care services delivered via telehealth by a contracted health care provider if: (i) the health care services are covered by way of in-person consultation or delivery; and (ii) the health care services may be appropriately provided through the use of telehealth.

The rate of payment for telehealth services provided via interactive audio-video technology and audio-only telephone may be greater than the rate of payment for the same service delivered by other telehealth modalities.

Coverage that reimburses a provider with a global payment shall account for the provision of telehealth services to set the global payment amount.  See services section below for behavioral health services specific requirements for payment.

SOURCE: Massachusetts General Laws, Part I, Title XVII, Ch. 118E, Sec. 79. (Accessed Apr. 2024).

Telehealth is a modality of treatment, not a separate covered service. Providers are not required to deliver services via telehealth.

The bulletin does not apply to services under the Children’s Behavioral Health Initiative (CBHI) program, which may continue to be delivered via all modalities currently authorized in applicable program specifications.

SOURCE: MassHealth All Provider Bulletin 281, p. 1, Jan. 2019. (Accessed Apr. 2024).

Under this policy, MassHealth will continue to allow MassHealth-enrolled providers to deliver a broad range of MassHealth-covered services via telehealth. MassHealth will reimburse for such services at parity with their in-person counterparts, including services provided through live-video, audio-only, or asynchronous visits that otherwise meet billing criteria, including use of required modifiers. All providers delivering services via telehealth must comply with the policy detailed in this bulletin.

This bulletin applies to members enrolled in MassHealth fee-for-service, the Primary Care Clinician (PCC) Plan, a Managed Care Organization (MCO), an Accountable Care Partnership Plan (ACPP), or a Primary Care Accountable Care Organization (PCACO). Information about coverage through MassHealth Managed Care Entities (MCEs) and the Program for All-inclusive Care for the Elderly (PACE) will be issued in a forthcoming MCE bulletin.

SOURCE: MassHealth All Provider Bulletin 379, Oct. 2023. (Accessed Apr. 2024).

ELIGIBLE SERVICES/SPECIALTIES

Health Care Services

The division and its contracted health insurers, health plans, health maintenance organizations, behavioral health management firms and third-party administrators under contract to a Medicaid managed care organization, accountable care organization or primary care clinician plan shall provide coverage for health care services delivered via telehealth by a contracted health care provider if: (i) the health care services are covered by way of in-person consultation or delivery; and (ii) the health care services may be appropriately provided through the use of telehealth.

SOURCE:  Massachusetts General Laws, Part I, Title XVII, Ch. 118E, Sec. 79. (Accessed Apr. 2024).

Behavioral Health Services

The division shall ensure that the rate of payment for in-network providers of behavioral health services delivered via interactive audio-video technology and audio-only telephone shall be no less than the rate of payment for the same behavioral health services delivered via in-person methods; provided, that this subsection apply to providers of behavioral health services covered as required (see text for applicable behavioral health providers).

SOURCE:  Massachusetts General Laws, Part I, Title XVII, Ch. 118E, Sec. 79. (Accessed Apr. 2024).

The division of medical assistance shall ensure that the rate of payment for in-network providers of behavioral health services delivered via interactive audio-video technology and audio-only telephone shall be no less than the rate of payment for the same behavioral health service delivered via in-person methods, provided certain conditions.  See statute.

Source: Massachusetts General Laws, Ch. 32A Sec. 30, Ch. 118E Sec. 79, Ch. 175 47MM, Ch. 176A Sec. 38, Ch. 176B Sec. 25, Ch. 176G Sec. 33, Ch. 176I Sec. 13. (Accessed Apr. 2024).

Unlicensed or Not Independently Licensed Staff. All professionals who are unlicensed, who are in a profession without licensure, or who are not independently licensed or certified as a peer supervisor must receive direct and continuous supervision. Direct and continuous supervision may be provided using telehealth technology

Independently Licensed and Certified Peer Supervisor Staff. All independently licensed professionals and certified peer supervisors must receive supervision in accordance with the relevant licensing requirements and program policy. Supervision may be provided using telehealth technology

The MassHealth agency will pay a provider only for a case consultation that involves a personal meeting with a professional of another agency. Personal meetings may be conducted via audio-only telephonic, audio-video, or in person meetings.

SOURCE: MA Regulations 130 CMR Sec. 418.410 and 412, (Accessed Apr. 2024).

Community Health Centers, Community Mental Health Centers, and Outpatient Substance Use Disorder providers (provider types 20, 26 and 28) may deliver the following covered services via telehealth:

• All services specified in 101 CMR 306.00 et seq.; and
• The outpatient services specified in the following categories:
• Opioid Treatment Services: Counseling;
• Ambulatory Services: Outpatient Counseling; Clinical Case Management; and
• Services for Pregnant/Postpartum Clients: Outpatient Services

SOURCE: MassHealth All Provider Bulletin 281, p. 1, Jan. 2019. (Accessed Apr. 2024).

Mental Health Centers

Satellite Clinics: All clinic locations must meet, independently of its parent clinic, all requirements set forth in 130 CMR 429. Satellite locations must be able offer in person services for up to 20 hours per week; use of telehealth is acceptable when agreed upon by the member.

Case Consultation:  intervention, including scheduled audio-only telephonic, audio-video, or in person meetings, for behavioral and medical management purposes on a member’s behalf with agencies, employers, or institutions which may include the preparation of reports of the member’s psychiatric status, history, treatment, or progress (other than for legal purposes) for other physicians, agencies, or insurance carriers.

The MassHealth agency pays only for a case consultation that involves a personal meeting with a professional of another agency. Personal meetings may be conducted via audio-only telephonic, audio-video, or in person meetings.

Staff Supervision:

• Unlicensed or Not Independently Licensed Staff:  All professionals who are unlicensed, who are in a profession without licensure, or who are not independently licensed or certified as a peer supervisor must receive Direct and Continuous Supervision. Direct and Continuous Supervision may be provided using telehealth technology.
• Independently Licensed and Certified Peer Supervisor Staff. All independently licensed professionals and certified peer supervisors must receive supervision in accordance with center policy. Supervision may be provided using telehealth technology.

SOURCE: MassHealth Mental Health Center Manual, Ch. 4, 1/1/23, (Accessed Apr. 2024).

Crisis Intervention:  The MassHealth agency pays for crisis intervention as defined in 130 CMR 429.402 … This service is limited to face-to-face contacts, which includes Telehealth, with the member

Group behavioral health, group medical visit, individual behavioral health visits, individual dental visit, individual medical visit, individual mental health visit, nurse-midwife medical visit, can be conducted via a clinically appropriate telehealth modality.  See manual for codes.

SOURCE: MassHealth Rates for Community Health Centers, 101 CMR Sec. 304.02 (Accessed Apr. 2024).

MassHealth lists specific codes that may be used by community health centers for services delivered through telehealth. See Transmittal Letter for details.

SOURCE: MassHealth Community Health Center Manual, Ch. 6, 1/1/23, (Accessed Jan. 2024).

CARES program providers may deliver services via telehealth.

SOURCE: MassHealth Rates for Community Health Centers, 130 CMR Sec. 405.477 and Sec. 433.485, & Physician Manual, 7/7/23, (Accessed Apr. 2024).

The Community Support Program (CSP) provider delivers CSP services on a mobile basis to members in any setting that is safe for the member and staff. Services may be provided via telehealth, as appropriate.

SOURCE: Massachusetts Regulations, Sec. 130 CMR 461.410, & Community Support Service Manual, 4/28/23, (Accessed Apr. 2024).

Important Note: Although MassHealth allows reimbursement for the delivery of certain services through telehealth for certain billing providers as described in this bulletin, MassHealth does not require providers to deliver services via telehealth.

As under All Provider Bulletin 355, Section B of this bulletin identifies specific categories of service that MassHealth has deemed inappropriate for delivery via any telehealth modality. Except for those services identified in Section B in this bulletin, and notwithstanding any regulation to the contrary, including the physical-presence requirement at 130 CMR 433.403(A)(2), a MassHealth enrolled provider may deliver medically necessary MassHealth-covered services on an outpatient basis to a MassHealth member via the telehealth modalities of audio-only, live video, and asynchronous visits, if:

• the provider has determined that it is clinically appropriate to deliver such service via telehealth, including the telehealth modality and technology employed, including obtaining member consent;
• such service is payable under that provider type;
• the provider satisfies all requirements set forth in this bulletin, including in Appendix A, and any applicable program-specific bulletin;
• the provider delivers those services in accordance with all applicable laws and regulations (including M.G.L. c. 118E, § 79 and MassHealth program regulations); and
• the provider is appropriately licensed or credentialed to deliver those services.

MassHealth will continue to monitor telehealth’s impacts on quality of care, cost of care, patient and provider experience, and health equity to inform the continued monitoring and iteration of its telehealth policy. Based on the results of this monitoring, and its analysis of relevant data and information, MassHealth may adjust its coverage policy, including by imposing limitations on the use of certain telehealth modalities for various covered services or provider types.

As under All Provider Bulletin 355, MassHealth has deemed these following categories of service ineligible for delivery via any telehealth modality.

• Ambulance Services
• Ambulatory Surgery Services
• Anesthesia Services
• Certified Registered Nurse
• Anesthetist Services
• Chiropractic Services
• Hearing Aid Services
• Inpatient Hospital Services1
• Laboratory Services
• Nursing Facility Services
• Orthotic Services
• Personal Care Services
• Prosthetic Services
• Renal Dialysis Clinic Services
• Surgery Services
• Transportation Services
• X-Ray/Radiology Services

Telehealth and Children’s Behavioral Health Initiative (CBHI) Services

As under All Provider Bulletin 355, existing performance specifications for Children’s Behavioral Health Initiative (CBHI) services allow for the telephonic delivery of services, other than for initial assessments. Notwithstanding any requirements that initial assessments be conducted in person, where appropriate, services for new clients may be initiated by telephone or other telehealth modality. CBHI providers must use the regular CBHI codes, as well as the POS code and modifiers described above, as appropriate, when billing for CBHI services delivered via approved telehealth modalities.

SOURCE: MassHealth All Provider Bulletin 379, Oct. 2023. (Accessed Apr. 2024).

SOURCE:  MassHealth Hospice Agencies, Bulletin 29, Jul. 2023, (Accessed Apr. 2024).

Adult Foster Care

The Executive Office of Health and Human Services (EOHHS) is not imposing specific requirements for technologies used to deliver services via telehealth and will allow reimbursement for MassHealth-covered AFC/GAFC services delivered via telehealth, as long as such services are medically necessary and clinically appropriate and delivered in accordance with this bulletin. Providers are encouraged to use appropriate technologies to communicate with individuals and should, to the extent feasible, ensure the same rights to confidentiality and security as provided in in-person services. Providers must inform members of any relevant privacy considerations.

EOHHS does not require providers to deliver AFC/GAFC services via telehealth and may continue to provide services in-person as necessary or appropriate. AFC/GAFC providers must clearly document in the member record if the member refuses an in-person visit.

AFC and GAFC providers may use telehealth for

• Level I AFC home visit structure – telehealth may be used for up to three nonconsecutive visits in a 12-month period;
• Level II AFC home visit structure – telehealth may be used for up to six nonconsecutive visits in a 12-month period;
• GAFC home visit structure – telehealth may be used for up to three nonconsecutive visits in a 12-month period;
• Level I AFC admission visit – may be done in person/on-site or via telehealth;
• Level II AFC admission visits – for the first month of service, the first and last admission visits must be done in person/on-site, the two weekly visits in between may be conducted via telehealth;
• GAFC admission visits –for the first month of service, the first and last admission visits must be done in person/on-site, the two weekly visits in between may be conducted via telehealth; and
• Extraordinary circumstances resulting from unusual and unavoidable circumstances that substantially impede the ability of the provider to conduct a visit or other AFC/GAFC program requirement in person that can be directly addressed by use of telehealth. This may include, but is not necessarily limited to, staffing shortages due to illness and/or medical leave (such as Family Medical Leave Act absences). In these limited instances, the AFC/GAFC program director must document the approved temporary telehealth use. Further, for each use of telehealth for extraordinary circumstances, the AFC/GAFC provider must document the description of the extraordinary circumstance, the timeframe during which the extraordinary circumstances necessitated the telehealth visits, which types of visits are permitted to be conducted by telehealth, and how the use of telehealth is narrowly tailored to address this extraordinary circumstance. Such documentation must be made available upon request by EOHHS or other appropriate auditor. The AFC/GAFC provider must also document in the relevant member record each visit that occurred via telehealth in accordance with this bulletin. If telehealth use extends past three months, the AFC/GAFC provider must contact MassHealth for approval and must provide a deadline by which the use of telehealth for extraordinary circumstances will conclude. Such use of telehealth to address extraordinary circumstances cannot be used for caregiver or direct care aide assistance with activities of daily living or instrumental activities of daily living, including cueing and supervision of such activities.

Adult foster care and group adult foster care providers may not use telehealth for

• Caregiver or direct care aide assistance with activities of daily living or instrumental activities of daily living, including cueing and supervising such activities; and
• Initial evaluations and reassessments, including reassessments based on significant change.

AFC/GAFC providers must conduct both initial and annual member home inspections in person/on-site.

STATUS: MassHealth Adult Foster Care, Bulletin 29, Apr. 2023, (Accessed Apr. 2024).

Durable Medical Equipment

Federal regulations require that, for certain DME services, physicians or certain authorized nonphysician practitioners must document a face-to-face meetingwith the Medicaid-eligible beneficiary. See 42 CFR 440.70. Through the end of the FPHE, and as described in 42 CFR 440.70 (f) (6), any required face-to-face meeting may be delivered via telehealth (including telephone and live video)according to the standards in All Provider Bulletin 314.

This is consistent with Centers for Medicare & Medicaid Services (CMS) Interim Final Rules with Comment Period (CMS-1744-IFC (April 6, 2020) and CMS-5531-IFC (May 8, 2020) which provide that the face-to-face meeting requirement does not apply for DME for the duration of the COVID-19 emergency, except for power mobility devices (PMDs) with a statutory requirement for a face-to-face meeting. For those PMDs, a telehealth face-to-face meeting may satisfy the requirement. See  CMS COVID-19 Frequently Asked Questions on Medicare Fee-for-Service Billing Question AA.

On May 12, 2023, consistent with 42 CFR 440.70, providers may use telehealth for face-to-face meetings. Providers must follow the federal DME Face-to-Face Requirements identified in 42 CFR 440.70 and maintain the required documentation in the member’s record. See 130 CMR 409.430(C) and DME Bulletin 26. All documentation, recordkeeping, and other applicable provisions of 130 CMR 450.000 and 130 CMR 409.000 apply.

STATUS: MassHealth Durable Medical Equipment, Bulletin 32, Apr. 2023, (Accessed Apr. 2024).

Oxygen and Respiratory Therapy

Federal regulations require that, for certain oxygen services, physicians or certain authorized nonphysician practitioners, must document a face-to-face meeting with the Medicaid-eligible beneficiary. See 42 CFR 440.70. Through the end of the FPHE, and as described in 42 CFR 440.70(f)(6), any required face-to-face meetings may be delivered via telehealth (including telephone and live video) according to the standards in All Provider Bulletin 314.

