Medicaid & Medicare

Live Video

The most predominantly reimbursed form of telehealth modality is live video, with Medicare and every state offering some type of live video reimbursement in their Medicaid program. However, what and how it is reimbursed varies widely.  The most common restrictions include restricting it to certain specialty types, service codes, types of providers or limiting the location of the patient to specific originating sites.

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Federal

Last updated 09/01/2022

POLICY

The Secretary shall pay for telehealth services that are …

POLICY

The Secretary shall pay for telehealth services that are furnished via a telecommunications system by a physician or a practitioner to an eligible telehealth individual 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 Sept. 2022).

Medicare Part B pays for covered telehealth services included on the telehealth list when furnished by an interactive telecommunications system if certain conditions are met.

Requirements for mental health services furnished through telehealth

Payment may not be made under this paragraph for telehealth services furnished on or after the day that is the 152nd 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 Sept. 2022).

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.

SOURCE:  Medicare Learning Network Factsheet. Telehealth Services, p. 3, June 2021, (Accessed Sept. 2022).

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.

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 Sept. 2022).


ELIGIBLE SERVICES/SPECIALTIES

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 Sept. 2022).

Medicare Part B pays for covered telehealth services included on the telehealth list when furnished by an interactive telecommunications system if certain 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.

SOURCE: 42 CFR Sec. 410.78 (Accessed Sept. 2022).

The physician visits required for rehabilitative services such as physical therapy, speech-language pathology, occupational therapy, and rehabilitative services for mental disorders and intellectual disability may not be furnished as telehealth services.

SOURCE: 42 CFR Sec. 410.78 (Accessed Sept. 2022).

A physician, NP, PA, or CNS must furnish at least one ESRD-related “hands on visit” (not telehealth) each month to examine the beneficiary’s vascular access site.

The subsequent nursing facility services frequency limitation provided via telehealth is now 14 days, not 30 days.

SOURCE:  Medicare Learning Network Factsheet. Telehealth Services, p. 4, June 2021, (Accessed Sept. 2022).

Changes to the list of Medicare telehealth services are made through the annual physician fee schedule rulemaking process. During the Public Health Emergency for the COVID-19 pandemic, as defined in § 400.200 of this chapter, we will use a sub-regulatory 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. A list of the services covered as telehealth services under this section is available on the CMS website.

SOURCE: 42 CFR Sec. 410.78 (Accessed Sept. 2022).

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

SOURCE:  Medicare Learning Network Factsheet. Telehealth Services, p. 5, June 2021 & CMS Telehealth List.  (Accessed Sept. 2022).

Category 3 codes will remain eligible until the end of Calendar Year (CY) 2023.  See Fee Schedule for list of category 3 codes.

SOURCE: CY 2022 Physician Fee Schedule, CMS, p. 60 & Centers for Medicare and Medicaid Services. List of Telehealth Services (Accessed Sept. 2022).

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 Sept. 2022).


ELIGIBLE PROVIDERS

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 title had such service been furnished without the use of a telecommunications system.

SOURCE:  Social Security Act, Sec. 1834(m) (Title 42, Sec. 1395m).  (Accessed Sept. 2022).

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 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

SOURCE: 42 CFR Sec. 410.78 & Medicare Learning Network Factsheet. Telehealth Services, p. 4, June 2021 (Accessed Sept. 2022).

A clinical psychologist and a clinical social worker may bill and receive payment for individual psychotherapy via a telecommunications system, but may not seek payment for medical evaluation and management services.

SOURCE: 42 CFR Sec. 410.78 (Accessed Sept. 2022).

CPs and CSWs cannot bill Medicare for psychiatric diagnostic interview examinations with medical services or medical evaluation and management services. They cannot bill or get paid for Current Procedural Terminology (CPT) codes 90792, 90833, 90836, and 90838.

SOURCE: Medicare Learning Network Factsheet. Telehealth Services, p. 4, June 2021 (Accessed Sept. 2022).

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.

SOURCE:  CY 2020 Final Physician Fee Schedule. CMS, p. 249, (Accessed Sept. 2022).

Communication Technology-Based Services

Payment for communication technology-based and remote evaluation services. For communication technology-based and remote evaluation (including the virtual check-in) 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 Sept. 2022).

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 Sept. 2022).

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 Sept. 2022).

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 will 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.

SOURCE: CY 2022 Physician Fee Schedule, CMS, p. 214-215  (Accessed Sept. 2022).

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.

These visits are different from telehealth services provided during the COVID-19 Public Health Emergency (PHE). Don’t bill HCPCS code G2025 for a mental health visit you provide via telecommunications.

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 304 of the Consolidated Appropriations Act (CAA), 2022, delayed the in-person visit requirements under Medicare for mental health visits that RHCs and FQHCs provide via telecommunications technology. For RHCs and FQHCs, in-person visits won’t be required until the 152nd day after the end of the COVID-19 PHE.

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, (June 6, 2022), (Accessed Sept. 2022).


ELIGIBLE SITES

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 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.

The 2018 Bipartisan Budget Act removed originating site geographic conditions and added eligible originating sites to diagnose, evaluate, or treat acute stroke symptoms.

SOURCE:   Social Security Act, Sec. 1834(m) (Title 42, Sec. 1395m) & Medicare Learning Network Factsheet. Telehealth Services, p. 3, June 2021, & 42 CFR Sec. 410.78.  (Accessed Sept. 2022).

Requirements for mental health services furnished through telehealth

Payment may not be made under this paragraph for telehealth services furnished 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 title:

  • 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.

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.

SOURCE:  Social Security Act, Sec. 1834(m) (Title 42, Sec. 1395m) & Medicare Learning Network Factsheet. Telehealth Services, p. 3, June 2021, (Accessed Sept. 2022).

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 Sept. 2022).

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”.

SOURCE: CY 2022 Physician Fee Schedule, CMS, p. 63 & 64, (Accessed Sept. 2022).

Treatment of stroke telehealth services

The originating site and 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 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 Sept. 2022).

Providers qualify as originating sites, regardless of location, if they were participating in a Federal telemedicine demonstration project approved by (or getting funding from) the U.S. Department of Health & Human Services.

SOURCE: Medicare Learning Network Factsheet. Telehealth Services, p. 3, June 2021, (Accessed Sept. 2022).

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 Sept. 2022).


GEOGRAPHIC LIMITS

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) & Medicare Learning Network Factsheet. Telehealth Services, p. 3, June 2021 (Accessed Sept. 2022).

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 Sept. 2022).

Substance Use Disorder

The geographic requirements shall not apply with respect to telehealth services furnished on or after July 1, 2019, to an eligible telehealth individual with a substance use disorder diagnosis for purposes of treatment of such disorder or co-occurring mental health disorder, as determined by the Secretary, or, on or after the first day after the end of the emergency period described in section 1135(g)(1)(B), subject to subparagraph (B), to an eligible telehealth individual for purposes of diagnosis, evaluation, or treatment of a mental health disorder, as determined by the Secretary at any originating site except a renal dialysis facility.

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 a hospital-based or critical access hospital-based renal dialysis center, a renal dialysis facility, or the home; 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.
  • Provision of mental health services if certain conditions are met (see eligible sites section above for requirements).

SOURCE: 42 CFR Sec. 410.78 (Accessed Sept. 2022).

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 Sept. 2022).


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 Sept. 2022).

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 originating site facility fee does not count toward the number of services used to determine payment for partial hospitalization services when a CMHC serves as an originating site.

SOURCE: Medicare Learning Network Factsheet. Telehealth Services, p. 5, June 2021, (Accessed Sept. 2022).

READ LESS

Alabama

Last updated 08/15/2022

POLICY

Alabama Medicaid reimburses for live video for certain services …

POLICY

Alabama Medicaid reimburses for live video for certain services and under certain circumstances.

SOURCE: AL Medicaid Management Information System Provider Manual, Physician Services (28-17). Jul 2022, (Accessed Aug. 2022).

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), p. 31. (Accessed Aug. 2022).

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, Jul. 2022, pg. 37-16, (Accessed Aug. 2022).

Rehabilitative Services (ASD) – DMH

If any of these services are provided via video telecommunication, it must be provided in the most private available setting and must be conducted through a two-way interactive audio and video technology system that permits two-way communication between the treatment provider and the Medicaid recipient.

SOURCE:  AL Medicaid Management Information system Provider Manual, Rehabilitative Services (ASD) – DMH, Jul. 2022, 110-16, (Accessed Aug 2022).


ELIGIBLE SERVICES/SPECIALTIES

Alabama Medicaid reimburses for the following services when billed with a GT modifier:

  • Consultations;
  • Office or other outpatient visits;
  • Individual psychotherapy;
  • Psychiatric diagnostic services;
  • Neurobehavioral status exams.

Procedure codes for Applied Behavior Analysis therapy is also covered.

SOURCE: AL Medicaid Management Information System Provider Manual, Physician Services (Ch. 28, p.17). Jul 2022. (Accessed Aug 2022).

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

SOURCE:  AL Admin. Code r. 560-X-6-.14(f)(5). (Accessed Aug. 2022).

Rehabilitation services that are delivered face to face can either be in person or via telemedicine/telehealth, as approved by the Alabama Medicaid Agency.  Telemedicine/telehealth may also be used to deliver Nursing Assessment and Care and Rehabilitative Services when certain conditions are met.

SOURCE: AL Medicaid Management Information System Provider Manual, Rehabilitative Services (ch. 105, p. 1 and 105-65). Jul. 2022. (Accessed Aug. 2022).

An appropriately trained staff or employee familiar with the recipient’s treatment plan or familiar to the recipient must be immediately available in-person to the recipient receiving a telehealth service to attend to any urgencies or emergencies that may occur during the service. “Immediately available” means the staff or employee must be either in the room or in the area outside the telehealth room in easy access for the recipient. If the recipient chooses to waive this requirement, the health care provider administering the telehealth service shall document this fact in the medical record.

SOURCE: AL Medicaid Management Information System Provider Manual, Rehabilitative Services – DMH, DHR, DYS, DCA (105, p. 11).  Jul. 2022. (Accessed Aug 2022).

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, Jul. 2022, pg. 37-16, (Accessed Aug 2022).

Rehabilitative Services (ASD) – DMH

Certain codes are only approved for the use of telehealth billing.  See manual.

SOURCE:  AL Medicaid Management Information system Provider Manual, Rehabilitative Services (ASD) – DMH, Jul. 2022, 110-15, (Accessed Aug 2022).


ELIGIBLE PROVIDERS

All physicians with an Alabama license, enrolled as a provider with the Alabama Medicaid Agency, regardless of location, 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:

  • Physicians must be enrolled with Alabama Medicaid with a specialty type of 931 (Telemedicine Service)
  • Physician must submit the telemedicine Service Agreement/Certification form
  • Physician must obtain prior consent from the recipient before services are rendered. This will count as part of each recipient’s benefit limit of 14 annual physician office visits currently allowed.

SOURCE: AL Medicaid Management Information System Provider Manual, Physician Services (ch. 28, p.17) Jul. 2022, & Therapy Services, Jul. 2022, pg. 37-16. (Accessed Aug 2022).

Telemedicine providers who render maternity-related services are required to sign a Non-Delivering Telemedicine DHCP Participation agreement with at least one of the Alabama Coordinated Health Networks(ACHNs) in order to receive reimbursement from Medicaid. Refer to Chapter 28 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. 34). Jul. 2022) & AL Medicaid Management Information System Provider Manual, Physician billing (Manual Ch. 28-p. 17). Jul. 2022. (Accessed Aug 2022).

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

SOURCE: AL Medicaid Management Information System Provider Manual, Rehabilitative Services – DMH, DHR, DYS, DCA(105, p. 1).  Jul. 2022. (Accessed Aug. 2022).

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) Jul. 2022 (Accessed Aug. 2022).

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,  Jul. 2022. (Accessed Aug. 2022).

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, Jul. 2022, pg. 37-16, (Accessed Aug 2022).

Rehabilitative Services (ASD) – DMH

All services (including those rendered via teleconference with a direct service or consultation recipient) must be rendered by an approved Medicaid treatment provider (operating within their scope of practice) as outlined in Section 110.1.1.

The distant site is the location of the treatment provider providing the telehealth professional services. For physicians, telemedicine can be provided within or outside of the state of Alabama as long as the physician has an Alabama license and is enrolled as an Alabama Medicaid provider. For all other treatment providers, treatment services can only be provided by a treatment provider located within the state of Alabama.

SOURCE:  AL Medicaid Management Information system Provider Manual, Rehabilitative Services (ASD) – DMH, Jul. 2022, 110-16, (Accessed Aug. 2022).


ELIGIBLE SITES

For rehabilitative services, the origination site for treatment services can be delivered in any setting that is convenient for both the family and staff member, that affords an adequate therapeutic environment, and that protects the recipient’s rights to privacy and confidentiality. In order for providers to qualify for Medicaid reimbursement for telehealth services, the origination site must be located in the state of Alabama. The distant site is the location of the treatment provider providing the telehealth professional services. For physicians, telemedicine can be provided within or outside of the state of Alabama as long as the physician has an Alabama license and is enrolled as an Alabama Medicaid provider. For all other treatment providers, treatment services can only be provided by a treatment provider located within the state of Alabama.

SOURCE: AL Medicaid Management Information System Provider Manual, Rehabilitative Services (105-9). Jul. 2022. (Accessed Aug. 2022).

Rehabilitative Services (ASD) – DMH

The origination site for treatment services can be delivered in any setting that is convenient for both the recipient/family and staff member, that affords an adequate therapeutic environment, and that protects the recipient’s rights to privacy and confidentiality. In order for providers to qualify for Medicaid reimbursement for telehealth services, the origination site must be located in the state of Alabama.

SOURCE:  AL Medicaid Management Information system Provider Manual, Rehabilitative Services (ASD) – DMH, Jul. 2022, 110-16, (Accessed Aug. 2022).

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. 106-28, Jul. 2022, (Accessed Aug. 2022).


GEOGRAPHIC LIMITS

For rehabilitative services, the distant site may be located outside of Alabama as long as the physician has an Alabama license and is enrolled as an Alabama Medicaid provider.

SOURCE: AL Medicaid Management Information System Provider Manual, Rehabilitative Services, (105-9). Jul. 2022 & Rehabilitative Services (ASD) – DMH, Jul. 2022, 110-16, (Accessed Aug. 2022).


FACILITY/TRANSMISSION FEE

the Alabama Medicaid Agency (Agency) will begin paying an origination site facility fee of $20.00. The origination fee will be limited to one per date of service per recipient.  Federally Qualified Health Centers and Rural Health Clinics should bill Q3014 independent of the encounter rate on a CMS-1500 claim form.

SOURCE: AL Medicaid Agency, Alert – Telemedicine Origination Site Facility Fee, Mar. 13, 2020, (Accessed Aug. 2022).

AL Medicaid reimburses providers for origination site fees for covered telemedicine services. The origination fee is limited to one per date of service per recipient.

SOURCE: AL Medicaid Management Information System Provider Manual, Physician Services (ch. 28, p. 17). Jul. 2022. (Accessed Aug 2022).

The telemedicine origination site and/or transmission fees is not reimbursable under the Rehabilitative Services program.

SOURCE:  AL Medicaid Management Information system Provider Manual, Rehabilitative Services (ASD) – DMH, Jul. 2022, 110-19, (Accessed Aug. 2022).

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Alaska

Last updated 06/02/2022

POLICY

The department shall pay for all services covered by …

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 House Bill 265 (2022 Session) and Sec. 47.07.069, (Accessed Aug. 2022).

Alaska’s Medicaid program will reimburse for services “provided through the use of camera, video, or dedicated audio conference equipment on a real-time basis.”

SOURCE: AK Admin. Code, Title 7, 110.625(a)(1). (Accessed Aug. 2022).

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

Source: State of AK Dept. of Health and Social Svcs, Alaska Medical Assistance Provider Billing Manuals for Community Behavioral Health Services; Mental Health Physician Clinic (1/2/2019); Physician, PA, ARNP Services (5/13). (Accessed Aug. 2022).

The department will pay for telemedicine applications provided by a treating, consulting, presenting, or referring provider for a medical service covered by Medicaid and provided within the scope of the provider’s license. A presenting provider is only eligible to receive Medicaid payment for a live or interactive telemedicine application.

SOURCE: AK Admin. Code, Title 7, 110.630. (Accessed Aug. 2022).

The department will pay for medical services furnished through telemedicine applications as an alternative to traditional methods of delivering services to Medicaid recipients. For the provider to receive payment, the provider’s use of telemedicine applications must comply with the standards for services delivered under the Medicaid program and for the medical services provided by the type of provider, including provisions that affect the efficiency, economy and quality of service; and coverage limitations.

SOURCE:  Alaska Admin Code. Title 7, Sec. 110.620. (Accessed Aug. 2022).

The department will pay a provider for a telemedicine application if the provider provided the medical services through one of the following methods of delivery in the specified manner:

  • Live or interactive: the service must be provided through the use of camera, video, or dedicated audio conference equipment on a real-time basis; medical services provided by a telephone that is not a part of a dedicated audio conference system or by a facsimile machine are not eligible for payment under this paragraph
  • Store-and-forward: the service must be provided through the transference of digital images, sounds, or previously recorded video from one location to another to allow a consulting provider to obtain information, analyze it, and report back to the referring provider
  • Self-monitoring or testing: the services must be provided by a telemedicine application based in the recipient’s home, with the provider only indirectly involved in the provision of the service.