This is consistent with Centers for Medicare & Medicaid Services (CMS) Interim Final Rules with Comment Period (CMS-1744-IFC (April 6, 2020) and CMS-5531-IFC (May 8, 2020), which provide that the face-to-face meeting requirement does not apply for oxygen and respiratory equipment for the duration of the COVID-19 emergency, except for power mobility devices (PMDs) with a statutory requirement for a face-to-face meeting. For those PMDs, a telehealth face-to-face meeting may satisfy the requirement. See the CMS COVID-19 Frequently Asked Questions on Medicare Fee-for-Service Billing.

On May 12, 2023, consistent with 42 CFR 440.70, providers may use telehealth for face-to-face meetings. Providers must follow the federal oxygen Face-to-Face Requirements identified in 42 CFR 440.70. Providers must also maintain the required documentation in the member’s record. See Oxygen and Respiratory Therapy Equipment Provider Bulletin 17. All documentation, recordkeeping, and other applicable provisions of 130 CMR 450.000 and 130 CMR 427.000 apply.

STATUS: MassHealth Oxygen and Respiratory Therapy, Bulletin 26, Apr. 2023, (Accessed Apr. 2024).

Therapy

After the FPHE ends, consistent with the federal Consolidated Appropriations Act of 2023, MassHealth will continue to cover therapy appropriately provided by telehealth services until December 31, 2024, or when specified by MassHealth via regulation or Congress. See Consolidated Appropriations Act, 2023, H.R.2617, Sec. 4113, 117th Cong. (2022).

Services must meet all requirements under the MassHealth Guidelines for Medical Necessity Determination for Speech and Language Therapy, Physical Therapy, and Occupational Therapy [MassHealth Guidelines for Medical Necessity Determination for Speech and Language Therapy].

MassHealth is not imposing specific requirements for technologies used to deliver services via telehealth and will allow reimbursement for MassHealth therapist services delivered through telehealth, as long as such services

• are medically necessary;
• are clinically appropriate;
• meet requirements within 130 CMR 430.000 [432.00 and 413.000] 130 CMR 450.000; and
• meet all additional requirements of the therapy telehealth guidance in this bulletin.

Providers are encouraged to use appropriate technologies to communicate with individuals and should, to the extent possible, ensure the same rights to confidentiality and security as provided in face-to-face services. Providers must inform members of any relevant privacy considerations.

Therapy telehealth visits may be used for therapist services that

• require the member’s consent, documented as described below; and
• are follow-up visits that do not require any hands-on care.

Follow-up visits do not include evaluations or re-evaluations and may be conducted by telephone if appropriate, but live video is preferred

STATUS: MassHealth Rehabilitation Center Bulletin 16, Apr. 2023; Therapist Bulletin 18, Apr. 2023; Speech and Hearing Center Bulletin 16, Apr. 2023, (Accessed Apr. 2024).

Therapy telehealth visits may not be used for any therapy specifically requiring hands-on care.

STATUS: MassHealth Therapist Bulletin 18, Apr. 2023; (Accessed Apr. 2024).

Community Behavioral Health Center

Adult and Youth Mobile Crisis intervention and maybe provided via telehealth.

SOURCE: MassHealth Commonwealth of Massachusetts MassHealth Provider Manual Series, Community Behavioral Health Center Manual, 1/1/23, (Accessed Apr. 2024).

Mobile Crisis Intervention:  Services may be provided via telehealth.

SOURCE: MA Admin Code Sec. 352.02, (Accessed Apr. 2024).

Managed Care Entity and PACE Organizations

Some specialized community support program services are appropriate to deliver via telehealth.  See bulletin.

SOURCE: MassHealth Managed Care Entity Bulletin 99, Mar. 2023, (Accessed Apr. 2024).

Continuous Skilled Nursing Agencies

If clinically appropriate, the 14-day RN supervisory visit may be performed using two-way audio-video telecommunications technology that allows for real-time interaction between the RN and the patient, and representative as needed. If a CSN agency determines that a member’s clinical needs require in-person supervision, the RN supervisor must perform the supervisory visit in person and in the member’s home. MassHealth will update the CSN agency provider regulations to reflect this clarification. The 60-day supervisory visits under 130 CMR 438.415(C)(5)(c) cannot be performed using telecommunications technology.

SOURCE: MassHealth Continuous Skilled Nursing Agencies Bulletin 15, Aug. 2023, (Accessed Apr. 2024).

The MassHealth agency pays for medically necessary doula services including perinatal visits and labor and delivery support provided in-person or via telehealth.

SOURCE: MA Admin Code Sec. 463.407, & Doula Services Manual, 12/8/23, (Accessed Apr. 2024).

Psychologists – Case Consultation

The MassHealth agency pays only for a case consultation that involves a personal meeting with a professional of another agency. Personal meetings may be conducted via audio-only telephonic, audio-video, or in person meetings.

The MassHealth agency pays for case consultation delivered in person or via telephonic or audio-visual methods only when written communication alone, and other non-reimbursable forms of communication, clearly will not suffice. Such circumstances must be documented in the member’s record. Such circumstances are limited to situations in which both the provider and the other party are actively involved in treatment or management programs with the member (or family members) and where a lack of direct communication would impede a coordinated treatment program

SOURCE: MassHealth Psychologist Manual, Sec. 411.405, (1/1/23), (Accessed Apr. 2024).

Substance Use Disorder Treatment 

Telehealth: Telehealth. Services including the prescribing of controlled substances must be in accordance with state and federal regulations.

Case Consultation: intervention, including scheduled audio-only telephonic, audio-video, or in-person meetings, for behavioral and medical management purposes on a member’s behalf with agencies, employers, or institutions which may include the preparation of reports of the member’s psychiatric status, history, treatment, or progress (other than for legal purposes) for other physicians, agencies, or insurance carriers.

The MassHealth agency will pay a provider only for a case consultation that involves a personal meeting with a professional of another agency. Personal meetings may be conducted via audio-only telephonic, audio-video, or in person meetings.

The MassHealth agency will pay for case consultation only when written communication, and other non-reimbursable forms of communication clearly, will not suffice. Such circumstances must be documented in the member’s record. Such circumstances are limited to situations in which the program and the other party are actively involved in the treatment or management programs with the member (or family members) and where a lack of face-to-face communication would impede a coordinated treatment program.

Staff Supervision Requirements.

• Unlicensed or Not Independently Licensed Staff. All professionals who are unlicensed, who are in a profession without licensure, or who are not independently licensed or certified as a peer supervisor must receive direct and continuous supervision. Direct and continuous supervision may be provided using telehealth technology.
• Independently Licensed and Certified Peer Supervisor Staff. All independently licensed professionals and certified peer supervisors must receive supervision in accordance with the relevant licensing requirements and program policy. Supervision may be provided using telehealth technology.

SOURCE: MassHealth Substance Use Disorder Treatment Manual, 418.412, (1/1/23), (Accessed Apr. 2024).

ELIGIBLE PROVIDERS

Coverage shall not be limited to services delivered by third-party providers.

SOURCE: Massachusetts General Laws, Part I, Title XVII, Ch. 118E, Sec. 79. (Accessed Apr. 2024).

ELIGIBLE SITES

Originating site is the location of the member at the time the service is being provided. While the originating site must be located in the United States or its territories, there are no additional geographic or facility restrictions on originating sites in this bulletin. A member may receive telehealth services while located within their own home, or any other appropriate site, provided that the provider complies with all applicable laws and regulations, including those related to privacy and data security.

Providers must include the place of service (POS) code 02 when submitting a professional claim for telehealth provided in a setting other than in the patient’s home. They must include POS code 10 when submitting a professional claim for telehealth provided in the patient’s home. Additionally, for any such professional claim, providers must include:

• modifier 95 to indicate counseling and therapy services rendered via audio-video telecommunications;
• modifier 93 to indicate services rendered via audio-only telehealth;
• modifier FQ to indicate counseling and therapy services provided using audio-only telecommunications;
• modifier FR to indicate a supervising practitioner was present through a real-time two-way, audio and video communication technology; and/or
• modifier GQ to indicate services rendered via asynchronous telehealth.

Additionally, for any institutional claim, providers are allowed to use the following modifiers:

• modifier 95 to indicate counseling and therapy services rendered via audio-video telecommunications;
• modifier 93 to indicate services rendered via audio-only telehealth;
• modifier GT to indicate services rendered via interactive audio and video telecommunications systems;
• modifier FQ to indicate counseling and therapy services provided using audio-only telecommunications;
• modifier FR to indicate that a supervising practitioner was present through a real-time two-way, audio and video communication technology; and/or
• modifier GQ to indicate services rendered via asynchronous telehealth.

Modifier GT is required on the institutional claim, for the distant-site provider, when there is an accompanying professional claim containing POS 02 or 10.

Effective August 31, 2023, modifier V3, which was previously used to indicate services rendered via audio-only telehealth, will no longer be available. Providers must use modifier 93 in its place.

SOURCE: MassHealth All Provider Bulletin 379, Oct. 2023. (Accessed Apr. 2024).

A health care provider shall not be required to document a barrier to an in-person visit nor shall the type of setting where telehealth services are provided be limited for health care services provided via telehealth; provided, however, that a patient may decline receiving services via telehealth in order to receive in-person services.

SOURCE: Massachusetts General Laws, Part I, Title XVII, Ch. 118E, Sec. 79. (Accessed Apr. 2024).

Psychologists

The MassHealth agency pays for medically necessary services provided in any suitable location, such as the psychologist’s office, the member’s place of residence, other facility, or by telehealth.

SOURCE: MassHealth Psychologist Manual, Sec. 411.405, (1/1/23), (Accessed Apr. 2024).

GEOGRAPHIC LIMITS

Originating site is the location of the member at the time the service is being provided. While the originating site must be located in the United States or its territories, there are no additional geographic or facility restrictions on originating sites in this bulletin. A member may receive telehealth services while located within their own home, or any other appropriate site, provided that the provider complies with all applicable laws and regulations, including those related to privacy and data security.

SOURCE: MassHealth All Provider Bulletin 379, Oct. 2023. (Accessed Apr. 2024).

A health care provider shall not be required to document a barrier to an in-person visit nor shall the type of setting where telehealth services are provided be limited for health care services provided via telehealth.

SOURCE: Massachusetts General Laws, Part I, Title XVII, Ch. 118E, Sec. 79. (Accessed Apr. 2024).

A health care provider shall not be required to document a barrier to an in-person visit nor shall the type of setting where telehealth services are provided be limited for health care services provided via telehealth; provided, however, that a patient may decline receiving services via telehealth in order to receive in-person services.

SOURCE: Massachusetts General Laws, Part I, Title XVII, Ch. 118E, Sec. 79. (Accessed Apr. 2024).

FACILITY/TRANSMISSION FEE

POLICY

The Michigan Department of Health and Human Services (MDHHS) covers both synchronous (real-time interactions) and asynchronous (over separate periods of time) telemedicine services. MDHHS requires that all telemedicine policy provisions within this policy and other current policy are established and maintained within all telemedicine services.

Recognizing that telemedicine can never fully replace in-person care, MDHHS has established the following principles to be used by MDHHS-enrolled providers during the provision of telemedicine services:

• Effectual services – a service provided via telemedicine should be as effective as its in-person equivalent, ensuring convenient and high-quality care.
• Improved and appropriate access – the right visit, for the right beneficiary, at the right time by minimizing the impact of barriers to care, such as transportation needs or availability of specialty providers in rural areas.
• Appropriate beneficiary choice – the beneficiary is an active participant in the decision for telemedicine as a means for service delivery as appropriate (e.g., Does the beneficiary prefer telemedicine to an in-person visit? What is the optimal combination of ongoing service delivery for the individual? etc.).
• Appropriate utilization – ensure providers are utilizing telemedicine appropriately and that items listed above are taken into consideration when offering these services.
• Value considerations – telemedicine visits should yield the desired outcomes and quality measures; health outcomes should be improving and remain consistent with in-person care at a minimum.
• Privacy and security measures – providers must ensure the privacy of the beneficiary and the security of any information shared via telemedicine in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and other privacy/security regulations as applicable.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2139-2140 Jan. 1, 2024 & MI Dept. of Health and Human Services., Bulletin 23-10, Telemedicine Policy Post-COVID PHE, Mar. 2, 2023. (Accessed Jan. 2024).

The reimbursement rate for allowable telemedicine services will be the same (also known as “at parity”) as in-person services. This means that all providers will be paid the equivalent amount, no matter the physical location of the beneficiary during the visit. To effectuate this policy, the provider must report the place of service as they would if they were providing the service in-person. See the “Telemedicine Billing Requirements” section of this policy for further details.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2145 Jan. 1, 2024 & MI Dept. of Health and Human Services., Bulletin 23-10, Telemedicine Policy Post-COVID PHE, Mar. 2, 2023, (Accessed Jan. 2024).

Targeted Case Management Services for Recently Incarcerated Beneficiaries

Accessing Services Via In-Reach – The in-reach visit is to be provided face-to-face. Face-to-face is defined as either in-person or via telehealth (i.e., simultaneous audio and visual technology).

SOURCE: MI Bulletin MMP 23-37, Targeted Case Management Services for Recently Incarcerated Beneficiaries, July 1, 2023, (Accessed Jan. 2024).

ELIGIBLE SERVICES/SPECIALTIES

As standard practice, in-person visits are the preferred method of service delivery; however, in cases where this option is not available or in-person services are not ideal or are challenging for the beneficiary, telemedicine may be used as a complement to in-person services. Telemedicine services cannot be continued indefinitely for a given beneficiary without reasonably frequent and periodic in-person evaluations of the beneficiary by the provider to personally reassess and update the beneficiary’s medical treatment/history, effectiveness of treatment modalities, and current medical/behavioral condition and/or treatment plan. Applicable beneficiary records must contain documentation regarding the reason for the use of telemedicine and the steps taken to ensure the beneficiary was provided utilization guidance in an appropriate manner.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2141-2142 Jan. 1, 2024, (Accessed Jan. 2024).

SOURCE: MI Dept. of Health and Human Services, Medicaid Bulletin, 7/5/22, (Accessed Jan. 2024).

Professional Providers

Procedure code and modifier information for all telemedicine services is contained in the MDHHS Telemedicine Services Databases available on the MDHHS website. (Refer to the Directory Appendix for website information.)

Appropriate telemedicine modifiers must be used in conjunction with the appropriate CPT/HCPCS procedure code to identify the professional telemedicine services provided by the distant site provider.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 270-271, Jan. 1, 2024  (Accessed Jan. 2024).

Child Therapy

Telemedicine is approved for Individual Therapy or Family Therapy using approved children’s evidencebased practices (i.e., Trauma Focused Cognitive Behavioral Therapy, Parent Management TrainingOregon, Parenting Through Change) and utilizes the GT modifier when reporting the service. Qualified providers of children’s evidence-based practices have completed their training in the model, its implementation via telehealth, and are able to provide the practice with fidelity.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 339 Jan. 1, 2024  (Accessed Jan. 2024).

Behavioral Health

Behavioral health services may be delivered via telemedicine in accordance with current Medicaid policy. In compliance with the Michigan Insurance Code of 1956 (Act 218 of 1956), telemedicine services must be provided by a health care professional who is licensed, registered, or otherwise authorized to engage in his or her health care profession in the state where the patient is located.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 545 Jan. 1, 2024 (Accessed Jan. 2024).