SOURCE: AK Admin. Code, Title 7, 110.625 & Alaska Medicaid Policy Clarification: Medicaid Telehealth Coverage. Mar. 1, 2022. (Accessed Aug. 2022).


ELIGIBLE SERVICES/SPECIALTIES

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. 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 House Bill 265 (2022 Session) and Sec. 47.07.069, (Accessed Aug. 2022).

Medically necessary office consultations provided via telemedicine may be covered only when used as a second opinion and the provider is of a different specialty than the requesting provider.  Documentation requirements apply.

SOURCE: Alaska Medicaid Policy Clarification: Office Consultations via Telemedicine Applications.  March 30, 2017. (Accessed Dec. 2021)Alaska Medicaid Policy Clarification; Medicaid Telehealth Coverage. Mar. 1, 2022. (Accessed Aug. 2022)

Eligible services:

  • Initial or 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.

SOURCE: State of AK Dept. of Health and Social Svcs., Alaska Medical Assistance Provider Billing Manuals for Community Behavioral Health Services; Mental Health Physician Clinic (1/2/2019); & Physician, ARNP, PA Services (5/13) & Alaska Medicaid Policy Clarification: Medicaid Telehealth Coverage. Mar. 1, 2022 (Accessed Aug. 2022).

Family psychotherapy may be provided through telemedicine, with or without recipient involvement, if the services could not be provided in person and the clinician documents the reason for providing the service telephonically in the recipient’s treatment notes for each session.

SOURCE: AK Dept. of Health and Social Svcs. Billing for Telemedicine Services. Community Behavioral Health Clinic Services; Mental Health Physician Clinic (1/2/19). (Accessed Aug.. 2022).

The GT or 95 modifier should be used to indicate live interactive mode. Use place of service 10 if member is in their home during the telehealth visit and 02 if member is at any
other location.

SOURCE: Alaska Medicaid Policy Clarification: Medicaid Telehealth Coverage. Mar. 1, 2022. (Accessed Aug. 2022).

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

SOURCE: AK Dept. of Health and Social Svcs.  Dental Services.  Tribal Services Manual (1/3/17).  (Accessed Aug. 2022).

The department will pay only for professional services for a telemedicine application of service. The department will not pay for the use of technological equipment and systems associated with a telemedicine application to render the service.

SOURCE:  AK Admin. Code, Title 7, 110.635 (Accessed Jun. 2022).

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 fax

SOURCE: State of AK Dept. of Health and Social Svcs., Alaska Medical Assistance Provider Billing Manuals for Community Behavioral Health Services; Mental Health Physician Clinic (1/2/2019); Physician, ARNP and PA Services (5/13) (Aug. 2022).

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)

SOURCE: State of AK Dept. of Health and Social Svcs., Alaska Medical Assistance Provider Billing Manuals for Community Behavioral Health Services; Mental Health Physician Clinic (1/2/2019); Physician, ARNP and PA Services (5/13), & AK Admin. Code, Title 7, 110.635 & Alaska Medicaid Policy Clarification: Medicaid Telehealth Coverage. Mar. 1, 2022. (Accessed Aug. 2022).

The department will pay for a service rendered by a consulting or referring provider by a telemedicine application. Payment to the presenting provider is limited to the rate established for brief evaluation and management of an established patient.  The department will pay the receiving provider in the same manner as payment is made for the same service provided through traditional 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 Aug. 2022).

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 telemedicine services.

SOURCE: Alaska Admin Code, Title 7, 110.445, (Accessed Aug. 2022).


ELIGIBLE PROVIDERS

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 House Bill 265 (2022 Session) and Sec. 47.07.069, (Accessed Aug. 2022).

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.

SOURCE: AK Dept. of Health and Social Svcs. Billing for Telemedicine Services. Audiology  Services (6/12); Autism Services (6/12); Chiropractic Services (6/12)Community Behavioral Health Clinic Services (6/12); Direct-Entry Midwives Services (6/12); EPSDT (6/12); Family Planning (6/12); FQHC/RHC (6/12); Imaging Services (6/12); Independent Laboratory (6/12); Mental Health Physician Clinic (6/12); Nutrition (6/12); Physician (6/12); Private Duty Nursing (6/12); Psychologist (6/12); Podiatry (6/12); School-Based Services (6/12); Residential Behavioral Rehabilitation Services (6/12); Therapies (6/12); Vision (6/12) & Alaska Admin Code Title 7, Sec. 110.639. (Accessed Aug. 2022).

Office consultations performed by a provider of the same specialty within the same organization are not covered.

SOURCE: Alaska Medicaid Policy Clarification: Office Consultations via Telemedicine Applications.  March 30, 2017. (Accessed Aug. 2022).

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 House Bill 265 (2022 Session) and Sec. 47.30.585, (Accessed Aug. 2022).

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 House Bill 265 (2022 Session) and Sec. 47.37.145, (Accessed Aug. 2022).


ELIGIBLE SITES

No reference found.


GEOGRAPHIC LIMITS

No reference found.


FACILITY TRANSMISSION FEE

The department will pay only for professional services for a telemedicine application of service. The department will not pay for the use of technological equipment and systems associated with a telemedicine application to render the service.

SOURCE: AK Admin. Code, Title 7, 110.635(b). (Accessed Aug. 2022)

 

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Arizona

Last updated 07/12/2022

POLICY

Fee-for-Service Provider Manual

AHCCCS covers medically necessary, non-experimental and …

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, (1/22/2022), pg. 47, & IHS/Tribal Provider Billing Manual, (1/22/2022), pg. 50. (Accessed Jul. 2022).

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.

SOURCE: AZ Health Care Cost Containment System, AHCCCS Medical Policy for AHCCCS Covered Services, Ch. 300, (320-I pg. 1). Apr. 2022. (Accessed Jul. 2022).


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.

SOURCE: AZ Health Care Cost Containment System, AHCCCS Fee-For-Service Provider Billing Manual, Ch. 10: Individual Practitioner Services, (1/22/2022), pg. 47-49; IHS/Tribal Provider Billing Manual, Ch. 8 Individual Practitioner Services, (1/22/2022), pg. 50-52 (Accessed Jul. 2022).

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, (1/22/2022), pg. 50, (Accessed Jul. 2022).

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.

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.

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), Apr. 2022. (Accessed Jul. 2022)

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 Jul. 2022).

Two HCPCS codes used for a Virtual check-in with physicians:

  • 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. 346. (Accessed Jul. 2022).


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, (1/22/2022), pg. 50,  & IHS/Tribal Provider Billing Manual (1/22/2022), pg. 53. (Accessed Jul. 2022).

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, (7/12/21), pg. 3, (Accessed Jul. 2022).

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. 4), Apr. 2022. (Accessed Jul. 2022).


ELIGIBLE SITES

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 (formerly hub site).”

Originating site means “the location of the AHCCCS member at the service is being furnished via telehealth or where the asynchronous service originates (formerly spoke site). 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, (1/22/2022), pg. 49, & IHS/Tribal Provider Billing Manual, (1/22/2022). pg. 51-52 (Accessed Jul. 2022).

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), Apr. 2022. (Accessed Jul. 2022).


GEOGRAPHIC LIMITS

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

SOURCE: AZ Medical Policy for AHCCCS Covered Services. Telehealth and Telemedicine Ch 300, (320-I pg. 1), Apr. 2022 ; AZ Health Care Cost Containment System, AHCCCS Fee-For-Service Provider Billing Manual, Ch. 10: Individual Practitioner Services, (1/22/22), pg. 47, & IHS/Tribal Provider Billing Manual, (1/22/2022), pg. 50. (Accessed Jul. 2022).


FACILITY/TRANSMISSION FEE

No Reference Found

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Arkansas

Last updated 07/04/2022

POLICY

Arkansas Medicaid provides payment to a licensed or certified …

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. 13 Updated Jan. 1, 2022 (Accessed Jul. 2022).

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. 24 Updated Jan. 1, 2022.  (Accessed Jul. 2022).

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. 6 Updated Oct. 13, 2003. (Accessed July. 2022).

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 Jul. 2022).


ELIGIBLE SERVICES/SPECIALTIES

Arkansas Medicaid must provide coverage and reimbursement for healthcare services provided through telemedicine on the same basis as they provide coverage and reimbursement for health services provided in-person.

SOURCE: AR Code 23-79-1602(c). (Accessed Jul. 2022).

Telemedicine is listed as an allowed delivery throughout the the Outpatient Behavioral Health Services manual. See manual for specific services and special instructions of dyadic treatment by telemedicine.

SOURCE: AR Medicaid Provider Manual. Section II OBHS Manual. Updated Jun. 1, 2022.  (Accessed Jul. 2022).

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 Jul. 2022).

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 Jul. 2022).

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.  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.

SOURCE: PASSE Program, Section. II, p. 9, (3/1/19).  (Accessed Jul. 2022).

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 Jul. 2022).

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 Jul 2022).

Division of Developmental Disabilities

Teleservices are one (1) of the following Early Interventions Services conducted via a telecommunication device:

  • Developmental Therapy Services;
  • Occupational Therapy Services;
  • Physical Therapy Services;
  • Speech-Language Pathology Services; and
  • Sign Language and Cued-Language Services.

Developmental therapy, occupational therapy, physical therapy, and speech-language pathology evaluations must be performed through traditional in-person methods.

SOURCE: AR Administrative Rules Sec. 016.05.22.-003, (Accessed Jul. 2022).


ELIGIBLE PROVIDERS

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

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

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. (Accessed Oct. 2021) & Section III Billing Documentation.  Rule 305.000.  Updated Jan. 1, 2022, (Accessed Jul. 2022).

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 Jul. 2022.)

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 Jul. 2022).

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-136, Feb. 1, 2022, (Accessed Jul. 2022)

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-9 (3/1/19).  (Accessed Jul. 2022).

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 p. 12 (9/1/2020) (Accessed Jul. 2022).

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 Jul. 2022).


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-9 (3/1/19).  (Accessed Jul. 2022).

“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 Jul. 2022).

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 Jul. 2022).


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 Jul. 2022).

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. p. 24, Updated Jan. 1, 2022 (Accessed Jul. 2022).

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 Jul. 2022).

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 Jul. 2022).

READ LESS

California

Last updated 09/06/2022

POLICY

Synchronous Interaction

“Synchronous interaction” means a real-time interaction between …

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 Sept. 2022). 

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.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth (Aug. 2020). Pg. 6. (Accessed Sept. 2022).

Effective January 1, 2023

Recently enacted legislation requires CA Medicaid and Medi-Cal managed care plans 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.

A health care provider may establish a new patient relationship with a Medi-Cal beneficiary via video synchronous interaction consistent with any requirements imposed by the department.

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 Medi-Cal provider 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.

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). (Accessed Sept. 2022).

Federally Qualified Health Center (FQHC) & Rural Health Clinic (RHC) – Effective January 1, 2023

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.

Pursuant to an effective date designated by the department that is no sooner than January 1, 2024, an FQHC or RHC furnishing applicable health care 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). (Accessed Sept. 2022).

Services rendered via telehealth must be FQHC or RHC 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.

SOURCE: CA Department of Health Care Services (DHCS).  Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHC) Outpatient Services Manual. Aug. 2020. Pg. 12. (Accessed Sept. 2022).

Family PACT

Family PACT telehealth policy mirrors the fee-for-service policy.

SOURCE: CA Department of Health Care Services.  Family Planning, Access, Care and Treatment Program. Benefits Manual. Aug. 2022, Pg. 6. (Accessed Sept. 2022).

Managed Care

Existing Medi-Cal covered services may be provided via a telehealth modality (includes live video) if certain conditions are met (as outlined in fee-for-service manual).

SOURCE: CA Department of Health Care Services (DHCS). All Plan Letter 19-009: Telehealth Services Policy.  Oct. 16, 2019. (Accessed Sept. 2022).  

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.

SOURCE: CA Department of Health Care Services (DHCS).  Indian Health Services, Memorandum of Agreement (MOA) 638, Clinics Manual. Aug. 2020. Pg. 8. (Accessed Sept. 2022). 

Local Education Agency: Speech Therapy

For dates of service on July 1, 2016 up to March 1, 2020, LEAs may only bill for covered speech therapy services provided via telehealth under the LEA Medi-Cal Billing Option Program. Speech therapy services are reimbursable when performed according to telemedicine guidelines and billed with modifier 95 and the appropriate CPT code.

For dates of service on or after March 1, 2020, until the termination of the COVID-19 PHE, 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, such as specialized medical transportation services, that preclude a telehealth modality. For dates of service on or after July 1, 2021, allowable services delivered via telehealth must be billed with modifier 95 (synchronous telehealth service rendered via a real-time interactive audio and video telecommunications system) and the appropriate CPT code.

For all dates, a telemedicine service must use interactive audio, video or data communication to qualify for reimbursement. The qualified service must be in real-time or near real-time (delay in seconds or minutes) to qualify as an interactive two-way transfer of medical data and information between the student and health care provider.

Upon termination of the COVID-19 PHE, DHCS will provide guidance to LEAs on the permanent telehealth policy by which LEAs will be reimbursed for services delivered via telehealth.

SOURCE: CA Department of Health Care Services (DHCS). Local Education Agency (LEA) Telehealth. Aug. 2021. Pg. 2-3, 5-7.  (Accessed Sept. 2022). 

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 when the beneficiary requests it or if the health care provider believes the service is clinically appropriate.

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.

SOURCE:  CA Department of Health Care Services (DHCS). Dental Provider Handbook. Aug. 2022. Pg. 4-21 – 4-24 (Accessed Sept. 2022). 

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 Sept. 2022).

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 Sept. 2022).


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.

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.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth (Aug. 2020). Pg. 6. (Accessed Sept. 2022).  

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 Sept. 2022).

Evaluation and management services may be delivered via telehealth when Medi-Cal requirements are met.

SOURCE: Department of Health Care Services. Evaluation & Management Manual. Page 29. June 2022. (Accessed Sept. 2022).

Modifier 95 must be used for Medi-Cal covered benefits or services delivered via synchronous, interactive audio/visual, telecommunications systems. Only the portion(s) of the telehealth service rendered at the distant site are billed with modifier 95. The use of modifier 95 does not alter reimbursement for the CPT or HCPCS code. See manual for telecommunications system requirements.

Evaluation and Management (E&M) and all other covered Medi-Cal services provided at the originating site (in-person with the patient) during a telehealth transmission are billed according to standard Medi-Cal policies (without modifier 95). The E&M service must be in real-time or near real-time (delay in seconds or minutes) to qualify as an interactive two-way transfer of medical data and information between the patient and health care provider.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth (July 2022). Pg. 7-8. (Accessed Sept. 2022).

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

SOURCE: CA Department of Health Care Services (DHCS).  Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHC) Outpatient Services Manual. Aug. 2020. Pg. 12.; CA Department of Health Care Services (DHCS).  Indian Health Services, Memorandum of Agreement (MOA) 638, Clinics Manual. Aug. 2020. Pg. 8. (Accessed Sept. 2022). 

Dental Services

Synchronous live transmissions are covered. Live transmissions are limited to 90 minutes per beneficiary per provider, per day. They may be provided at the beneficiary’s request or if the health care provider believes the service is clinically appropriate. All dental information transmitted during the delivery of services 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. Aug. 2022. Pg. 4-21 – 4-24. (Accessed Sept. 2022).

Home Health & Durable Medical Equipment

Live video 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 Sept. 2022).

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: 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.  & Number Letter 09-0718 to CA Children’s Services Program.  Jul. 10, 2018.  (Accessed Sept. 2022). 

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. Aug. 2022. Accessed Sept. 2022.

The Program for All Inclusive Care for the Elderly (PACE)

A PACE organization approved by the department pursuant to Chapter 8.75 (commencing with Section 14591) may use video telehealth to conduct initial assessments and annual re-assessments for eligibility for enrollment in the PACE program.

SOURCE: Welfare and Institutions Code 14132.725, as amended by SB 184 (2022 Session). (Accessed Sept. 2022).


ELIGIBLE PROVIDERS

Providers must meet all of the following criteria:

  • The provider rendering covered benefits or services must meet the requirements of B&P 2290.5(a)(3) or equivalent requirements under California law in which the provider is considered licensed (ex: Behavior Analyst Certification Board).
  • Provider 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 (Aug. 2020). Pg. 2-3. (Accessed Sept. 2022). 

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

Billable providers are eligible to deliver covered FQHC/RHC services.

SOURCE: CA Department of Health Care Services (DHCS).  Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHC) Outpatient Services Manual. Aug. 2020. Pg. 11-12. (Accessed Sept. 2022).

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. Aug. 2020. Pg. 7-8. (Accessed Sept. 2022). 

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. Aug. 2022. Pg. 4-23. (Accessed Sept. 2022). 

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 Sept. 2022).


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 Sept. 2022).

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

Refers to fee-for-service policy for the definition of an ‘originating site’.  See manual for examples.

SOURCE: CA Department of Health Care Services (DHCS).  Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHC) Outpatient Services Manual. Aug. 2020. Pg. 13. (Accessed Sept. 2022).