Brain Injury – Referral and Admission Process

When appropriate, the evaluation may occur through telecommunication technology (telemedicine). MDHHS requires a real-time interactive system at both the originating and distant sites, allowing instantaneous interaction between the patient and the health care professional via the telecommunication system. Telemedicine should be used primarily when travel is prohibitive for the beneficiary. Providers must ensure the privacy of the beneficiary and the security of any information shared via telemedicine.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 552 Jan. 1, 2024 (Accessed Jan. 2024).

Children’s Special Health Care Services

The primary CSHCS benefits may include: …

• Telemedicine

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 588 Jan. 1, 2024 (Accessed Jan. 2024).

Doula Services

It is the expectation that doula services be provided face-to-face with the beneficiary. Prenatal and postpartum services may be delivered via telehealth. Doula providers will be expected to adhere to current MDHHS telemedicine policy.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 684 Jan. 1, 2024  (Accessed Jan. 2024).

Home and Community Based Services

Independent assessment is a face-to-face assessment, conducted by a conflict-free individual or agency. The assessment is based on the individual’s needs and strengths and is part of the person-centered planning process. Telemedicine is an acceptable method of assessment.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 873 Jan. 1, 2024, (Accessed Jan. 2024).

Laboratory – Provider Evaluation

The consultation must be documented in the beneficiary’s medical record and, if performed via telemedicine, should follow all the requirements specified in Medicaid’s telemedicine policy.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 1125 Jan. 1, 2024  (Accessed Jan. 2024).

Maternal Infant Health Program

MIHP agencies may conduct initial assessment visits and professional visits via telehealth. Agencies will be allowed to provide a maximum of up to 40 percent of their total caseload of visits as telehealth, while 60 percent of visits must remain as in-person visits.  This percentage is applied to the agency and not per beneficiary to allow for telehealth visit flexibility dependent on beneficiary needs.

Telehealth visits must include a dual audio/visual platform. Providers must ensure the privacy of the beneficiary and the security of any information shared via telehealth. MDHHS requires either direct or indirect beneficiary consent for all services provided via telehealth. This consent must be properly documented in the beneficiary’s chart in accordance with applicable standards of practice. Telehealth visits must follow policy guidelines and program requirements for typical MIHP initial assessment and professional visits.

Appropriate use of telehealth will be determined by a combination of beneficiary preference and MIHP provider judgement. Examples of when telehealth is an appropriate option may include, but are not limited to, circumstances such as when a beneficiary:

• Refuses an in-person visit and would benefit from receiving MIHP services,
• Has an illness in their household, or
• Needs to share sensitive information that cannot be discussed in the home environment and a transportation barrier exists for an office visit.

Inappropriate use of telehealth may include, but is not limited to, circumstances such as when a beneficiary has no barrier for an in-person visit and does not request a telehealth visit.

Telehealth visits that occur via telephone-only are allowable only when a beneficiary barrier exists for use of an audio/visual platform (e.g., lack of smart phone or internet access). Documentation in the beneficiary’s chart must include the reason for a telephone-only visit.

MIHP providers are required to follow current Medicaid telemedicine policy requirements as applicable.

SOURCE: MI Medicaid Policy Bulletin, MMP 23-17, Apr. 10, 2023, & MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 1158-1158 Jan. 1, 2024  (Accessed Jan. 2024).

Medical Supplier – Face-to-Face (F2F) Visit Requirement

Prior to the initial written order and delivery of selected durable medical equipment and medical supplies (some accessories), the beneficiary must have a face-to-face visit with a physician or NPP within six months prior to the initial written order. The visit must be related to the primary condition that supports the medical need for the equipment or supply. Telemedicine visits (refer to the Telemedicine Chapter) qualify as face-to-face visits.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 1200 Jan. 1, 2024, (Accessed Jan. 2024).

Practitioner – CoCM Services

CoCM services must include:

• Initial assessment: Visit occurring either in-person or via audio-visual telemedicine in which the beneficiary sets goals and is screened by a diagnosis-appropriate and consistent validated clinical rating scale, such as the PHQ-9 or GAD-7, which also must be done prior to subsequent CoCM services.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 1923 Jan. 1, 2024, (Accessed Jan. 2024).

PIHP/CMHSP

The MDHHS Bureau of Specialty Behavioral Health Services requires all the requirements of Telemedicine policy are attained and maintained during all beneficiary visits. In addition to the Determination of Appropriateness/Documentation section of this policy, the Bureau of Specialty Behavioral Health Services would like to reiterate that services delivered to the beneficiary via telemedicine be done at the convenience of the beneficiary, not the convenience of the provider. In addition, these services must be a part of the person-centered plan of service and available as a choice, not a requirement, to the beneficiary.

If the individual (beneficiary) is not able to communicate effectively or independently, they must be provided appropriate on-site support from natural supports or staff. This includes the appropriate support necessary to participate in assessments, services, and treatment.

The PIHP/CMHSP must guarantee the individual is not being influenced or prompted by others when utilizing telemedicine.

Use of telemedicine should ensure and promote community integration and prevent isolation of the beneficiary. Evidence-based practice policies must be followed as appropriate for all services. For services within the community, in-person interactions must be prioritized.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2148 Jan. 1, 2023  & MI Dept. of Health and Human Services., Bulletin 23-10, Telemedicine Policy Post-COVID PHE, Mar. 2, 2023, (Accessed Jan. 2024).

Physical Therapy, Occupational Therapy and Speech Therapy Services

MDHHS will allow select therapy services to be provided via telemedicine when performed by Medicaid enrolled private practice and outpatient hospital physical therapy (PT), occupational therapy (OT) and speech therapy (ST) providers. PT, OT and ST services allowed via telemedicine will be represented by applicable CPT/HCPCS codes on the telemedicine fee schedule. Therapy services provided via telemedicine are intended to be an additional treatment tool and complement in-person services where clinically appropriate for the individual beneficiary.

Documentation re-evaluation, performance, and treatment elements that typically require hands-on contact for measurement or assessment must include a thorough description of how the assessment or performance findings were established via telemedicine. This includes, but is not limited to, such elements as standardized tests, strength, range of motion, and muscle tone.

Initial PT and OT evaluations and oral motor/swallowing services are not allowed via telemedicine and should be provided in-person.

Services that require utilization of equipment during treatment and/or physical hands-on interaction with the beneficiary cannot be provided via telemedicine.

Therapy re-evaluations performed via telemedicine must be provided by a therapist whose facility/clinic has previously evaluated and/or treated the beneficiary in-person.

Durable Medical Equipment (DME) re-assessments performed via telemedicine must be provided by a therapist who has previously evaluated and/or treated the beneficiary in-person, otherwise an in-person visit is required.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2149 Jan. 1, 2024 & MI Dept. of Health and Human Services., Bulletin 23-10, Telemedicine Policy Post-COVID PHE, Mar. 2, 2023, (Accessed Jan. 2024).

Audiology Services

MDHHS will allow speech therapy, auditory rehabilitation, select hearing device adjustments, programming, device performance evaluations, and education or counseling to be performed via telemedicine (simultaneous audio/visual). Remote device programming must be provided in compliance with current U.S. Food and Drug Administration (FDA) guidelines. Auditory brainstem response (ABR) and auditory evoked potential (AEP) testing may also be conducted via telemedicine when performed using remote technology located at a coordinating clinical site with appropriately trained staff (i.e., mobile unit, office/clinic, or hospital).

Reimbursable procedure codes are limited to the specific set of audiology codes listed in the telemedicine fee schedule. Audiology services provided via telemedicine are intended to be an additional treatment tool and complement in-person services where clinically appropriate.

Audiological diagnostic tests (other than those mentioned above), hearing aid examinations, surgical device candidacy evaluations, and other audiology and hearing aid services conducted via telemedicine are not reimbursable by Michigan Medicaid and should be provided in-person.

This policy supplements the existing audiology, hearing aid dealer and speech therapy services policies. All current referral, PA, documentation requirements, standards of care, and limitations remain in effect regardless of whether the service is provided through telemedicine. Providers should refer to the Hearing Services chapter of this Manual for complete information.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2150 Jan. 1, 2024 & MI Dept. of Health and Human Services., Bulletin 23-10, Telemedicine Policy Post-COVID PHE, Mar. 2, 2023, (Accessed Jan. 2024).

Dentistry

Services delivered to the beneficiary via telemedicine must be done for the convenience of the beneficiary, not the convenience of the provider. Services must be performed using simultaneous audio/visual capabilities. All services using telemedicine must be documented in the beneficiary’s record, including the date, time, and duration of the encounter, and any pertinent clinical documentation required per CDT code description. The provider is responsible for ensuring the safety and quality of services provided with telemedicine technologies.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2151-2152 Jan. 1, 2024 & MI Dept. of Health and Human Services., Bulletin 23-10, Telemedicine Policy Post-COVID PHE, Mar. 2, 2023, (Accessed Jan. 2024).

School Services Program (SSP)

Billing and reimbursement for telemedicine services are accomplished using the same methodology as other services; however, the service must be billed using POS 03—school and modifier 95 or modifier 93. Telemedicine claims for SSP are paid according to the Centers for Medicare & Medicaid Services (CMS) approved cost-based methodology used for other services provided within the program and not the information provided previously in this policy. SSP providers are not eligible for the facility fee as the facility is an integral part of the service provided and is covered under the service claim. A database of allowable telemedicine services for SSP can be found on the MDHHS website. (Refer to the Directory Appendix for website information.)

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2151 Jan. 1, 2024, & MI Dept. of Health and Human Services., Bulletin 23-10, Telemedicine Policy Post-COVID PHE, Mar. 2, 2023, (Accessed Jan. 2024).

School Services Program (SSP) PT and OT services, as outlined in this policy, will also be allowed via telemedicine. These services must meet all other telemedicine policies as outlined.

SOURCE:  MI Dept. of Health and Human Services., Bulletin 23-10, Telemedicine Policy Post-COVID PHE, Mar. 2, 2023, & MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2150 Jan. 1, 2024  (Accessed Jan. 2024).

FQHCs and RHCs

Claims for telemedicine services must be submitted using the ASC X 12N 837 5010 form using the appropriate telemedicine HCPCS or CPT code. All telemedicine claims must include the corresponding modifier 95- “Synchronous Telemedicine Service rendered via a real-time interactive audio and video telecommunications system” or 93 – “Synchronous Telemedicine Service rendered via telephone or other real-time interactive audio-only telecommunications system” and the appropriate revenue code.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2152 Jan. 1, 2024  (Accessed Jan. 2024).

Clinics are also permitted to submit for reimbursement telemedicine services (using simultaneous audio/visual technologies) per bulletin MSA 20-09 if all other provisions of telemedicine policy are maintained. Simultaneous audio/visual telemedicine services, as indicated by CPT/HCPCS codes listed on the telemedicine fee schedule and considered qualifying visits, will also be considered face-to-face and will trigger the PPS/AIR if the service billed is listed as a qualifying visit.

Center (THC)/ Tribal Federally Qualified Health Centers (Tribal FQHC) Considerations – PT, OT and ST, when provided in accordance with this policy using both audio/visual modalities, will be considered face-to-face and will trigger the PPS AIR if the service billed is listed as a qualifying visit.

For FQHCs, RHCs, THCs and Tribal FQHCs, the appropriate CPT/HCPCS code, PPS/AIR payment code (if the service generates a Qualifying Visit), and modifier 95 – synchronous telemedicine must be used. Refer to www.michigan.gov/medicaidproviders >> Provider Specific Information for additional information.

SOURCE:  MI Dept. of Health and Human Services., Bulletin 23-10, Telemedicine Policy Post-COVID PHE, Mar. 2, 2023, (Accessed Jan. 2024).

Healthy Michigan Plan – Diabetes Prevention Program (MiDPP)

Sessions may take place in the following modalities and make-up sessions are encouraged:

• In-person
• Distance Learning (synchronous audio-visual or audio-only telemedicine): Lifestyle coaches deliver sessions where the coach is present in one location and participants are participating from another location. Claims for an audio-only session must include the appropriate procedure code, place of service code and modifier 93 and claims for an audio-visual session must include the appropriate
  procedure code, place of service code and modifier 95.
• Online: An asynchronous mode of delivery where participants log into course sessions via a computer, tablet, or smart phone. Per CDC requirements, MiDPP lifestyle coach interaction (in person or via synchronous telemedicine) is required and must be no less than once per week during the first six months and once per month during the second six months.

When billing for a telemedicine session, synchronous or asynchronous, MiDPP providers are expected to adhere to current MDHHS telemedicine policy and modifiers. Refer to the Michigan Medicaid Telemedicine Fee schedule for the list of current codes acceptable for MiDPP telemedicine claims. Claims for an asynchronous session must include the appropriate procedure code and the following remark: “Service provided via an asynchronous telemedicine platform”.

SOURCE: MI Bulletin MMP 23-33, Michigan Diabetes Prevention Program (MiDPP), July 1, 2023, (Accessed Jan. 2024).

Psychiatric Residential Treatment Facilities (PRTF)

The Prepaid Inpatient Health Plan (PIHP) is responsible for managing Medicaid mental health services for all Medicaid beneficiaries residing within the service area covered by the PIHP. This includes the responsibility for timely screening, referral and certification of requests for admission to, PRTF services, defined as follows:

• Screening means the PIHP has been notified of the youth and has been provided enough information to support a referral to a PRTF based on the admission criteria established below.  The screening may be provided on-site, face-to-face by PIHP personnel, the telephone or via a video conference platform.
• Certification means the PIHP has screened the youth and has documented that the services requested seem appropriate. Telephone screening must be followed by the written certification.
• All PRTC service authorizations will be made by MDHHS. The PIHP should make referrals when appropriate and will be actively involved in treatment planning/monitoring meetings, discharge planning and transition to the community.

SOURCE: MI Bulletin MMP 23-39, Psychiatric Residential Treatment Facilities (PRTF), July 1, 2023, (Accessed Jan. 2024).

Dialysis

MDHHS follows the Medicare billing guidelines for hemodialysis and peritoneal dialysis for both in-person and telemedicine visits.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 1000 Jan. 1, 2024, (Accessed Jan. 2024).

ELIGIBLE PROVIDERS

In compliance with the Michigan Insurance Code of 1956 (Act 218 of 1956), telemedicine services must be provided by a provider who is licensed, registered, or otherwise authorized to engage in his or her health care profession in the state where the beneficiary is located. The provider at the distant site who is licensed under State law to furnish a covered telemedicine service (as described in the Allowable Services subsection) may bill, and receive payment for, the service when it is delivered via a telecommunications system.

If providing services through the Prepaid Inpatient Health Plan (PIHP)/Community Mental Health Services Program (CMHSP), the provider must have a contract with or be authorized by the appropriate entity. To be reimbursed for services, providers must be enrolled in Michigan Medicaid.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2139 Jan. 1, 2024  (Accessed Jan. 2024).

Distant site is defined as the location of the provider providing the professional service at the time of the telemedicine visit. This definition encompasses the provider’s office, or any established site considered appropriate by the provider, so long as the privacy of the beneficiary and security of the information shared during the telemedicine visit are maintained.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2142, Jan. 1, 2024  (Accessed Jan. 2024).

A CMH/PIHP can be either an originating or distant site for telemedicine services. Practitioners must meet the provider qualifications for the covered service provided via telemedicine.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 354 Jan. 1, 2024  (Accessed Jan. 2024).

Assertive Community Treatment Program

Typically, although not exclusively, physician activities may include team meetings, beneficiary appointments during regular office hours, psychiatric evaluations, psychiatric meetings/consultations, medication reviews, home visits, telephone consultations and telemedicine.