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

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

SOURCE: CA Department of Health Care Services (DHCS). Indian Health Services, Memorandum of Agreement (MOA) 638, Clinics Manual. Aug. 2020. Pg. 10. (Accessed Sept. 2022).


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 (Aug. 2020). Pg. 11. (Accessed Sept. 2022). 

FQHC & RHC/IHS-MOA

These sites are not eligible for the facility or transmission fee.

SOURCE: CA Department of Health Care Services (DHCS).  Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHC) Outpatient Services Manual. Aug. 2020. Pg. 12. (Accessed Sept. 2022).

Local Education Agency:  Speech Therapy

The facility and transmission fee are not covered.

SOURCE: CA Department of Health Care Services (DHCS). Local Education Agency (LEA) Telehealth. Aug. 2021. Pg. 5,7  (Accessed Sept. 2022).

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. 34-35. April 2022. (Accessed Sept. 2022).

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Colorado

Last updated 07/27/2022

POLICY

CO Medicaid will cover medically necessary medical and surgical …

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,” 2/22 (Accessed July 2022). 

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 & HB 20-1230. (Accessed July 2022).

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, 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 July 2022).


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 & SB 20-212 (2020 Session). (Accessed July 2022).

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 ‘Telemedicine Website’ for list of billing codes.

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.

SOURCE: CO Department of Health Care Policy and Financing.  “Telemedicine Billing Manual”, 2/22. (Accessed July 2022).

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 July 2022). 

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

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.

The following are listed under the covered services heading in the Telemedicine Manual:

  • Physician services may be provided as telemedicine
  • Providers may only bill procedure codes which they are already eligible to bill
  • Any health benefits provided through telemedicine shall meet the same standard of care as in-person care.

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 and FR 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.

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”, 2/22. (Accessed July 2022).

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” 2/22.  (Accessed July 2022).

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”, 7/22. (Accessed July 2022).

Pediatric Behavioral Therapy

Pediatric Behavioral Therapists are not listed as a provider type that can bill the facility fee (Q3014) or GT modifier. However, if the provider believes that providing behavioral therapy via telemedicine is medically appropriate in the situation and within the scope of their license/training, then doing so is allowed. In this case, the provider will not be paid the fee associated with Q3014 or GT modifier.

SOURCE: CO Department of Health Care Policy and Financing.  “Pediatric Behavioral Therapies Billing Manual”, 7/21 (Accessed July 2022). 

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”, 10/21. (Accessed July 2022).

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 July 2022). 

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

SOURCE: CO Department of Health Care Policy and Financing.  “Telemedicine Billing Manual” 2/22.  (Accessed July 2022).

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 July 2022).

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 July 2022). 

FQHC/RHC

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” 2/22. (Accessed July 2022).

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).

SOURCE: CO FQHC & RHC Billing Manual 7/22. (Accessed July 2022).

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 July 2022).

The 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 July 2022).


ELIGIBLE PROVIDERS

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.

SOURCE: CO Department of Health Care Policy and Financing.  “Telemedicine Billing Manual” 2/22.  (Accessed July 2022).

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 & Senate Bill 20-212 (2020 Session). (Accessed July 2022).


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.

SOURCE: CO Department of Health Care Policy and Financing.  “Telemedicine Billing Manual” 2/22.  (Accessed July 2022).

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.

SOURCE: CO Department of Health Care Policy and Financing.  “Telemedicine Billing Manual” 2/22.  (Accessed July 2022). 

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 July 2022).  

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”, 6/22. (Accessed July 2022). 

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. (Accessed July 2022).

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 July 2022).

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. (Accessed Jan. 2022).

Family Planning Services

Eligible places of service include:  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 8.730.3.B. (Accessed July 2022).


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” 2/22.  (Accessed July 2022).

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 July 2022).

Pediatric Behavioral Therapy

Pediatric Behavioral Therapists are not listed as a provider type that can bill the facility fee or GT modifier. However, if the provider believes that providing behavioral therapy via telemedicine is medically appropriate in the situation and within the scope of their license/training, then doing so is allowed. In this case, the provider will not be paid the fee associated with Q3014 or GT modifier.

SOURCE: CO Department of Health Care Policy and Financing.  “Pediatric Behavioral Therapies Billing Manual” 7/21. (Accessed July 2022).

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Connecticut

Last updated 08/10/2022

POLICY

Effective Now Until June 30, 2024

During the period …

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.

The Commissioner of Social Services may, in the commissioner’s discretion and to the extent permissible under federal law, provide coverage under the Connecticut medical assistance program for audio-only telehealth services until June 30, 2023.

SOURCE: HB 5596 (2021 Session), Sec. 1, 6. & SB 2 (2022 Session), Sec. 32. (Accessed Aug. 2022).

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 Aug. 2022).

In accordance with section 17b- 245e of the 2020 supplement to the Connecticut General Statutes, the Department of Social Services (DSS or Department) will implement full coverage of specified synchronized telemedicine, which is defined as an audio and video telecommunication system with real-time communication between the patient and practitioner. The coverage of specified synchronized telemedicine services will be covered under both Connecticut’s Medicaid Program and Children’s Health Insurance Program (CHIP) when they:

  • Are medically necessary, in accordance with the statutory definition of medical necessity
  • Are rendered via a HIPAA-compliant, real time audio and video communication system (but note that certain popular video chatting software programs are not HIPAA-compliant); and
  • Comply with all CMAP requirements that would otherwise apply to the same service performed face-to-face (in-person), including, but not limited to, enrollment, scope of practice, licensure, documentation, and other applicable requirements.

SOURCE: CT Policy – Provider Bulletin 2020-09. March 2020. (Accessed Aug. 2022).

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 Aug. 2022).

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 Aug. 2022).


ELIGIBLE SERVICES/SPECIALTIES

See bulletin for the behavioral health services that may be rendered via telemedicine.

SOURCE: CT Policy – Provider Bulletin 2020-09. March 2020. (Accessed Aug. 2022).

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 Aug. 2022).

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 Aug. 2022).


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
  • Nurse-midwife licensed under chapter 377
  • Dentist licensed under chapter 379
  • Behavior analyst licensed under chapter 382a
  • Genetic counselor licensed under chapter 383d
  • Music therapist certified in the manner described in chapter 383f
  • Art therapist licensed in the manner described in chapter 383g
  • Athletic trainer licensed under chapter 375a

A telehealth provider may also be an appropriately licensed, certified or registered provider as listed below, that is in another state or territory of the United States or the District of Columbia and that provides telehealth services pursuant to his or her authority under any relevant order issued by the Commissioner of Public Health and 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 health care providers:

  • physician
  • physician assistant
  • physical therapist
  • physical therapist assistant
  • chiropractor
  • naturopath
  • podiatrist
  • occupational therapist
  • occupational therapy assistant
  • optometrist
  • registered nurse
  • advanced practice registered nurse
  • psychologist
  • marital and family therapist
  • clinical social worker
  • master social worker
  • alcohol and drug counselor
  • professional counselor
  • dietitian
  • nutritionist
  • speech and language pathologist
  • respiratory care practitioner
  • audiologist
  • pharmacist
  • paramedic
  • nurse-midwife
  • dentist
  • behavior analyst
  • genetic counselor
  • music therapist
  • art therapist
  • athletic trainer

SOURCE: HB 5596 (2021 Session), Sec. 1, & SB 2 (2022 Session), Sec. 32. (Accessed Aug. 2022).

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 Aug. 2022).

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 Aug. 2022).

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) as amended by CT HB 6470 (2021 Session). (Accessed Aug. 2022).

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 Aug. 2022).

Medical and Behavioral Health Federally Qualified Health Centers (FQHCs) are eligible to bill their encounter rate when an approved, medically necessary telemedicine service is rendered.

SOURCE: CT Policy – Provider Bulletin 2020-09. March 2020. (Accessed Aug. 2022).

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 Aug. 2022).


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 Aug. 2022).

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 Aug. 2022).


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 Aug. 2022).

Permanent Statute

No telehealth provider shall charge a facility fee for telehealth services.

SOURCE: CT Gen. Statutes Sec. 19a-906(h). (Accessed Aug. 2022).

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), as proposed to be amended by SB 2 (2022 Session), Sec. 31. (Accessed Aug. 2022).

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Delaware

Last updated 08/24/2022

POLICY

DE Medicaid reimburses for live video telemedicine services for …

POLICY

DE Medicaid reimburses for live video telemedicine services for up to three different consulting providers for separately identifiable telemedicine services provided to a member per date of service.

SOURCE: DE Medical Assistance Program.  Practitioner Provider Specific Manual, 2/21/22. Ch. 16 Telemedicine, Sec. 16..8.2, pg. 76 & Adult Behavioral Health Service Certification and Reimbursement. Dec. 1, 2016. Sec. 1.8, p. 14. (Accessed Aug. 2022).

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 Aug. 2022).