Typically, although not exclusively, physician assistant activities may include team meetings, beneficiary appointments during regular office hours, evaluations, psychiatric meetings/consultations, medication reviews, home visits, telephone consultations and telemedicine.

Typically, although not exclusively, nurse practitioner/clinical nurse specialist activities may include team meetings, beneficiary appointments during regular office hours, evaluations, psychiatric meetings/consultations, medication reviews, home visits, telephone consultations and telemedicine.

The telemedicine modifier must be used in conjunction with the ACT encounter reporting code when telemedicine is used.

All telemedicine interactions shall occur through real-time interactions between the ACT consumer and the physician/nurse practitioner/physician’s assistant/clinical nurse specialist from their respective physical location. Psychiatric services are the only ACT services that are approved to be provided in this manner.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 364-265 Jan. 1, 2024  (Accessed Jan. 2024).

Behavioral Health

Behavioral health services may be delivered via telemedicine in accordance with current Medicaid policy. In compliance with the Michigan Insurance Code of 1956 (Act 218 of 1956), telemedicine services must be provided by a health care professional who is licensed, registered, or otherwise authorized to engage in his or her health care profession in the state where the patient is located.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 544 Jan. 1, 2024  (Accessed Jan. 2024).

Federally Qualified Health Centers

An FQHC can be either an originating or distant site for telemedicine services.

An allowable FQHC encounter means a face-to-face medical visit or an interaction using a qualifying telemedicine modality (audio/visual or audio-only) between a patient and the provider of health care services who exercises independent judgment in the provision of health care services. Encounters may be classified as medical, dental, or behavioral health.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 747 & 749, Jan. 1, 2024  (Accessed Jan. 2024).

Hospital

A hospital can be either an originating or distant site for telemedicine services. Refer to the Billing & Reimbursement for Institutional Providers Chapter for specific billing instructions.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 1023, Jan. 1, 2024  (Accessed Jan. 2024).

Nursing Facility

A nursing facility can be either an originating or distant site for telemedicine. Refer to the Billing & Reimbursement for Institutional Providers Chapter for information regarding billing the originating site facility fee.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 1557, Jan. 1, 2024  (Accessed Jan. 2024).

Rural Health Clinic

An RHC can be either an originating or distant site for telemedicine services. Refer to the Billing & Reimbursement for Institutional Providers Chapter for specific billing instructions.

An encounter is a face-to-face visit or an interaction using a qualifying telemedicine modality (audio/visual or audio-only) between a patient and the provider of health care services who exercises independent judgment in the provision of health care services. For a health service to be defined as an encounter, the provision of the health service must be recorded in the patient’s medical record. Encounters may be classified as medical or behavioral health.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 1992-1993, Jan. 1, 2024  (Accessed Jan. 2024).

When the outpatient facility provides administrative support for a telemedicine service, the outpatient hospital facility may bill the hospital outpatient clinic visit on the institutional claim with modifier 95 or modifier 93 and the appropriate revenue code.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2148, Jan. 1, 2024, & MI Dept. of Health and Human Services., Bulletin 23-10, Telemedicine Policy Post-COVID PHE, Mar. 2, 2023, (Accessed Jan. 2024).

PIHP/CMHSP

PIHP/CMHSP providers must submit encounters for audio/visual telemedicine with POS 02 or 10 (as applicable) and for audio-only POS 02 or 10 (as applicable) and Modifier 93.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2147, Jan. 1, 2024 & Bulletin 23-10, Telemedicine Policy Post-COVID PHE, Mar. 2, 2023, (Accessed Jan. 2024).

Telemedicine is allowed for all services indicated in the Bureau of Specialty Behavioral Health Services Telemedicine Database. The features of what will be counted as a telemedicine visit need to align with the same standards of an in-person visit. Any phone call or web platform used to schedule, obtain basic information or miscellaneous work that would have been billed as a non-face-to-face and therefore non-billable contact, will remain non-billable. Telemedicine visits must include service provision as indicated in the IPOS and should reflect work towards or review of goals and objectives indicated forthwith.

Medicaid beneficiaries whose needs do not render them eligible for specialty services and supports through the PIHPs/CMHSPs may receive outpatient mental health services through Medicaid FFS or MHPs as applicable. These FFS/MHP enrolled non-physician behavioral health services may be provided via telemedicine when performed by Medicaid-enrolled psychologists, social workers, counselors, and marriage and family therapists. Services are covered when performed in a non-facility setting or outpatient hospital clinic. All applicable services are listed in the telemedicine audio/visual and audio-only fee schedules [databases].

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2149 Jan. 1, 2024 & MI Dept. of Health and Human Services., Bulletin 23-10, Telemedicine Policy Post-COVID PHE, Mar. 2, 2023, (Accessed Jan. 2024).

Physical Therapy, Occupational Therapy and Speech Therapy Services

This policy supplements existing PT, OT, and ST services policy. All current therapy referral, PA, documentation requirements, standards of care, and limitations remain in effect regardless of whether the service is provided through telemedicine. All telemedicine therapy services will count toward the beneficiary’s therapy service limits. (Refer to the Therapy Services chapter for additional information.)

Modifier 95 should be used in addition to the required modifiers for therapy services as outlined in therapy policy.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2149 Jan. 1, 2024  (Accessed Jan. 2024).

Dentistry

MDHHS will allow dentists to provide the limited oral evaluation (Current Dental Terminology [CDT] code D0140) via telemedicine (simultaneous audio/visual) technology so long as all other telemedicine policy is followed.

All requirements of the general telemedicine policy must be followed when providing the limited oral evaluation via telemedicine, including scope of practice requirements, contingency plan, and the use of both audio/visual service delivery unless otherwise indicated by federal guidance.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2150 Jan. 1, 2024 & MI Dept. of Health and Human Services., Bulletin 23-10, Telemedicine Policy Post-COVID PHE, Mar. 2, 2023, (Accessed Jan. 2024).

Billing instructions depend upon the claim format used:

• American Dental Association (ADA) Claim Format: Use POS 02 or POS 10.
• Institutional Claim Format: POS 02 and POS 10 are not required; Use modifier 95.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2151 Jan. 1, 2024  (Accessed Jan. 2024).

Vision

Telemedicine vision services can be provided through a Medicaid-enrolled provider who can report E/M services as listed in the telemedicine fee schedules.

An intermediate ophthalmological exam can be provided via telemedicine for an established patient with a known diagnosis. The provider must have a previous in-person encounter with the beneficiary to ensure the provider is knowledgeable of the beneficiary’s current medical history and condition. For cases in which the provider must refer the beneficiary to another provider, a consulting provider is not required to have a pre-existing provider-patient relationship if the referring provider shares medical history, past eye examinations, and any related beneficiary diagnosis with the consulting provider. Intermediate ophthalmological exam codes should not be used to diagnose eye health conditions (an initial diagnosis). When medically necessary, providers must refer beneficiaries for an in-person encounter to receive a diagnosis and/or care. Telemedicine cannot act as a replacement for recommended in-person interactions.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2151 Jan. 1, 2024, & MI Dept. of Health and Human Services., Bulletin 23-10, Telemedicine Policy Post-COVID PHE, Mar. 2, 2023, (Accessed Jan. 2024).

School Services Program (SSP)

Because of the unique circumstances regarding the delivery of services within the School Services Program (SSP), telemedicine may be the primary delivery modality for some beneficiaries; however, the decision to use telemedicine should be based on the needs or convenience of the beneficiary, and not those of the provider.

In cases where the beneficiary is unable to use telemedicine equipment without assistance, an attendant must be provided by the provider. The attendant must be trained in the use of the telemedicine equipment to the point where they can provide adequate assistance. The attendant must also be available for the entire telemedicine session; however, they should also ensure the beneficiary’s privacy to the greatest extent possible. When the originating site for the service is the student’s home, any cost for an attendant is not reimbursable.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2151 Jan. 1, 2024, & MI Dept. of Health and Human Services., Bulletin 23-10, Telemedicine Policy Post-COVID PHE, Mar. 2, 2023, (Accessed Jan. 2024).

Durable Medical Equipment (DME) Providers

All DME providers must reference the Medical Supplier chapter of this Manual for specific requirements in the provision of services via telemedicine.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2127 Jul. 1, 2023  (Accessed Jan. 2024).

FQHCs and RHCs

All current Medicaid policy for telemedicine services, including definitions, requirements and parameters of telemedicine, apply to FQHCs and RHCs. FQHCs and RHCs are responsible for ensuring compliance with all telemedicine policy.

Distant site services provided by qualified Medicaid enrolled providers may be covered when the qualified provider is employed by the clinic or working under the terms of a contractual agreement with the clinic. FQHCs and RHCs must maintain all practitioner contracts and provide them to MDHHS upon request.

During the Medicaid provider enrollment process, contracted providers must associate to the FQHC or RHC billing NPI. Refer to the Billing & Reimbursement for Institutional Providers chapter of this Manual for further information.

PPS is reimbursed according to the billing rules described below (See manual).

If both the originating and distant sites submit identical procedure code(s) for a telemedicine visit for the same beneficiary on the same date of service, it is considered duplicate billing. MDHHS will recover payment from the appropriate FQHC, RHC, or contracted provider. Recovery will be based on the terms specified in the contract.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2152-2153 Jan. 1, 2024  (Accessed Jan. 2024).

Tribal FQHC

A Tribal facility may choose to enroll as a Tribal FQHC and be reimbursed for outpatient face-to-face visits within the FQHC scope of services provided to Medicaid beneficiaries, including telemedicine and services provided by contracted employees. Tribal FQHCs are eligible to receive the IHS outpatient AIR for eligible encounters.

A Tribal Health Clinic can be either an originating or distant site.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2197 & 2201, Jan. 1, 2024  (Accessed Jan. 2024).

ELIGIBLE SITES

Originating site is defined as the location of the eligible beneficiary at the time of the telemedicine service.

Authorized originating sites include:

• County mental health clinic or publicly funded mental health facility
• Federally Qualified Health Center (FQHC)
• Hospital (inpatient, outpatient, or critical access hospital)
• Office of a physician or other provider (including medical clinics)
• Hospital-based or Critical Access Hospital (CAH)-based Renal Dialysis Centers (including satellites)
• Rural Health Clinic (RHC)
• Skilled nursing facility
• Tribal Health Center (THC)
• Local Health Department (LHD) as defined in Sections 333.2413, 333.2415 and 333.2421 of the Michigan Public Health Code (PA 368 of 1978 as amended)
• Home, as defined as a location, other than a hospital or other facility, where the beneficiary receives care in a private residence
• Other established site considered appropriate by the provider (in accordance with clinical judgement)

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2142, Jan. 1, 2024, & MI Dept. of Health and Human Services. Bulletin 20-09, General Telemedicine Policy, Mar. 12, 2020, [Provider Bulletin 23-10 indicates policy is permanent] (Accessed Jan. 2024).

Effective March 1, 2020. The distant site is defined as the location of the practitioner, providing the professional service at the time of the telemedicine visit. The definition encompasses the providers office or any established site, considered appropriate by the provider so long as the privacy of the beneficiary and security of the information shared during the telemedicine visit are maintained.

Telemedicine services where “home” or another “establish site, considered appropriate by the provider” are utilized as the originating site or not eligible to receive the telehealth facility fee. Distant site providers in these situations are instructed to bill the appropriate current procedural term analogy HCPCS code for the services provided.

Neither the originating site or the distant side is permitted to bill both the telehealth facility and the code for the professional service for the same beneficiary at the same time.

SOURCE:  MI Dept. of Health and Human Services. Bulletin 20-09, General Telemedicine Policy, Mar. 12, 2020, [Provider Bulletin 23-10 indicates policy is permanent] (Accessed Jan. 2024).

All audio/visual telemedicine services, as allowable on the telemedicine fee schedule and submitted on the professional invoice, must be reported with the Place of Service (POS) code that would be reported as if the beneficiary were in-person for the visit along with modifier 95—”Synchronous Telemedicine Service rendered via a real-time interactive audio and video telecommunications system”.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2146, Jan. 1, 2024 & Bulletin 23-10, Telemedicine Policy Post-COVID PHE, Mar. 2, 2023, (Accessed Jan. 2024).

PIHP/CMHSP providers must submit encounters for audio/visual telemedicine with POS 02 or 10 (as applicable) and for audio-only POS 02 or 10 (as applicable) and Modifier 93.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2147, Jan. 1, 2024 & Bulletin 23-10, Telemedicine Policy Post-COVID PHE, Mar. 2, 2023, (Accessed Jan. 2024).

For PIHP/CMHSP service providers, refer to the MDHHS Bureau of Specialty Behavioral Health Services Telemedicine Database and the Audio-Only Telemedicine Database on the MDHHS website for services allowed via both audio/visual and audio-only telemedicine.

This information should be used in conjunction with the Billing & Reimbursement for Professionals and the Billing & Reimbursement for Institutional Providers Chapters as well as the Medicaid Code and Rate Reference tool and other related procedure databases/fee schedules located on the MDHHS website.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2147, Jan. 1, 2024, (Accessed Jan. 2024).

For services submitted on the institutional invoice, the appropriate National Uniform Billing Committee (NUBC) revenue code, along with the appropriate telemedicine CPT/HCPCS procedure code and modifier 95 or modifier 93, must be used.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2147, Jan. 1, 2024, (Accessed Jan. 2024).

Beginning October 1, 2020, telemedicine services are covered under the medical assistance program and Healthy Michigan program if the originating site is an in-home or in-school setting, in addition to any other originating site allowed in the Medicaid provider manual or any established site considered appropriate by the provider.

SOURCE: MI Compiled Laws Sec. 400.105h. (Accessed Jan. 2024).

Federally Qualified Health Centers

An FQHC can be either an originating or distant site for telemedicine services.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 747 Jan. 1, 2024  (Accessed Jan. 2024).

Hospital

A hospital can be either an originating or distant site for telemedicine services. Refer to the Billing & Reimbursement for Institutional Providers Chapter for specific billing instructions.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 1023, Jan. 1, 2024. (Accessed Jan. 2024).

Nursing Facility

A nursing facility can be either an originating or distant site for telemedicine. Refer to the Billing & Reimbursement for Institutional Providers Chapter for information regarding billing the originating site facility fee.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 1557, Jan. 1, 2024. (Accessed Jan. 2024).

Pharmacy

In the event that the beneficiary is unable to physically access an in-person (revised per bulletin MMP 23-20) care setting, an eligible pharmacist may provide MTM services via telemedicine. Telemedicine is the use of telecommunications and information technologies for the exchange of encrypted patient data for the provision of services. Telemedicine must be obtained through real-time interactions between the beneficiary’s physical location (originating site) and the pharmacist provider’s physical location (distant site). MTM telemedicine audio/visual services are provided to beneficiaries through hardwire or internet connection. It is the expectation that providers and facilitators involved in telemedicine are trained in the use of equipment and software prior to servicing beneficiaries. The arrangements for telemedicine will be made by the pharmacist. The administration of telemedicine services is subject to the same provision of services that are provided to a beneficiary in person. Providers must ensure the privacy of the beneficiary and secure any information shared via telemedicine. Refer to the Telemedicine chapter for additional information regarding telemedicine service provision.

For services provided through telemedicine, each procedure code must include the modifier 95.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 1840, Jan. 1, 2024. (Accessed Jan. 2024).

Rural Health Clinic

An RHC can be either an originating or distant site for telemedicine services. Refer to the Billing & Reimbursement for Institutional Providers Chapter for specific billing instructions.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 1992, Jan. 1, 2024. (Accessed Jan. 2024).

Dentistry

Billing instructions depend upon the claim format used:

• American Dental Association (ADA) Claim Format: Use POS 02 or POS 10.
• Institutional Claim Format: POS 02 and POS 10 are not required; Use modifier 95.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2151 Jan. 1, 2024. (Accessed Jan. 2024).

FQHC/RHC

If both the originating and distant sites submit identical procedure code(s) for a telemedicine visit for the same beneficiary on the same date of service, it is considered duplicate billing. MDHHS will recover payment from the appropriate FQHC, RHC, or contracted provider. Recovery will be based on the terms specified in the contract.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2153 Jan. 1, 2024. (Accessed Jan. 2024).

Tribal Health Centers

A Tribal Health Clinic can be either an originating or distant site.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2201 Jan. 1, 2024. (Accessed Jan. 2024).

Tribal FQHCs are eligible to receive all-inclusive rate (AIR) reimbursement for clinic services provided outside of the four walls of the facility, including telemedicine and services provided by contracted employees.

SOURCE: MI Medical Services Administration Bulletin MSA 20-60, Sept. 1, 2020. (Accessed Jan. 2024).

GEOGRAPHIC LIMITS

No Reference Found

FACILITY/TRANSMISSION FEE

Allowable originating sites are permitted to submit claims for the telehealth facility fee. This fee is intended to reimburse the provider for the expense of hosting the beneficiary at their location. To submit this code, the originating site must ensure the technology is functioning, the privacy of the beneficiary is secured, and that the information is shared confidentially.

Telemedicine services where “home” or another “established site considered appropriate by the provider” are utilized as the originating site are not eligible to receive the telehealth facility fee. Distant site providers in these situations are instructed to bill the appropriate Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) code (as represented by the Telemedicine database) for the service(s) provided.

Neither the originating site nor the distant site is permitted to bill both the telehealth facility fee and the code for the professional service for the same beneficiary at the same time.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2146 Jan. 1, 2024, & MI Dept. of Health and Human Services. Bulletin 20-09, General Telemedicine Policy, Mar. 12, 2020, [Provider Bulletin 23-10 indicates policy is permanent] (Accessed Jan. 2024).

Institutional Providers

To be reimbursed for the originating site facility fee, the hospital must bill the appropriate telemedicine NUBC revenue code with the appropriate telemedicine facility fee code and modifier.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 188 & 202 Jan. 1, 2024. (Accessed Jan. 2024).

Professional Providers

To be reimbursed for the originating site facility fee, the originating site provider must bill the telehealth facility fee. MDHHS will reimburse the originating site provider the current Medicaid fee screen. Additional services provided at the originating site on the same date as the telemedicine service may be billed and reimbursed separately according to published policy.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 270 Jan. 1, 2024. (Accessed Jan. 2024).

Nursing Facility

To be reimbursed for the originating site facility fee, the NF must bill the appropriate telemedicine NUBC revenue code with the appropriate telemedicine facility fee and modifier.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 215 Jan. 1, 2024. (Accessed Jan. 2024).

FQHCs and RHCs

The telehealth facility fee does not qualify as a face-to-face visit and does not generate the PPS payment. Telemedicine service(s) provided at the distant site that qualify as a face-to-face visit may generate the PPS payment. All current PPS rules and encounter criteria apply to telemedicine visits. Refer to the Federally Qualified Health Centers and the Rural Health Clinics chapters of this Manual and the FQHC and RHC reimbursement lists on the MDHHS website for further information. (Refer to the Directory Appendix for website information.)

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2152 Jan. 1, 2024. (Accessed Jan. 2024).

POLICY

Medical assistance covers medically necessary services and consultations delivered by a health care provider through telehealth in the same manner as if the service or consultation was delivered through in-person contact.  Services or consultations delivered through telehealth shall be paid at the full allowable rate.

SOURCE: MN Statute Sec. 256B.0625, Subdivision 3b(a). (Accessed Feb. 2024).

MHCP programs will cover telehealth services in the same manner as any other benefits covered through the programs. Coverage will not be limited on the basis of geography or location. Out-of-state coverage policy applies to services provided via telehealth.

SOURCE: MN Dept. of Human Services, Provider Manual, Telehealth Services, As revised Jun. 2, 2023. (Accessed Feb. 2024).

Minnesota’s Medical Assistance program reimburses live video for fee-for-service programs.

Providers must self-attest that they meet all of the conditions of the MHCP telehealth policy by completing and submitting the Telehealth Provider Assurance Statement (DHS-6806) (PDF) to be eligible for reimbursement.

SOURCE: MN Dept. of Human Services, Provider Manual, Physician and Professional Services (Telehealth), As revised Nov. 8, 2023. (Accessed Feb. 2024).

ELIGIBLE SERVICES/SPECIALTIES

MHCP programs will cover telehealth services in the same manner as any other benefits covered through the programs. Coverage will not be limited on the basis of geography or location. Out-of-state coverage policy applies to services provided via telehealth.

SOURCE: MN Dept. of Human Services, Provider Manual, Telehealth Services, As revised Jun. 2, 2023. (Accessed Feb. 2024).

The CPT and HCPC codes that describe a telehealth service are generally the same codes that describe an encounter when the health care provider and patient are at the same site. Examples of eligible services:

• Consultations
• Telehealth consults: emergency department or initial inpatient care
• Subsequent hospital care services with the limitation of one telehealth visit every 30 days per eligible provider
• Subsequent nursing facility care services with the limitation of one telehealth visit every 30 days
• End-stage renal disease services
• Individual and group medical nutrition therapy
• Individual and group diabetes self-management training with a minimum of one hour of in-person instruction to be furnished in the initial year training period to ensure effective injection training
• Smoking cessation [in telehealth services manual only]
• Alcohol and substance abuse (other than tobacco) structured assessment and intervention services

SOURCE: MN Dept. of Human Services, Provider Manual, Physician and Professional Services (Telehealth), As revised Nov. 8, 2023 & Telehealth Services, As revised Jun. 2, 2023. (Accessed Feb. 2024).

Telehealth does not include:

Non-covered services:

• See list above from Telehealth Services manual page.

SOURCE: MN Dept. of Human Services, Provider Manual, Physician and Professional Services (Telehealth), As revised Nov. 8, 2023, (Accessed Feb. 2024).

Two-way interactive video consultation in an emergency department (ED)

Two-way interactive video consultation may be billed when no physician is in the ED and the nursing staff is caring for the patient at the originating site. The ED physician at the distant site bills the ED CPT codes with place of service 02. Nursing services at the originating site would be included in the ED facility code. If the ED physician requests the opinion or advice of a specialty physician at a “hub” site, the ED physician bills the ED CPT codes and the consulting physician bills the consultation E/M code with place of service 02.

SOURCE: MN Dept of Human Services, Telehealth Services Manual, Jun. 2, 2023. (Accessed Feb. 2024).

Mental Health Services

Subject to federal approval, mental health services that are otherwise covered by medical assistance as direct face-to-face services may be provided via telehealth in accordance with subdivision 3b.

SOURCE: MN Statute Sec. 256B.0625, Subd. 46. (Accessed Feb. 2024).

MHCP members eligible for mental health services can receive mental health services delivered through telehealth.

Mental health services covered by medical assistance as direct face-to-face services may be provided via telehealth and are covered by MHCP. For mental health services or assessments delivered through telehealth that are based on an individual treatment plan, the provider may document the client’s verbal approval or electronic written approval of the treatment plan or change in the treatment plan in lieu of the client’s signature.

Authorization is required for mental health services delivered through telehealth if authorization is required for the same service through in-person contact.

SOURCE: MN Dept. of Human Services, Provider Manual, Telehealth Delivery of Mental Health Services, Revised Oct. 17, 2022, (Accessed Feb. 2024).

Assertive Community Treatment and Intensive Residential Treatment Services

Physician services that are not separately billed may be included in the rate to the extent that a psychiatrist, or other health care professional providing physician services within their scope of practice, is a member of the intensive residential treatment services treatment team. Physician services, whether billed separately or included in the rate, may be delivered by telehealth.

SOURCE:  MN Statute Sec 256B.0622, subdivision 8(e), (Accessed Feb. 2024).

Individualized Education Program (IEP)

Telehealth coverage applies to a child or youth who is MA eligible, has an IEP and the service provided is identified in the IEP. Whether the originating site is a home or school must be documented in the child’s health record.  Limited to three visits per week per child or youth.

To be eligible for reimbursement, the school or school district must self-attest that the telehealth services provided by the professional provider either employed by or contracted by the school meet all of the conditions of the MHCP telehealth policy by completing the Provider Assurance Statement for Telehealth (DHS-6806) (PDF).

Non-Covered Services:

• Evaluation or assessments that are less effective than if provided in-person, face-to-face
• Supervision evaluations or visits
• Personal care assistants
• Nursing services
• Transportation services
• Electronic connections that are conducted over a website that is not secure and encrypted as specified by the Health Insurance Portability & Accountability Act of 1996 Privacy & Security rules (for example, Skype)
• Prescription renewals
• Scheduling a test or appointment
• Clarification of issues from a previous visit
• Reporting test results
• Non-clinical communication
• Communication via telephone, email or fax

Use the same HCPC codes and modifiers that describe the IEP services being performed via telehealth as you would if the service was being provided in person with the child at the same site.

IEP Telehealth Place of Service Codes:

Originating site

• Use place of service 10 on claims to indicate when the child receives the health-related service via telecommunication technology in the child’s home. This is a location other than a hospital or other facility where the child receives care in a private residence.

Distant site

• Use place of service 02 on claims to indicate when the child receives the health-related service via telecommunication technology when the child is in a location other than a child’s home.

SOURCE: MN Dept. of Human Svcs., Provider Manual, IEP Services, Revised May 19, 2022, (Accessed Feb. 2024).

The following medically necessary substance use disorder (SUD) services provided by eligible SUD providers via telehealth are covered:

• Comprehensive assessments
• Individual and group treatment services
• Peer recovery support services

See the Telehealth Services section of the MHCP Provider Manual for noncovered telehealth services.

SOURCE: Substance Use Disorder Telehealth, May 23, 2023, (Accessed Feb. 2024).

Child Welfare Targeted Case Management (CW-TCM)

Case management activities are those that help the eligible member gain access to needed medical, social, educational and other services as identified in an individual service plan. Only services delivered on a face-to-face or interactive video basis are claimable as CW-TCM unless the client is in placement more than 60 miles beyond county or reservation boundaries. If a client is in placement more than 60 miles beyond county or reservation boundaries, a provider may deliver services using telephone or interactive video contact for two consecutive months. There must be a face-to-face contact in the month before the eligible telephone or ITV contacts when children have been and continue to be in placement.  See manual for examples of CW-TCM activities.

Interactive video means the delivery of targeted case management services in real time through the use of two-way interactive audio and visual communication, or accessible video-based platforms.

CW-TCM services may be provided through ITV according to Minnesota Statutes, 256B.0625, subdivision 20b and reimbursed according to Minnesota Statutes, 256B.094, subdivision 6. ITV or face-to-face contact meets the minimum face-to-face contact requirements for CW-TCM services with the exception of children in out-of-home placement or receiving case management for child protection reasons require an eligible in-person contact.

Exception – if the child is placed more than 60 miles beyond the county or reservation boundaries, telephone contact or ITV, is claimable for up to two consecutive months and there must be face-to-face contact at least once every three months. Providers must have a Targeted Case Management Provider Interactive Video Assurance Statement (DHS-8398) on their provider file to provide services via ITV.

SOURCE: MN Dept. of Human Svcs., Child Welfare Targeted Case Management (CW-TCM), Jan. 11, 2024, (Accessed Feb. 2024).

Dental

MHCP allows payment for teledentistry services.  Reimbursement for teledentistry is the same as face-to-face encounters. See list of codes, documentation and billing requirements in provider manual.  A provider must self-attest to meet all the conditions of the MHCP telehealth policy by completing the Provider Assurance Statement for telehealth.

Covered Services (See manual for exact CDT codes):

• Periodic oral evaluation (with an established patient)
• Limited oral exam
• Oral evaluation for a patient under 3 years of age
• Comprehensive oral evaluation (new or established patient)
• Intraoral (complete series of radiographic images)
• Intraoral (periapical first radiographic image)
• Intraoral (periapical each additional radiographic image)
• Bitewing (single radiographic image)
• Bitewings (two radiographic images)
• Bitewings (four radiographic images)
• Intraoral—occlusal radiographic image
• Panoramic radiographic imaging
• Medical dental consultation

Limitations

• MHCP will pay for only one reading or interpretation of diagnostic tests such as X-rays, lab tests and diagnostic assessment.
• Payment is not available to providers for sending materials.
• Out-of-state coverage policy applies to services provided via teledentistry services
• Consultations performed by providers who are not located in Minnesota and contiguous counties require authorization prior to the service being provided.

SOURCE (Dental): MN Dept. of Human Svcs., Provider Manual, Dental Svcs. Jan. 16, 2024 (Accessed Feb. 2024).

Early Intensive Developmental and Behavioral Intervention (EIDBI) services

Telehealth is an option for Early Intensive Developmental and Behavioral Intervention (EIDBI) services.

Eligible services include:

• Comprehensive multi-disciplinary evaluation
• Coordinated care conference
• Family/caregiver training and counseling
• Individual treatment plan (ITP) development and progress monitoring
• Intervention- group or individual only (higher intensity intervention sessions cannot occur via telehealth)
• Observation and direction

See grid for more information.

SOURCE: MN Dept. of Human Svcs., EIDBI Services Benefits billing grid, updated Dec. 2023 & MN Dept. of Human Services, EIDBI Benefit Policy Manual, EIDBI Telehealth Services.  Mar. 16, 2022. (Accessed Feb. 2024).

Medical assistance covers medically necessary EIDBI services and consultations delivered via telehealth, as defined under section 256B.0625, subdivision 3b, in the same manner as if the service or consultation was delivered in person.

SOURCE: MN Statute Sec. 256B.0949, Subdivision. 13. (Accessed Feb. 2024).

Rehabilitation Services

MHCP allows payment for some rehabilitation services through telehealth. Physical and occupational therapists, speech-language pathologists and audiologists may use telehealth to deliver certain covered rehabilitation therapy services that they can appropriately deliver via telehealth. Service delivered by this method must meet all other rehabilitation therapy service requirements and providers must adhere to the same standards and ethics as they would if the service was provided face to face. Must use GT or GQ modifiers.  Providers must self-attest that they meet all of the conditions of MHCP telehealth policy by completing the “Provider Assurance Statement for Telehealth”.   When submitting claims for telehealth services, use place-of-service code 02 to certify that the services meets the telehealth requirements. The GQ modifier is required when billing for services via asynchronous telecommunication systems.

Limited to three sessions per week per member.  Payment not available for sending materials to a recipient, other providers or other facilities. Payment is made only for one reading or interpretation of diagnostic tests such as x-rays, lab tests, and diagnostic assessments.