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, 2/21/22. Ch. 16.2.6.1.1, 16.2.6.1.2,& 16.5.1 Telemedicine, pg. 75. & Adult Behavioral Health Service Certification and Reimbursement. Dec. 1, 2016. Sec. 1.8, p. 12. (Accessed Aug. 2022).

The recipient:

  • must be able to verbally communicate, either directly or through a representative, with the originating and distant site providers,
  • must be able to receive services via telemedicine, and
  • must have provided consent for the use of telemedicine.

SOURCE: DE Medical Assistance Program. Practitioner Provider Specific Manual, 2/21/22. Ch. 16.5.5 Telemedicine, pg. 75 (Accessed Aug, 2022).


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, 2/21/22. Ch. 16 Telemedicine, Sec. 16.5.2, pg. 75 & Adult Behavioral Health Service Certification and Reimbursement. Dec. 1, 2016. Sec. 1.8, p. 12. (Accessed Aug. 2022).

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 Aug. 2022).

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. Nov. 19, 2021. Sec. 4.2. p. 8 (Accessed Aug. 2022).

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 Aug. 2022).

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, 3.1.5, p. 19 (Mar. 9, 2022). (Accessed Aug. 2022).


ELIGIBLE PROVIDERS

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 Aug. 2022).

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: DE Medical Assistance Program.  Practitioner Provider Specific Manual, 2/21/22. Ch. 16.2.4.3 Telemedicine, pg. 72-73, & Adult Behavioral Health Service Certification and Reimbursement. Dec. 1, 2016. Sec. 1.8. Pg. 12 (Accessed Aug. 2022).


ELIGIBLE SITES

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: DE Medical Assistance Program. Practitioner Provider Specific Manual, 2/21/22. Ch. 16.2.5.4.1 & 16.2.5.4.2 Telemedicine, pg. 73 & Adult Behavioral Health Service Certification and Reimbursement. Dec. 1, 2016. Sec. 1. 8. pg. 11 & 12 (Accessed Aug. 2022).


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 Aug. 2022).


FACILITY/TRANSMISSION FEE

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 Medical Assistance Program.  Practitioner Provider Specific Manual, 2/21/22. Ch. 16 Telemedicine, Sec. 16.2,4.2 16.2.5.3 & 16.8.3, pg. 72-76 & DE Adult Behavioral Health Service Certification and Reimbursement. Dec. 1, 2016. Sec. 1.8, p. 11. (Accessed Aug. 2022).

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District of Columbia

Last updated 09/03/2022

POLICY

DC Medicaid must reimburse for health care services through …

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 Sept. 2022).

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. Jun. 7, 2022, Sec. 15.9.2. P. 66 & Department of Health Care Finance – Telemedicine Provider Guidance, Jan. 7, 2022, pg. 2 (Accessed Sept. 2022).


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 Sept. 2022)

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
  • Rehabilitation services including speech therapy

SOURCE: DC Municipal Regulation. Title 29, Ch. 9, Sec. 910.11 & Physicians Billing Manual.  DC Medicaid.  (Jan. 10, 2022) Sec. 15.10.6. P. 68, Clinic Billing Manual, DC Medicaid (Aug. 24, 2022), Sec. 15.2.6, P. 52. FQHC Billing Manual, DC Medicaid 15.2.6, P. 51. (Aug. 24, 2022), & Department of Health Care Finance – Telemedicine Provider Guidance, Jan. 7, 2022, pg. 5, (Accessed Sept. 2022)

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. 7, 2022, pg. 5. (Accessed Sept. 2022).

Distant site providers may only bill for the appropriate codes outlined (see manuals).

SOURCE: DC Municipal Regulation. Title 29, Ch. 9, Sec. 910.12, Physicians Billing Manual. DC Medicaid. (Jan. 10, 2022) Sec. 15.9.8. P. 67-68, Clinic Billing Manual, DC Medicaid (Aug. 24, 2022), Sec. 15.2.8, P. 52-53. & FQHC Billing Manual, DC Medicaid 15.2.8, P. 51-52. (Aug. 24, 2022). (Accessed Sept. 2022).

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 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. 7, 2022, pg. 5. (Accessed Sept. 2022).

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. 7, 2022, pg. 5, Clinic Billing Manual, DC Medicaid (Aug. 24, 2022), Sec. 15.2.7, P. 52. FQHC Billing Manual, DC Medicaid 15.2.7, P. 51. (Aug. 24, 2022). & Physicians Billing Manual. DC Medicaid. (Jan. 10, 2022) Sec. 15.10.7. P. 68 (Accessed Sept. 2022).

Certain dental procedures require prior authorization.

Providers should consult the fee schedule to determine if the procedure code requires prior authorization.

Medical necessity or a medically necessary service is defined as medical, surgical or other services required for the prevention, diagnosis, cure, or treatment of a health related illness, condition or disability including services necessary to prevent a detrimental change in either medical, behavioral, mental or dental health status. Only supplies, equipment, appliances, and services that are determined as medically necessary by the Department of Health Care Finance or its contracted representative are covered. See manual for complete list to determine medical necessity.

SOURCE: Physicians Billing Manual. DC Medicaid. (Jun. 7, 2022) Sec. 15.10.9-10 P. 69 (Accessed Sept. 2022).


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 Sept. 2022)

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 & Physicians Billing Manual. DC Medicaid. Jun. 7, 2022, Sec. 15.10.3-4. P. 66-67 &Department of Health Care Finance – Telemedicine Provider Guidance, Jan. 7, 2022, pg. 3-4., Clinic Billing Manual, DC Medicaid (Aug. 24, 2022), Sec. 15.2.3-4, P. 51-52.FQHC Billing Manual, DC Medicaid 15.2.3-4, P. 50. (Aug. 24, 2022). (Accessed Sept. 2022).

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. 7, 2022, pg. 3, 5-7. (Accessed Sept. 2022).

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 Sept. 2022).

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. 7, 2022, pg. 4., Clinic Billing Manual, DC Medicaid (Aug. 24, 2022), Sec. 15.2.5, P. 52. FQHC Billing Manual, DC Medicaid 15.2.5, P. 50-51. (Aug. 24, 2022). & Physicians Billing Manual. DC Medicaid. Jun. 7, 2022. Sec. 15.10.5. P. 67. (Accessed Sept. 2022).


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 telemedicine, distant site providers shall enter the “GT” (via real-time interactive video-audio communication) procedure modifier on the claim. Additionally, the distant site provider must report the National Provider Identifier (NPI) of the originating site provider in the “referring provider” portion of the claim.

SOURCE: Department of Health Care Finance – Telemedicine Provider Guidance, Jan. 7, 2022, pg. 3-4. (Accessed Sept. 2022).

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 Sept. 2022).

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,  Physicians Billing Manual. DC Medicaid. Jun. 7, 2022. Sec. 15.10.3. P. 66-67, Clinic Billing Manual, DC Medicaid (Aug. 24, 2022), Sec. 15.2.3, P. 51. & FQHC Billing Manual, DC Medicaid 15.2.3, P. 49-50. (Aug. 24, 2022). & Department of Health Care Finance – Telemedicine Provider Guidance, Jan. 7, 2022, pg. 3. (Accessed Sept. 2022).

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.

In the event the beneficiary’s home is the originating site, the distant site provider must bill using the GT modifier and specify the place of service ‘02’.

SOURCE: Department of Health Care Finance – Telemedicine Provider Guidance, Jan. 7, 2022, pg. 4., 6 (Accessed Sept. 2022).

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 Sept. 2022).


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. 7, 2022, pg. 5, Clinic Billing Manual, DC Medicaid (Aug. 24, 2022), Sec. 15.2.7, P. 52. FQHC Billing Manual, DC Medicaid 15.2.7, P. 51. (Aug. 24, 2022). & Physicians Billing Manual. DC Medicaid. (Jan. 10, 2022) Sec. 15.10.7. P. 68 (Accessed Sept. 2022).

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Florida

Last updated 08/04/2022

POLICY

FL Medicaid reimburses for real time, two-way, interactive telemedicine.…

POLICY

FL Medicaid reimburses for real time, two-way, interactive telemedicine.

Providers must include the GT modifier.

SOURCE: FL Admin Code 59G-1.057. (Accessed Aug. 2022).


ELIGIBLE SERVICES/SPECIALTIES

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 Aug. 2022).

Child Protective Team (CPT) Services

Real-time CPT telemedicine services for the evaluation of children suspected to be abused or neglected has been implemented in rural or remote areas.

SOURCE: FL Dept. of Health, Child Protection Team Program, Program Handbook, p. 24 (Jun. 28, 2019). (Accessed Aug. 2022).


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 Aug. 2022).

Child Protective Team (CPT) Services

Real-time CPT telemedicine services for the evaluation of children suspected to be abused or neglected has been implemented in rural or remote areas.  Only CPT medical providers approved as CMS medical providers and are specifically trained to do telemedicine exams can perform exams at the hub site.  Only registered nurses trained to assist in telemedicine exams can participate in the CPT medical exam at the remote site. All persons at remote site must act under the direct supervision of the telemedicine physician or physician extender.

SOURCE: FL Dept. of Health, Child Protection Team Program, Program Handbook, p. 24 (Jun. 28, 2019). (Accessed Aug. 2022).


ELIGIBLE SITES

No Reference Found


GEOGRAPHIC LIMITS

No Reference Found


FACILITY/TRANSMISSION FEE

No Reference Found

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Georgia

Last updated 08/01/2022

POLICY

The use of a telecommunications system may substitute for …

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. 168 (July 1, 2022). (Accessed Aug. 2022).

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. 5 (July 1, 2022). (Accessed Aug. 2022).


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. 168 (July 1, 2022). (Accessed Aug. 2022).

Claims must use the appropriate CPT or HCPCS code with the GT modifier and or the use of POS 02. POS 10 will indicate Telehealth services were provided in the patient’s home.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 8 (July 1, 2022). (Accessed Aug. 2022).

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.

Interactive audio and video telecommunications must be used, permitting real-time communications between the distant site provider or practitioner and the member.

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. 5 & 11 (July 1, 2022). (Accessed Aug. 2022).

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.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 48 (July 1, 2022) & GA Dept. of Community Health, Division of Medical Assistance, Part II Policies and Procedures for Nursing Facility Services, p. H-7 (p. 178). (July 1, 2022). (Accessed Aug. 2022).

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-22, p. 61 (July 2022). GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 40 (July 1, 2022). (Accessed Aug. 2022).

Autism Spectrum Disorder Services

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. 17 (July 1, 2022). (Accessed Aug. 2022).

Community Behavioral Health and Rehabilitation Services

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.  The circumstances in which it can be provided are:

  • For some services, any member who consents may receive services via telehealth;
  • For some services, telehealth is allowed only for members who speak English as a second language, and telehealth will enable the member to engage with a practitioner who can deliver services in his/her preferred language (e.g. American Sign Language, etc.) (one-to-one via Telehealth versus interpreters)
  • Telehealth is only allowed for certain CBHRS services and only two-way, real-time interactive audio and video communication as described in the Service Definitions section of this Guidance is allowable. Telehealth may not be used for any other Intervention.
  • See Behavioral Health and Development Disabilities manual for approved codes.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 21 (July 1, 2022). (Accessed Aug. 2022).

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. 69, 73-74 (July 1, 2022). (Accessed Aug. 2022).

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. 44 (July 1, 2022). (Accessed Aug. 2022).

School Based Services

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. 54-56 (July 1, 2022), & GA Dept. of Early and Periodic Screening, Diagnostic and Treatment Services ). pX-7 July 1, 2022). (Accessed Aug. 2022).

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. 35  (July 1, 2022). (Accessed Aug. 2022).

 


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. 10 (July 1, 2022). (Accessed Aug. 2022).

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. 16 (July 1, 2022). (Accessed Aug. 2022).

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. 24 (July 1, 2022). (Accessed Aug. 2022).

Teledentistry

Licensed dentists and dental hygienists are eligible providers.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 40 (July 1, 2022). (Accessed Aug. 2022).

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. 42 (July 1, 2022) & GA Dept. of Community Health, Policies and Procedures for Federally Qualified Health Center Services and Rural Health Clinic Services, p. 30, (July 1, 2022). (Accessed Aug. 2022).

Nursing Facility Specialized Services

See manual for eligible providers and levels.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 49 (July 1, 2022). (Accessed Aug. 2022).


ELIGIBLE SITES

The referring provider must be enrolled in GA Medicaid and comply with policy and procedures as outlines in applicable Georgia Medicaid manuals.

The referring provider must be the member’s attending physician, practitioner or provider in charge of their care.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 8 (July 1, 2022). (Accessed Aug. 2022).

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.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 14 (July 1, 2022). & Emergency Ambulance Services Handbook, p. 18 (July 2022). (Accessed Aug. 2022).

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.99 (July 1, 2022). (Accessed Aug. 2022).

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. 40 (July 1, 2022). (Accessed Aug. 2022).

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) (July 2022). (Accessed Aug. 2022).

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. 42 (July 1, 2022). & GA Dept. of Community Health, Policies and Procedures for Federally Qualified Health Center Services and Rural Health Clinic Services, p. 23, (July 1, 2022). (Accessed Aug. 2022).

Dialysis Services

Dialysis facilities are eligible originating sites for dialysis services.

SOURCE: GA Dept. of Community Health, GA Medicaid Telemedicine Guidance Handbook, p. 44 (July 1, 2022).  & GA Dept. of Community Health, GA Medicaid Dialysis Services Handbook, p. 17 (IX-10). (July 1, 2022) (Accessed Aug. 2022).

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. 48 (July 1, 2022). & GA Dept. of Community Health, Nursing Facility Services, p. H-7 (p. 178). (July 1, 2022). (Accessed Aug. 2022).

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. 53 (July 1, 2022).  & GA Dept. of Community Health, Children’s Intervention School Services (CISS). p. 9 (VI-6). (July 1, 2022). (Accessed Aug. 2022).


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. 8 (July 1, 2022). (Accessed Aug. 2022).

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, GA Medicaid Telehealth Guidance Handbook, p. 22 (July 1, 2022). (Accessed Aug. 2022).

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.

SOURCE: GA Dept. of Community Health, GA Medicaid Telemedicine Guidance Handbook, p. 53 (July 1, 2022).  & GA Dept. of Community Health, Children’s Intervention School Services (CISS). p. VI-6. (July 1, 2022). (Accessed Aug. 2022).

Ambulance Providers

Ambulances may bill a separate origination site fee. The Telehealth originating fee (03014) cannot be billed in combination with other rendered EMS services.

SOURCE: GA Dept. of Community Health, GA Medicaid Telemedicine Guidance Handbook, p. 14 (July 1, 2022). & Emergency Ambulance Services Handbook, p. 18 (July 2022). (Accessed Aug. 2022).

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. 44 (July 1, 2022). & GA Dept. of Community Health, GA Medicaid Dialysis Services Handbook, p. IX-10 (July 1, 2022). (Accessed Aug. 2022).

FQHC/RHC

FQHCs and RHCs that serve as an originating site for telehealth services are paid an originating site facility fee.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 42 (July 1, 2022). (Accessed Aug. 2022).

 

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Hawaii

Last updated 08/14/2022

POLICY

The State’s Medicaid managed care and fee-for-service programs shall …

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. Hawaii Medicaid is required under statute to reimburse telehealth equivalent to reimbursement for the same services provided via face-to-face contact.

SOURCE: HI Revised Statutes § 346-59.1 (a & b). (Accessed Aug. 2022). 

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 Aug. 2022).

Hawaii’s State Plan Amendment for telehealth services was approved. Approval is retroactive to January 1, 2017. Hawaii state telehealth law 346-59.1 continues to be in effect and adhered to by QI health plans and Medicaid fee-for-service providers

SOURCE: HI Department of Human Servies, Med-QUEST Division, Quest Integration (QI) Health Plans Memo QI-2139/FF2 21-15.  (Accessed Aug. 2022).


ELIGIBLE SERVICES/SPECIALTIES

GT, GQ or 95 modifiers must be used.  See Attachment A for full list of CPT codes that are “prime candidates” for telehealth services.  Distant site providers should use the 02 Place of Service Code.  Codes listed in Attachment A are considered prime candidates for telehealth reimbursement.

SOURCE: QI-2139 Tele-Health Law (Act 226, SLH 2016) Implementation/FFS-21-15 (Replaces QI-1702A/FFS-1701A) (Accessed Aug. 2022).

Dentistry

Eligible codes for reimbursement are listed in Attachment A.  All claims for services provided through telehealth technology must be identified by the applicable teledentistry CDT code D9995 or D9996.

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. 82 (Jan. 2021)., HI Department of Human Services.  Med-QUEST Division.  Attachment A., HI MedQUEST Division, CTR 19-01 Reimbursement for Procedures Related to FQHC Teledentistry Services. (Accessed Aug. 2022).

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).

SOURCE: HI Med-QUEST Memo QI-2028 (Jul. 21, 2020) & QI-2020 (Jun. 17, 2020), (Accessed Aug. 2022).

Federally Qualified Health Centers

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.

SOURCE: Med-QUEST Memo 20-03 (Mar. 16, 2020), QI-2139 Tele-Health Law (Act 226, SLH 2016) Implementation (Replaces QI-1702A), (Accessed Aug. 2022).