Noncovered services:

• Electronic connections that are not conducted over a secure encrypted website as specified by HIPAA
• Scheduling a test or appointment
• Clarification of issues from a previous visit
• Reporting test results
• Non-clinical communication
• Communication via telephone, email or fax

SOURCE: MN Dept. of Human Svcs., Provider Manual, Rehabilitation Svcs. Jan. 25, 2022 (Accessed Feb. 2024).

Medication Therapy Management Services (MTMS)

Under certain circumstances MTMS can be delivered via interactive video.  See section on “eligible sites” for more information.  To be eligible providers must submit a provider assurance statement, use equipment compliant with HIPAA (see manual for details) and use the GT modifier and 02 POS code.

Noncovered services:

• Encounters in the inpatient setting
• Encounters in skilled nursing facilities
• Encounters for MTMS for dual-eligible members

MTMS services delivered by telehealth must meet all state and federal requirements for equipment, privacy and billing, including the following:

SOURCE: MN Dept. of Human Svcs., Provider Manual, Medication Therapy Management Svcs. Nov. 3, 2021 (Accessed Feb. 2024).

Medication therapy management services may be provided via telehealth as defined in subdivision 3b and may be delivered into a patient’s residence. Reimbursement shall be at the same rates and under the same conditions that would otherwise apply to the services provided. To qualify for reimbursement under this paragraph, the pharmacist providing the services must meet the requirements of paragraph (b).

SOURCE:  256B.0625(Subd)(13h)(d), (Accessed Feb. 2024).

Behavioral Health Home Services

If an member accepts the offer for a face-to-face visit at six months, providers who are eligible to provide services via telehealth may do so. Providers must have a valid Telehealth Provider Assurance Statement (DHS-6806) (PDF) on file with DHS and must comply with all MA telehealth requirements for equipment, privacy and billing to serve individuals receiving BHH services through telehealth. Refer to the following sections for requirements, billing and additional information:

• Telehealth subsection of the Physician and Professional Services MHCP Provider Manual section
• Telehealth Delivery of Mental Health Services

SOURCE: MN Department of Human Services, Behavioral Health Home Services, Sept. 1, 2023. (Accessed Feb. 2024).

Targeted Case Management

Interactive video means the delivery of targeted case management services in real time through the use of two-way interactive audio and visual communication, or accessible video-based platforms.

MH-TCM services may be provided through ITV according to Minnesota Statutes 256B.0625, subdivision 20b. ITV or face-to-face contact meets the minimum face-to-face contact requirements for MH-TCM services with the exception of children in out-of-home placement who require an in-person or face-to-face visit only.

Children and youth in foster care for whom a responsible social service agency has placement and care responsibility, must be seen in person to claim targeted case management. Foster care is defined by Minnesota Statutes 260C.007, subdivision 18 and 260D.02, subdivision 10.

Providers must have a Targeted Case Management Provider Interactive Video Assurance Statement (DHS-8398) (PDF) on their provider file to provide services via ITV.

SOURCE: MN Dept. of Human Services, Adult Mental Health Targeted Case Management and Children’s Mental Health Targeted Case Management, Nov. 13. 2023 (Accessed Feb. 2024).

Screening, Brief Intervention, and Referral to Treatment (SBIRT)

Providers must have documentation of services provided and have followed all clinical standards to bill for services via telehealth or telephonic (audio-only) telehealth. Refer to the Telehealth Services section of the MHCP Provider Manual under Billing for information about billing for services provided via telehealth.

SOURCE: MN Dept. of Human Services, Screening, Brief Intervention and Referral to Treatment, Dec. 29, 2022 (Accessed Feb. 2024).

Services provided by a school-based health center may include but are not limited to…

• emerging services such as mobile health and telehealth.

SOURCE: MN Statute, Sec. 145.903, (Accessed Feb. 2024).

Doula Services

A telehealth labor and delivery doula visit can be billed if the member’s needs were met by the doula during the labor and delivery process; and the doula was available to the member with no other commitments throughout the entirety of the labor and delivery process by telephone or video conference.

SOURCE: MN Dept of Human Services, Doula Services, Jan. 12, 2024, (Accessed Feb. 2024).

ELIGIBLE PROVIDERS

Distant site

Site at which the health care provider is located while providing health care services or consultations by means of telehealth, which can include the provider’s home.

MHCP covers medically necessary services and consultations delivered by a health care provider through telehealth. A health care provider means a health care professional who is licensed or registered by the state to perform health care services within the provider’s scope of practice according to state law. A provider must self-attest that they meet all the conditions of the MHCP telehealth policy by completing and submitting the Telehealth Provider Assurance Statement to be eligible for reimbursement.

SOURCE: MN Dept. of Human Services, Telehealth Services Manual, Jun. 2, 2023. (Accessed Feb. 2024).

Providers must self-attest that they meet all of the conditions of the MHCP telehealth policy by completing and submitting the Telehealth Provider Assurance Statement (DHS-6806) (PDF) to be eligible for reimbursement. The following provider types are eligible to provide telehealth services:

SOURCE: MN Dept. of Human Services, Provider Manual, Physician and Professional Services (Telehealth), As revised Nov. 8, 2023, (Accessed Feb. 2024).

Medical assistance covers medically necessary services and consultations delivered by a health care provider through telehealth in the same manner as if the service or consultation was delivered through in-person contact. Services or consultations delivered through telehealth shall be paid at the full allowable rate.

“health care provider” means a health care provider as defined under section 62A.673; a community paramedic as defined under section 144E.001, subdivision 5f; a community health worker who meets the criteria under subdivision 49, paragraph (a); a mental health certified peer specialist under section 245I.04, subdivision 10; a mental health certified family peer specialist under section 245I.04, subdivision 12; a mental health rehabilitation worker under section 245I.04, subdivision 14; a mental health behavioral aide under section 245I.04, subdivision 16; a treatment coordinator under section 245G.11, subdivision 7; an alcohol and drug counselor under section 245G.11, subdivision 5; or a recovery peer under section 245G.11, subdivision 8

Telehealth visits provided through audio and visual communication or accessible video-based platforms may be used to satisfy the face-to-face requirement for reimbursement under the payment methods that apply to a federally qualified health center, rural health clinic, Indian health service, 638 tribal clinic, and certified community behavioral health clinic, if the service would have otherwise qualified for payment if performed in person.

SOURCE: MN Statute Sec. 256B.0625, Subd. 3b(d). (Accessed Feb. 2024).

Individualized Education Program (IEP)

Use place of service 02 on claims to indicate when the child receives the health-related service via telecommunication technology when the child is in a location other than a child’s home.

Eligible providers include the following:

• Charter schools
• Education districts
• Intermediate districts
• Public school districts
• Tribal schools (schools that receive funding from the Bureau of Indian Affairs-BIA)
• Service cooperatives
• Special education cooperatives
• State academies

SOURCE: MN Dept. of Human Svcs., Provider Manual, IEP Services, Revised May 19, 2022. (Accessed Feb. 2024).

Early Intensive Developmental and Behavioral Intervention (EIDBI) services

Eligible providers include health care professionals who are licensed or registered by the state to perform health care services within the provider’s scope of practice and in accordance with state law.

Eligible providers are defined as:

• Mental health professionals (as defined under Minn. Stat. §245.462, subd. 18 or Minn. Stat. §245.4871, subd. 27)
• Mental health practitioners (as defined by Minn. Stat. §245.462, subd. 17 or Minn. Stat. §245.4871, subd. 26) working under the general supervision of a mental health professional.

A comprehensive multi-disciplinary evaluation provider, qualified supervising professional, (Level I or Level II) EIDBI provider may apply to provide EIDBI services via telehealth.

SOURCE: MN Dept. of Human Services, EIDBI Benefit Policy Manual, EIDBI Telehealth Services.  Mar. 16, 2022.  (Accessed Feb. 2024).

Mental Health Services

Eligible providers include any of the following:

Providers must self-attest that they meet all of the conditions of the MHCP telehealth policy by completing and submitting a Telehealth Provider Assurance Statement (DHS-6806) (PDF) to be eligible to provide and be reimbursed for services provided via telehealth.

SOURCE: MN Dept. of Human Svcs., Provider Manual, Telehealth Delivery of Mental Health Services, Revised Oct. 17, 2022 (Accessed Feb. 2024).

Providers currently authorized to provide services may conduct the same services via telehealth. Providers must self-attest that they meet all of the conditions of the MHCP telehealth policy by completing and submitting the Telehealth Provider Assurance Statement (DHS-6806) (PDF) to be eligible to provide and be reimbursed for services via telehealth.

SOURCE: MN Dept. of Human Svcs., Provider Manual, Substance Use Disorder Telehealth, May 23, 2023 (Accessed Feb. 2024).

Targeted Case Management (TCM)

The following MHCP-enrolled TCM providers may deliver TCM through interactive video:

• Child Welfare Targeted Case Management
• Children’s Mental Health Targeted Case Management
• Adult Mental Health Targeted Case Management
• Vulnerable Adult/Developmental Disability Targeted Case Management

Organizational providers who want to deliver and bill for TCM services using interactive video must assure they meet the requirements of the interactive video policy and attest to the safety and effectiveness of interactive video for the person served, according to Minnesota Statutes 256B.0625, subdivision 20b. Complete and submit the Targeted Case Management Provider Interactive Video Assurance Statement (DHS-8398) (PDF) to DHS through the MPSE portal or by fax to add interactive video services to your current enrollment record.

SOURCE: MN Dept. of Human Svcs., Provider Manual, Targeted Case Management (TCM) Enrollment Criteria and Forms, Jun. 2, 2023 (Accessed Feb. 2024).

Rehabilitation Services

Eligible providers:

• Speech-language pathologists
• Physical therapists
• Physical therapist assistants
• Occupational therapists
• Occupational therapy assistants
• Audiologists

Physical therapist assistants and occupational therapy assistants providing services via telehealth must follow the same supervision policy as indicated in “Rehabilitation Service Practitioners”. The distant site is the location of the health care provider at the time the provider is delivering the service to an eligible MHCP member via telecommunication system. There are no specific authorized distant sites or restrictions, but providers must ensure a secure transmission that meets Health Insurance Portability & Accountability Act of 1996 Privacy and Security (HIPAA) requirements. Providers must self-attest that they meet all of the conditions of the MHCP telehealth policy by completing the Provider Assurance Statement for Telehealth (DHS-6806) (PDF). See manual for documentation requirements. When submitting claims for telemedicine services, use place-of-service code 02 to certify that the services meets the telemedicine requirements. The GQ modifier is required when billing for services via asynchronous telecommunication systems (via computer).

SOURCE: MN Dept. of Human Svcs., Provider Manual, Rehabilitation Svcs. Jan. 25, 2022. (Accessed Feb. 2024).

Dental

Eligible providers

• Dentist
• Advanced dental therapists
• Dental therapists
• Dental hygienists
• Licensed dental assistants
• Other licensed health care professionals

SOURCE: MN Dept. of Human Svcs., Provider Manual, Dental Svcs. Jan. 16, 2024. (Accessed Feb. 2024).

Medical Assistance Services and Payment Rates

Telehealth visits provided through audio and visual communication or accessible video-based platforms may be used to satisfy the face-to-face requirement for reimbursement under the payment methods that apply to a federally qualified health center, rural health clinic, Indian health service, 638 tribal clinic, and certified community behavioral health clinic, if the service would have otherwise qualified for payment if performed in person.

SOURCE: MN Statute 256B.0625, Subd. 3b, Sec. 7(d). (Accessed Feb. 2024).

Doula Services

A telehealth labor and delivery doula visit can be billed if the member’s needs were met by the doula during the labor and delivery process; and the doula was available to the member with no other commitments throughout the entirety of the labor and delivery process by telephone or video conference.

If the doula was unavailable during the entirety of the labor and delivery process but was able to provide key support during some of the labor and delivery, they may bill for a non-labor and delivery visit for their time spent with the member.

Providers must submit a completed and signed Telehealth Provider Assurance Statement (DHS-6806) (PDF) to the Minnesota Department of Human Services to bill for telehealth services. Review Telehealth Services in the MHCP Provider Manual for additional details.

SOURCE: MN Dept of Human Services, Doula Services, Jan. 12, 2024, (Accessed Feb. 2024).

ELIGIBLE SITES

The site at which the member is located at the time health care services are provided to them by means of telehealth, which can include the member’s home.

Providers who have an approved Telehealth Provider Assurance Statement (DHS-6806) (PDF) on file with MHCP who submit professional claims for services via telehealth should use claim format 837P (professional), CPT or HCPCS codes that describes the services rendered and with a required place of service 02 or new place of service 10 for services via telehealth. Include the 93 modifier when billing for services provided via audio only (telephone communication).

Outpatient facilities (Ambulatory Payment Classifications or Ambulatory Surgical Center claims) will continue to use telehealth modifiers on their claims.

Providers who service SUD H2035/HQ on type of bill 89X should continue to use telehealth modifiers on their claims.

SOURCE: MN Dept. of Human Services, Telehealth Services Manual, Jun. 2, 2023. (Accessed Feb. 2024).

Physician and Professional Services

Providers should have a Telehealth Provider Assurance Statement (DHS-6806) (PDF) on their provider file beginning June 1, 2022, to bill claims for services provided via telehealth. Providers who submit professional claims for services via telehealth should use claim format 837P (professional), including the CPT or HCPCS code that describes the services rendered and the place of service 02 or new place of service 10 for services via telehealth. Include the 93 modifier when billing for services provided via audio only (telephone communication).

Place of service 02 (newly redefined): Telehealth provided other than the patient’s home. It’s the location where health services and health-related services are provided or received through telecommunication technology. The patient is not located in their home when receiving health services or health-related service through telecommunication technology.

Place of service 10 (new place of service): Telehealth provided in patient’s home. The location where health services and health-related services are provided or received through telecommunication technology. Patient is located in their home (which is a location other than a hospital or other facility where the patient receives care in a private residence) when receiving health services or health-related services through telecommunication technology.

When reporting a service with place of service 02 or 10, you are certifying that you are rendering services to a patient located in an eligible originating site via an interactive audio and visual telecommunications system.

Modifier 93, Audio only: Synchronous telehealth service rendered via telephone or other real-time interactive audio-only telecommunications system. MHCP requires this modifier when audio-only telehealth is used.

All other telehealth modifiers: All the other telehealth modifiers (GT, GQ, GO, 95) can be used for informational purposes but will not be required. The telehealth place of service codes explain that the service is rendered through telehealth. No telehealth modifiers can be used without place of service 02 or 10 or the claim will deny.

SOURCE: MN Dept. of Human Services, Provider Manual, Physician and Professional Services (Telehealth), As revised Nov. 8, 2023, (Accessed Feb. 2024).

Mental Health Delivery

Providers should have a Telehealth Provider Assurance Statement (DHS-6806) (PDF) on their provider file beginning June 1, 2022, to bill claims for services provided via telehealth. Providers must have documentation of services provided and must have followed all clinical standards to bill for telehealth.

Place of service 02 (newly redefined): Telehealth provided other than the patient’s home. It’s the location where health services and health-related services are provided or received through telecommunication technology. The patient is not located in their home when receiving health services or health-related service through telecommunication technology.

Place of service 10 (new place of service): Telehealth provided in patient’s home. The location where health services and health-related services are provided or received through telecommunication technology. Patient is located in their home (which is a location other than a hospital or other facility where the patient receives care in a private residence) when receiving health services or health-related services through telecommunication technology.

When reporting a service with place of service 02 or 10, you are certifying that you are rendering services to a patient located in an eligible originating site via an interactive audio and visual telecommunications system.

Modifier 93, Audio only: Synchronous telehealth service rendered via telephone or other real-time interactive audio-only telecommunications system. MHCP requires this modifier when audio-only telehealth is used.

All other telehealth modifiers: All the other telehealth modifiers (GT, GQ, GO, 95) can be used for informational purposes but will not be required. The telehealth place of service codes explain that the service is rendered through telehealth. No telehealth modifiers can be used without place of service 02 or 10 or the claim will deny.

SOURCE: MN Dept. of Human Svcs., Provider Manual, Telehealth Delivery of Mental Health Services, Revised Oct. 17, 2022 (Accessed Feb. 2024)

Individualized Education Program (IEP)

Use place of service 10 on claims to indicate when the child receives the health-related service via telecommunication technology in the child’s home. This is a location other than a hospital or other facility where the child receives care in a private residence.

Eligible originating sites, the location of the child or youth at the time the service is provided.  Document in the child’s health record:

• Home
• School

SOURCE: MN Dept. of Human Svcs., Provider Manual, Individualized Education Program, May 19, 2022 (Accessed Feb. 2024)

Medication Therapy Management Services (MTMS)

Medication therapy management services include the following:

See manual for privacy, equipment and reimbursement requirements.

SOURCE: MN Dept. of Human Svcs., Provider Manual, Medication Therapy Management Svcs. Nov. 3, 2021 (Accessed Feb. 2024).

Telehealth Delivery of Substance Use Disorder Services

MHCP allows payment for telehealth services in substance use disorder treatment for services that are otherwise covered as direct face-to-face services.

Place of service 02 (newly defined): Telehealth provided other than the patient’s home. The location where health services and health-related services are provided or received through telecommunication technology. The patient is not located in their home when receiving health services or health-related services through telecommunication technology.

Place of service 10 (new place of service): Telehealth provided in patient’s home. The location where health services and health-related services are provided or received through telecommunication technology. The patient is located in their home (which is a location other than a hospital or other facility where the patient receives care in a private residence) when receiving health services or health-related services through telecommunication technology.

SOURCE: MN Dept. of Human Svcs., Provider Manual, Substance Use Disorder Telehealth, May 23, 2023, (Accessed Feb. 2024).

Dental

Affiliate practice or originator within Minnesota Board of Dentistry defined scope of practice must be present at originating site.

SOURCE: MN Dept. of Human Svcs., Provider Manual, Dental Svcs. Jan. 16, 2024. (Accessed Feb. 2024).

Rehabilitation Services

Eligible originating sites:

• Office of physician or practitioner
• Hospital (inpatient or outpatient)
• Critical access hospital (CAH)
• Rural health clinic (RHC) and Federally Qualified Health Center (FQHC)
• Hospital-based or CAH-based renal dialysis center (including satellites)
• Skilled nursing facility (SNF)
• End-stage renal disease (ESRD) facilities
• Community mental health center
• Dental clinic
• Residential facilities, such as a group home and assisted living
• Home (a licensed or certified health care provider may need to be present to facilitate the delivery of telehealth services provided in a private home)
• School

SOURCE: MN Dept. of Human Svcs., Provider Manual, Rehabilitation Svcs. Jan. 25, 2022. (Accessed Feb. 2024).

Tribal Facilities

Outpatient telemedicine services provided through tribal facilities may be paid at the IHS encounter ate or applicable fee-for-service rate.  An encounter for a tribal or IHS facility means a face-to-face visit between a member eligible for MA and any health professional at or through an IHS or tribal service location for the provision of MA covered services within a 24-hour period ending at midnight.

SOURCE: MN Dept. of Human Svcs., Provider Manual, Tribal and Federal Indian Health Svcs., September 9, 2021 (Accessed Feb. 2024).

Targeted Case Management

When services have been delivered via ITV, the appropriate place of service must be provided.

• Place of service 02: ITV contact provided other than the client’s home. The client is not located in their home when receiving MH-TCM service through ITV.
• Place of service 10: ITV contact provided in the client’s home. The client is located in their home when receiving MH-TCM service through ITV.

MHCP does not reimburse for connection charges, or origination, set-up or site fees.

SOURCE: MN Dept. of Human Services, Adult Mental Health Targeted Case Management and Children’s Mental Health Targeted Case Management, Nov. 13. 2023 (Accessed Feb. 2024).

GEOGRAPHIC LIMITS

No reference found.

FACILITY/TRANSMISSION FEE

Early Intensive Developmental and Behavioral Intervention (EIDBI) services

MHCP does not reimburse for connection charges or origination, set-up or site fees.

SOURCE: MN Dept. of Human Services, EIDBI Benefit Policy Manual, EIDBI Telehealth Services. Mar. 16, 2022. (Accessed Feb. 2024).

Physician and Professional Services

MHCP does not pay an originating site facility fee. Services billed on an outpatient claim with the GQ modifier will pay zero.

SOURCE: MN Dept. of Human Services, Provider Manual, Physician and Professional Services (Telehealth), As revised Nov. 8, 2023, (Accessed Feb. 2024).

Mental Health Delivery

MHCP does not pay an originating site facility fee. Services billed on an outpatient claim with the GQ modifier will pay zero.

SOURCE: MN Dept. of Human Svcs., Provider Manual, Telehealth Delivery of Mental Health Services, Revised Oct. 17, 2022 (Accessed Feb. 2024).

Prior to the delivery of nonemergency services, a provider-based clinic that charges a facility fee shall provide notice to any patient, including patients served by telehealth as defined in section 62A.673, subdivision 2, paragraph (h), stating that the clinic is part of a hospital and the patient may receive a separate charge or billing for the facility component, which may result in a higher out-of-pocket expense.

SOURCE: MN Statute Sec. 62J.824, (Accessed Feb. 2024).

POLICY

Mississippi Medicaid and private payers are required to provide coverage for telemedicine services to the same extent that the services would be covered if they were provided through in-person consultation, including services that are performed by out-of-network providers.

SOURCE: MS Code Sec. 83-9-351. (Accessed Apr. 2024).

Providers of telehealth services must be an enrolled Mississippi Medicaid provider acting within their scope-of-practice and license or medical certification or Mississippi Department of Health (MDSH) certification and in accordance with state and federal guidelines, including but not limited to, authorization of prescription medications at both the originating and distant site.

The Division of Medicaid requires that providers utilize telehealth technology sufficient to provide real-time interactive communications that provide the same information as if the telehealth visit was performed in-person. Equipment must also be compliant with all applicable provisions of the Health Insurance Portability and Accountability Act (HIPAA).

SOURCE: MS Admin. Code Title 23, Part 225, Rule. 1.2 (Accessed Apr. 2024).

ELIGIBLE SERVICES/SPECIALTIES

The Division of Medicaid covers medically necessary telehealth services as a substitution for an in-person visit for consultations, office visits, and/or outpatient visits when all the required medically appropriate criteria is met which aligns with the description of the Current Procedural Terminology (CPT) evaluation and management (E&M) and Healthcare Common Procedure Coding System (HCPCS) guidelines.

The Division of Medicaid does not:

• Cover a telehealth service if that same service is not covered in an in-person setting.
• Cover a separate reimbursement for the installation or maintenance of telehealth hardware, software and/or equipment, videotapes, and transmissions.
• Cover early and periodic screening, diagnosis, and treatment (EPSDT) well child visits through telehealth.
• Cover physician or other practitioner visits through telehealth for:  Non-established beneficiaries, and/or Level VI or V visits.
• Cover the installation or maintenance of any telecommunication devices or systems.

The division does not consider the following telehealth services:

• Telephone conversations,
• Chart reviews;
• Electronic mail messages;
• Facsimile transmission;
• Internet services for online medical evaluations, or
• Communication through social media, or
• Any other communication made in the course of usual business practices including, but not limited to,
  • Calling in a prescription refill, or
  • Performing a quick virtual triage.

The Division of Medicaid reimburses all providers delivering a medically necessary telehealth service at the distant site at the current applicable Mississippi Medicaid fee-for-service rate or encounter for the service provided. The provider must include the appropriate modifier on the claim indicating the service was provided through telehealth.

Providers delivering simultaneous distant and originating site services to a beneficiary are reimbursed:

• The current applicable Mississippi Medicaid fee-for-service rate for the medical service(s) provided, and
• Either the originating or distant site facility fees, not both, except for RHC, FQHC and CMHC when such services are appropriately provided by the same organization.

SOURCE: MS Admin. Code Title 23, Part 225, Rule. 1.3-1.5 (Accessed Apr. 2024).

The Division of Medicaid covers up to twelve (12) in-person or telehealth tobacco cessation counseling sessions per State Fiscal Year, when provided by:

• A physician, or
• Other licensed practitioner that has prescriptive authority, operating within their scope of practice.

SOURCE: MS Admin. Code Title 23, Part 200, Rule. 5.4 (Accessed Dec. 2023).

ELIGIBLE PROVIDERS

At the distant site the following provider types are allowed to render telehealth services:

• Physicians,
• Physician assistants,
• Nurse practitioners,
• Psychologists,
• Licensed Clinical Social Workers (LCSW),
• Licensed Professional Counselors (LPCs),
• Licensed Marriage and Family Therapists (LMFTs),
• Board Certified Behavior Analysts or Board-Certified Behavior Analyst Doctorals
• Community Mental Health Centers (CMHCs)
• Private Mental Health Centers
• Federally Qualified Health Centers
• Rural Health Clinics; or
• Physical, occupational or speech therapy
• Mississippi State Department of Health (MSDH) clinics.

The Division of Medicaid requires a telepresenter who meets the requirements of Miss. Admin Code Part 225, Rule 1.1.D. at the originating site unless the originating site is the beneficiary’s home or as determined by the Division.

SOURCE: MS Admin. Code Title 23, Part 225, Rule. 1.3(B) and (C). (Accessed Apr. 2024).

The Mississippi Division of Medicaid will allow additional coverage of telehealth services during a state of emergency as declared by either the Governor of Mississippi or the President of the United States.  See administrative code for details of enhanced services that will terminate at the discretion of the MS Division of Medicaid.

SOURCE: MS Admin. Code Title 23, Part 225, Rule. 1.7. (Accessed Apr. 2024).

Effective July 1, 2021 & Repealed on July 1, 2024

The division shall recognize federally qualified health centers (FQHCs), rural health clinics (RHCs) and community mental health centers (CMHCs) as both an originating and distant site provider for the purposes of telehealth reimbursement. The division is further authorized and directed to reimburse FQHCs, RHCs and CMHCs for both distant site and originating site services when such services are appropriately provided by the same organization.

SOURCE: MS Code Section 43-13-117 (Accessed Apr. 2024).

Rural Health Clinics

An encounter for face-to-face telehealth services provided by the RHC acting as a distant site provider.  MS Medicaid reimburses a RHC for both the distant and originating provider site when such services are appropriately provided by the RHC.

SOURCE: MS Admin Code Title 23, Part 212, Ch. 1, Rule. 1.5 (Accessed Apr. 2024).

Federally Qualified Health Centers

An encounter for face-to-face telehealth services provided by the FQHC acting as a distant site provider. MS Medicaid reimburses a FQHC for both the distant and originating provider site when such services are appropriately provided by the FQHC.

SOURCE: MS Admin. Code Title 23, Part 211, Rule. 1.5. (Accessed Apr. 2024).

Home Health Services

A face-to-face encounter, for home health services, as an in person visit, including telehealth, which occurs between a physician or allowed non-physician practitioner and a beneficiary for the primary reason the beneficiary requires home health services and must occur no more than ninety (90) days before or thirty (30) days after the start of home health services.

SOURCE: MS Admin Code, Title 23, Part 215, Ch. 1: Home Health Services, Rule 1.1, (Accessed Apr. 2024).

ELIGIBLE SITES

The Division of Medicaid covers telehealth services at the following locations: At the following originating sites:

• Office of a physician or practitioner,
• Outpatient Hospital (including a Critical Access Hospital (CAH)),
• Rural Health Clinic (RHC),
• Federally Qualified Health Center (FQHC),
• Community Mental Health/Private Mental Health Centers,
• Therapeutic Group Homes,
• Indian Health Service Clinic,
• School-based clinic,
• School which employs a school nurse,
• Inpatient hospital setting, or
• Beneficiary’s home.

The Division of Medicaid requires a telepresenter who meets the requirements of Miss. Admin Code Part 225, Rule 1.1.D. at the originating site unless the originating site is the beneficiary’s home or as determined by the Division.

SOURCE: MS Admin. Code Title 23, Part 225, Rule. 1.3. (Accessed Apr. 2024).

The Division of Medicaid defines the telepresenter as medical personnel who:

• Is a Mississippi Medicaid provider, or employed by a Mississippi Medicaid provider and directly supervised by the provider or an appropriate employee of the provider if the medical personnel’s license or certification requires supervision,
• Is trained to use the appropriate technology at the originating site,
• Is able to facilitate comprehensive exams under the direction of a distant site practitioner who is, or is employed by, a Mississippi Medicaid provider.
• Must remain in the exam room for the entirety of the exam unless otherwise directed by the distant site provider for the appropriate treatment of the beneficiary, and
• Must act within the scope of their practice, license, or certification.

SOURCE: MS Admin Code Title 23, Part 225, Rule 1.1. (Accessed Apr. 2024).

The Mississippi Division of Medicaid will allow additional coverage of telehealth services during a state of emergency as declared by either the Governor of Mississippi or the President of the United States. Details of enhanced services include the following that will terminate at the discretion of the Mississippi Division of Medicaid:

A beneficiary may seek treatment utilizing telehealth services from an originating site not listed in the Mississippi Medicaid State Plan regarding Telehealth (SPA 3.1-A Introductory Pages 1 and 2). These emergency exceptions include the following:

• A beneficiary’s residence may be an originating site without prior approval by the Division of Medicaid.
• Health care facilities not listed in the State Plan wishing to act as an originating site must first be granted approval by the Division of Medicaid before rendering originating site telehealth services.

When the beneficiary receives services in the home, the requirement for a telepresenter to be present may be waived.

See regulation for additional details.

SOURCE: MS Admin. Code Title 23, Part 225, Rule. 1.7. (Accessed Apr. 2024).

The division shall recognize federally qualified health centers (FQHCs), rural health clinics (RHCs)) and community mental health centers (CMHCs) as both an originating and distant site provider for the purposes of telehealth reimbursement. The division is further authorized and directed to reimburse FQHCs, RHCs and CMHCs for both distant site and originating site services when such services are appropriately provided by the same organization.

SOURCE: MS Code Section 43-13-117 – Sunsets July 1, 2024, (Accessed Dec. 2023).

Division of Medicaid (DOM) added place of service (POS) code 10 to indicate a Telehealth service was provided to a beneficiary located at their home. POS code 10 may not be loaded with updated billing rules at MESA Go-Live. Providers should continue to submit claims with the appropriate POS code. Impacted claims with POS 10 will be adjusted, and there will be no additional action needed by Providers.

SOURCE: MS Medicaid Provider Bulletin, Vol. 28 Issue 3 (Sept. 2022). (Accessed Apr. 2024).

GEOGRAPHIC LIMITS

No Reference Found

FACILITY/TRANSMISSION FEE

The Division of Medicaid reimburses the enrolled Medicaid provider at the originating site the Mississippi Medicaid telehealth originating site facility fee for telehealth services per completed transmission in addition to reimbursement for a separately identifiable covered service if performed.

The following providers are eligible to receive the originating site facility fee for telehealth services per transmission:

• Office of a physician or practitioner,
• Outpatient hospital, including a Critical Access Hospital (CAH),
• Rural Health Clinic (RHC),
• Federally Qualified Health Center (FQHC),
• Community Mental Health/Private Mental Health Center,
• Therapeutic Group Home,
• Indian Health Service Clinic,
• School-based clinic, or
• School which employs a nurse.

The originating site provider can only bill for an encounter or Evaluation and Management (E&M) visit if a separately identifiable covered service is performed.

An inpatient hospital’s originating site fee is included in the All Patient Refined/Diagnosis Related Group (APR-DRG) payment.

SOURCE: MS Admin. Code Title 23, Part 225, Rule. 1.5(A). (Accessed Apr. 2024).

Federally Qualified Health Centers

The Division of Medicaid reimburses a fee per completed transmission for telehealth services provided by the RHC acting as an originating site provider. The FQHC may not bill for an encounter visit unless a separately identifiable service is performed. The originating site facility fee will be paid at the existing fee-for-service rate in effect as of January 1, 2021.

SOURCE: MS Admin. Code Title 23, Part 211, Rule. 1.5. (Accessed Apr. 2024).

Rural Health Clinics

MS Medicaid provides a fee per completed transmission for telehealth services provided by the RHC acting as an originating site provider. The RHC may not bill for an encounter visit unless a separately identifiable service is performed. The originating site facility fee will be paid at the existing fee-for-service rate in effect as of January 1, 2021.

SOURCE: MS Admin Code Title 23, Part 212, Ch. 1, Rule. 1.5 (Accessed Apr. 2024).

The originating site is eligible to receive a facility fee, but facility fees are not payable to the distant site. Health insurance and employee benefit plans shall not limit coverage to provider-to-provider consultations only. Patients in a patient-to-provider consultation shall not be entitled to receive a facility fee.

SOURCE: MS Code Sec. 83-9-351. (Accessed Apr. 2024). 

POLICY

Services provided through telemedicine [or telehealth, as referred to in Rural Health Clinics manual] must meet the standard of care that would otherwise be expected should such services be provided in person.

Prior to the delivery of telehealth services in a school, the parent or guardian of the child shall provide authorization for such service. The authorization shall include the ability for the parent or guardian to authorize services via telehealth in the school for the remainder of the school year.

SOURCE: MO HealthNet, Physician Manual, 2.67 p. 112 (9/1/23), Provider Manual, Rural Health Clinics, Section 1,14 p. 9 (9/1/23) & MO HealthNet, Provider Manual, Behavioral Services, Section 1.19, p. 59 (9/1/23). (Accessed Jan. 2024).

The MO HealthNet Division reimburses for eligible services provided via telemedicine when the service can be performed by a MO HealthNet provider with the same standard of care as a face to face service.

Reimbursement for the distant site provider is equal to the current fee schedule allowed amount for the service provided.

SOURCE: MO HealthNet, Telemedicine Overview, (Accessed Jan. 2024).

The department of social services shall reimburse providers for services provided through telehealth if such providers can ensure services are rendered meeting the standard of care that would otherwise be expected should such services be provided in-person.  Reimbursement for telehealth services shall be made in the same way as reimbursement for in-person contact; however, consideration shall also be made for reimbursement to the originating site.

SOURCE: MO Revised Statute Ch. 208 Sec. 208.670. (Accessed Jan. 2024).

Reimbursement to the health care provider delivering the telemedicine service at the distant site shall be made at the same amount as the current fee schedule for an in person service.

SOURCE: MO Code of State Regulations, Title 13 Sec. 70-3.330(5), (Accessed Jan. 2024).

The COVID-19 public health emergency will expire on May 11, 2023. Effective May 12, 2023 MO HealthNet, will continue to allow any licensed health care provider, enrolled as a MO HealthNet provider, to provide telehealth services if the services are within the scope of practice for which the health care provider is licensed. The services must be provided with the same standard of care as services provided in person.

Telehealth services may be provided to a MHD participant, while the participant is at an originating site, and the provider is at another location (the distant site.) The originating site facility fee cannot be billed to MO HealthNet when the originating site is the participant’s home.

There is not a separate telehealth fee schedule. Reimbursement to health care providers delivering the medical service at the distant site is equal to the current fee schedule amount for the service provided.

SOURCE: MO HealthNet Provider Hot Tips, March 27, 2023, (Accessed Jan. 2024).

ELIGIBLE SERVICES/SPECIALTIES

Any licensed health care provider shall be authorized to provide telehealth services if such services are within the scope of practice for which the health care provider is licensed and are provided with the same standard of care as services provided in person.  This section shall not be construed to prohibit a health carrier, as defined in section 376.1350, from reimbursing nonclinical staff for services otherwise allowed by law.

Nothing in subsection 3 of this section shall apply to:

• Informal consultation performed by a health care provider licensed in another state, outside of the context of a contractual relationship, and on an irregular or infrequent basis without the expectation or exchange of direct or indirect compensation;
• Furnishing of health care services by a health care provider licensed and located in another state in case of an emergency or disaster; provided that, no charge is made for the medical assistance; or
• Episodic consultation by a health care provider licensed and located in another state who provides such consultation services on request to a physician in this state

SOURCE: MO Revised Statute Sec. 191.1145(6). (Accessed Jan. 2024).

Reimbursement to the health care provider delivering the medical service at the distant site is equal to the current fee schedule amount for the service provided. Use the appropriate CPT code for the service along with place of service 02 (telehealth/telemedicine).

Distant site services provided on school grounds should be billed with place of service 03 and a GT modifier.

When a participant is located in a residential or inpatient place of service (Place of service codes 14, 21, 33, 51, 55, 56 or 61), providers delivering behavioral health services via telemedicine must bill with the GT modifier and with the place of service where the participant is physically located. In these instances, providers must not bill with place of service 02.

SOURCE: MO HealthNet, Physician Manual, Sec. 2.67 p. 112 (9/1/23) & MO HealthNet, Provider Manual, Behavioral Services, Section 1.19, p. 60 (9/1/23). (Accessed Jan. 2024).

Services provided through telehealth must meet the standard of care that would otherwise be expected should such services be provided in person.

Prior to the delivery of telehealth services in a school, the parent or guardian of the child shall provide authorization for such service. The authorization shall include the ability for the parent or guardian to authorize services via telehealth in the school for the remainder of the school year.

SOURCE: MO HealthNet, Physician Manual, 2.67 p. 112 (9/1/23), Provider Manual, Rural Health Clinics, Section 1,14 p. 9 (9/1/23) & MO HealthNet, Provider Manual, Behavioral Services, Section 1.19, p. 59 (9/1/23). (Accessed Jan. 2024).

There is not a separate telemedicine fee schedule. Reimbursement to health care providers delivering the medical service at the distant site is equal to the current fee schedule amount for the service provided.

SOURCE:  MO Medicaid Provider Tips, Telemedicine, July 18, 2022, (Accessed Jan. 2024).

Behavioral Health Services

Telemedicine is subject to the same precertification requirements. Claims submitted for behavioral health telemedicine services without a required precertification will be denied.

SOURCE: MO HealthNet Provider Tips (Nov. 22, 2022). (Accessed Jan. 2024).

Behavioral Health Crisis Centers

Direct services shall be provided by a licensed physician (includes psychiatrist) or licensed psychiatric mental health nurse practitioner (PMHNP), advanced practice registered nurse (APRN), physician assistant, resident physician (includes psychiatrist), and/or assistant physician in a written collaborative practice arrangement with a physician and with experience treating the target population. Services may be provided via telemedicine.

SOURCE: 9 CSR 30-7.010, (Accessed Jan. 2024).

Comprehensive Substance Abuse Treatment & Rehabilitation (CSTAR) Program

Communication with a collateral contact may be made face to face, by phone, or by telehealth platforms. See manual for code list.

SOURCE: MO HealthNet, CSTAR Manual, Sec. 2.9 K p. 44 (9/1/23). (Accessed Jan. 2024).

Telemedicine is considered a face-to-face service. Services in all levels of care may be provided via telemedicine, including individual services within residential levels of care such as medication services, individual counseling, and medication services support.

SOURCE: MO HealthNet, Community Substance Treatment and Rehabilitation/American Society of Addiction Medicine (12/04/2023), p. 25, (Accessed Jan. 2024).

Community Psych Rehab Program

Several services are covered if delivered via telehealth. See manual for specific services.

SOURCE: MO HealthNet, Community Psych Rehab Program Manual,  (9/1/23), (Accessed Jan. 2024).

Home Health

The face-to-face encounter may occur through telehealth, as allowed by State law.

SOURCE: MO HealthNet, Home Health Manual, Sec. 2.7, p. 12. (11/1/23), (Accessed Jan. 2024).

Teledentistry

MHD covers teledentistry services for participants under the age of 21, blind, pregnant or in a SNF. This benefit allows any licensed dental provider, enrolled with MO HealthNet, to provide teledentistry services if the services are within the scope of practice for which the dental provider is licensed. Teledentistry services must be performed with the same standard of care as an in-person, face-to-face service.

Prior to the delivery of teledentistry services in a school, the parent or guardian of the child shall provide authorization for such service. The authorization shall include the ability for the parent or guardian to authorize services via teledentistry in the school for the remainder of the school year.

The MO HealthNet Dental Program allows reimbursement for CDT codes D9995 (Synchronous; real time encounter) and D9996 (Asynchronous; information stored and forwarded to dentist for subsequent review).

Teledentistry services must be billed by the distant site facility (physical location of the dentist or clinic providing the dental service to an eligible Medicaid participant through teledentistry). Dentists must bill either D9995 or D9996 and the CDT code(s) for services provided. Reimbursement to dental providers delivering the service at the distant site is equal to the current fee schedule amount for the service provided. There is not a separate teledentistry fee schedule. The originating site (physical location of the participant) is where diagnostic data is collected to be communicated to an off-site dentist for diagnosis or where a dental service is performed. The originating site cannot bill MHD for CDT codes D9995 or D9996. The originating site can bill procedure code Q3014 on the CMS-1500 claim form to receive reimbursement for use of the facility where teledentistry services were rendered. The distant site service must be billed on the 2019 ADA Dental Claim Form with the CDT code (D9995 or D9996) and any additional services provided, using place of service code 02 – Telehealth.

Services may be provided via telehealth to enhance accessibility for individuals served.

SOURCE: MO Code of State Regulation, Title 9, Sec. 30-3.132, (Accessed Jan. 2024).

A telemedicine service shall be covered only if it is medically necessary.

SOURCE: MO Code of State Regulations, Title 13 Sec. 70-3.330(3), (4)(D), (Accessed Jan. 2024). 

Health Assessment and Coordination Services (DD Waiver)

Health Assessment and Coordination (HAC) services are consultative telemedicine services designed for individuals with I/DD receiving Home and Community Based Services (HCBS) waiver services. The services are intended to coordinate care with local emergency departments, urgent cares and primary care physicians to enable real time support, consultation and coordination on health issues. HAC services assist individuals, families and support providers in understanding the health symptoms with which individuals present in order to identify the most appropriate next steps. Services are available 24 hours a day, seven (7) days a week and include immediate evaluations, video-assisted examinations, treatment plans, discussion and coordination with individuals and/or caregivers.

SOURCE: MO HealthNet, DD Waiver, Sec. 6.14, p. 76 (10/1/23).  (Accessed Jan. 2024).

Certain procedure codes are listed throughout Certified Community Behavioral Health Clinics/Certified Community Behavioral Health Organizations Manual as allowed.

SOURCE: MO HealthNet, Certified Community Behavioral Health Clinics/Certified Community Behavioral Health Organizations Manual (12/28/23), (Accessed Jan. 2024).

ELIGIBLE PROVIDERS

Any licensed health care provider shall be authorized to provide telemedicine [or telehealth, as referred to in Rural Health Clinic manual] services if such services are within the scope of practice for which the health care provider is licensed and are provided with the same standard of care as services provided in person.

To be reimbursed for telehealth/telemedicine services health care providers treating patients in this state, utilizing telehealth/telemedicine, must be fully licensed to practice in this state and be enrolled as a MO HealthNet/ MHD provider prior to rendering services.

SOURCE: MO HealthNet, Physician Manual, Sec. 2.67 p. 112 (9/1/23), Provider Manual, Rural Health Clinics, Section 1.14, p. 9 (9/1/23) & MO HealthNet Telemedicine Billing PPT, Education and Training Unit, Revised July 2022, (Accessed Jan. 2024).

Any licensed health care provider may provide telemedicine services if such services are within the scope of practice for which the health care provider is licensed and are provided with the same standard of care as services provided in person. Additionally, a health care entity may reimburse nonclinical staff for services otherwise allowed by law. This includes applied behavior analysis services rendered by a registered behavior technician under the supervision of a licensed behavior analyst or licensed psychologist or any individual provider delivering services within a Department of Mental Health (DMH) licensed, contracted, and/or certified organization (13 CSR 70-3.330(2)(A).

To be reimbursed for telemedicine services, health care providers treating patients in this state via telemedicine must be fully licensed to practice in this state and be enrolled as a MO HealthNet provider prior to rendering services.

SOURCE:  MO HealthNet, Provider Manual, Behavioral Services, Section 1.19 p. 59 (9/1/23), (Accessed Jan. 2024).

The originating site fee and distant site services can be billed by the same provider for the same date of service as long as the distant site is not located in the originating site facility.

SOURCE: MO HealthNet Telemedicine Billing PPT, Education and Training Unit, Revised July 2022, (Accessed Jan. 2024).

MO HealthNet covers Telehealth services. MO HealthNet allows any licensed health care provider, enrolled as a MO HealthNet provider, to provide telehealth services if the services are within the scope of practice for which the health care provider is licensed. The services must be provided with the same standard of care as services provided in person.

SOURCE:  MO Medicaid Provider Tips, Telehealth services, Jan. 11, 2022, (Accessed Jan. 2024).

Reimbursement to the health care provider delivering the medical service at the distant site is equal to the current fee schedule amount for the service provided. Use the appropriate CPT® code for the service along with place of service 02 (telemedicine).

Distant site services provided on school grounds should be billed with place of service 03 and a GT modifier.

When a participant is located in a residential or inpatient place of service (14, 21, 33, 51, 55, 56 or 61), providers delivering behavioral health services via telemedicine must bill with the GT modifier and with the place of service where the participant is physically located. In these instances, providers must not bill with place of service 02.

SOURCE: MO HealthNet, Physician Manual, Sec. 2.67, p. 112 (9/1/23) & MO HealthNet, Provider Manual, Behavioral Services, Section 1.19, p. 60 (9/1/23). (Accessed Jan. 2024).

Distant site – a telemedicine site where the health care provider providing the telemedicine service is physically located.

See originating and distant site scenario examples in Reimbursement Scenarios document.

SOURCE: MO HealthNet Telemedicine Billing PPT, Education and Training Unit, Revised July 2022, (Accessed Jan. 2024).

Anesthesiologist monitoring telemetry in the operating room is a non-covered service.

SOURCE: MO HealthNet, Physician Manual, p. 44 (9/1/23). (Accessed Jan. 2024).

Health care professional shall mean a physician or other health care practitioner licensed, accredited, or certified by the state of Missouri to perform specified health services consistent with state law.