Community Integration Services (CIS)-Supportive Housing Services

CIS services may be rendered via telehealth as appropriate, as long as the required face-to-face interaction requirements are met (See Section 16, Service Settings for more information). Services rendered via telehealth shall be billed with the additional and appropriate telehealth modifiers, and applicable POS codes, as outline in memorandum QI-1702A (NOTE: QI-1702A has been replaced with QI-2139/FFS-21-15). Services may also be rendered via an approved telehealth modality, if determined by the health plan to be appropriate and effective and agreed to by the member.

SOURCE: Med-QUEST Memo QI-2105 (April 1, 2021). (Accessed Aug. 2022).

Induced/Intentional Termination of Pregnancy (ITOP) Evaluation & Management Services

Telehealth (audio-visual modality) may be used for evaluation and management services performed prior to the date of the medical ITOP. Codes in the range of 99201-99215 with modifiers 95, GQ, or GT are allowed.

SOURCE: Med-QUEST Memo FFS 2105 (May 7, 2021). (Accessed Aug. 2022).

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 Aug. 2022).


ELIGIBLE PROVIDERS

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. 80, 85 (Jan. 2021) & MedQuest Memo, Reimbursement for Procedures Related to FFS Teledentistry Services, No. 19-01, Mar. 13, 2019. (Accessed Aug. 2022).

Federally Qualified Health Centers

Providers who are eligible to bill for Hawaii Medicaid services are also eligible to bill for telehealth. Please refer to Hawaii Provider Manual Chapter 21 (21.2.1) for a list of eligible providers.

SOURCE: Med-QUEST Memo 20-03 (Mar. 16, 2020), & HI Med-QUEST Medicaid Provider Manual: Federally Qualified Health Centers, Chapter 21 (21.2.1),pg. 2 (March 2016). (Accessed Aug. 2022)


ELIGIBLE SITES

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 Aug. 2022).

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 Aug. 2022).

Approved state plan amendment authorizes HI Medicaid to remove geographic and originating site requirements.

SOURCE: HI State Plan Amendment 16-0004. (Accessed Aug. 2022). 

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 Activiteis/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 Memo 20-03. (Accessed Aug. 2022).


GEOGRAPHIC LIMITS

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 Aug. 2022). – 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 Aug. 2022). 

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. 80 (Aug. 2022).

Federally Qualified Health Centers:

Services must be provided at an HRSA approved site or satellite.

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 Memo 20-03. (Accessed Aug. 2022).


FACILITY/TRANSMISSION FEE

For FQHCs

When a spoke or originating site is solely used to facilitate tele-health, payment for the facilitation shall not exceed the published Medicare rate for transmission services for spoke sites.

SOURCE: HI Dept. of Human Services, Med-QUEST Division, Memo No. QI-2007/FFS 20-03. (Accessed Aug. 2022).

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Idaho

Last updated 08/22/2022

POLICY

Telehealth services are covered and reimbursable fee-for-service if delivered …

POLICY

Telehealth services are covered and reimbursable fee-for-service if delivered via two-way live video between the provider and the participant. Services must be equal in quality to services provided in-person, and comply with HIPAA privacy requirements, licensure requirements, Medicaid Information Release MA18-07, and all Medicaid rules, regulations and policies.

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.  July 20, 2022, Section 10.9, 10.9.2 & 10.9.4 p. 128-129. (Accessed Aug. 2022).

Rendering providers must provide timely coordination of services, within three business days, with the participant’s primary care provider who should be provided in written or electronic format a summary of the visit, prescriptions and DME ordered.

SOURCE:  Idaho Medicaid Provider Handbook.  General Information and Requirements for Providers.  July 20, 2022, Section 10.9 p. 128 (Accessed Aug. 2022). 

Telehealth services that are properly identified in accordance with billing requirements are covered under Medicaid for physicians, within limitations defined by the Department in the Idaho Medicaid Provider Handbook.

SOURCE: ID Administrative Code 16.03.09 Sec. 210 (09), Pg. 25 (Accessed Aug. 2022).

For Home Health, the face-to-face encounter that initiates treatment may occur via telehealth.

SOURCE: ID Administrative Code 16.03.09 Sec. 210 (09), Pg. 102 (Accessed Aug. 2022). ID Medicaid Provider Handbook: Home Health and Hospice Services, 1.2.4.1, p. 6. (Mar. 2, 2021). (Accessed Aug. 2022).


ELIGIBLE SERVICES/SPECIALTIES

Services must be equal in quality to services provided in-person.

SOURCE:  Idaho Medicaid Provider Handbook. General Information and Requirements for Providers.  July 20, 2022, Section 10.9 p. 128 (Accessed Aug. 2022).

Place of service 02 (telehealth) is not used by Idaho Medicaid. All normal Place of Service codes are acceptable for telehealth. The place of service used should be the location of the participant. Claims must include a GT modifier (Via interactive audio and video telecommunications systems) on CPT® and HCPCS. FQHC, RHC or IHS providers should not report the GT modifier with encounter code T1015, but should include it with the supporting codes.

SOURCE:  Idaho Medicaid Provider Handbook. General Information and Requirements for Providers.  July 20, 2022, Section 10.9.4, pg. 129 (Accessed Aug. 2022).

Physician/Non-Physician Practitioner Services:

Physicians and non-physician practitioners enrolled as Healthy Connections primary care providers are eligible to provide primary care services via telehealth. Other services available through telehealth (manual lists specific CPT codes):

  • Specialty Services
  • Health and Behavioral Assessment/Intervention
  • Psychiatric Crisis Consultation (Physicians and psychiatric nurse practitioners only)
  • Psychotherapy with evaluation and management
  • Psychiatric diagnostic interview
  • Pharmacological management
  • Tobacco Use Cessation

School-based Services

Community Based Rehabilitation Services (CBRS) Supervision is covered via telehealth. Reimbursement is already included in CBRS payment.

Children with Developmental Disabilities

Therapeutic consultation and crisis intervention can be delivered via telehealth technology through the Bureau of Developmental Disability Services. See manual for specific codes.

Early Intervention Services (EIS) for Infants and Toddlers

Eligible services include:

  • Family training and counseling for child development, per 15 minutes (HCPCS T1027)
  • Home care training, family, per 15 minutes (HCPCS S5110)
  • Medical team conference with interdisciplinary team, 30 minutes (CPT 99366)

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 must be provided in-person and not by telehealth. The therapist must certify that the services can safely and effectively be done with telehealth and the physician or nonphysician practitioner order must specifically allow the services to be provided by telehealth. Therapists must adhere to all requirements of their licensing board for telehealth services. Specific service codes found in manual.

Interpretation Services

Idaho Medicaid will reimburse for interpretation, translation, Braille and sign language services provided to participants in person or through telehealth.

SOURCE:  ID Medicaid Provider Handbook, Therapy Services June 14, 2022 pg 37 & Idaho Medicaid Provider Handbook.  General Information and Requirements for Providers July 20, 2022, p. 124-129. (Accessed Aug. 2022).

Psychiatric Crisis

Physicians and psychiatric nurse practitioners may provide psychotherapy (CPT® 90839 and 90840) to participants in crisis via telehealth.

SOURCE: ID Medicaid Provider Handbook: Physician and Non-Physician Practitioner (June 14, 2022), p. 67. (Accessed Aug. 2022).


ELIGIBLE PROVIDERS

Physicians and non-physician practitioners enrolled as Healthy Connections primary care providers are eligible to provide primary care services via telehealth.

Idaho Medicaid will cover speech therapy (92507) when provided by a licensed speech language pathologist.

Idaho Medicaid will cover therapy services (97110, 97530) for occupational therapists and physical therapists.

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 July 20, 2022 p. 128-129 (Accessed Aug. 2022).

Idaho Medicaid will cover speech therapy (92507) when provided by a licensed speech language pathologist.

SOURCE: ID Medicaid Provider Handbook, Therapy Services June 14, 2022 pg 37  (Accessed Aug. 2022).

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. 4.32.3, Pg. 67, (4.36) 71. June 14, 2022, (Accessed Aug. 2022).

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.

SOURCE:  ID Medicaid Provider Handbook: IHS, FQHC, and RHC Services, June 14, 2022, p. 30.  (Accessed Aug. 2022).


ELIGIBLE SITES

Telehealth services as an encounter by a facility are reimbursable if the services are delivered in accordance with the ID Medicaid Telehealth Policy.

SOURCE: Idaho Medicaid Provider Handbook: IHS, FQHC, RHC Services. June 14, 2022 p. 30 (Accessed Aug. 2022).


GEOGRAPHIC LIMITS

No Reference Found


FACILITY/TRANSMISSION FEE

No Reference Found

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Illinois

Last updated 08/15/2022

POLICY

The Department of Healthcare and Family Services shall reimburse …

POLICY

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; and (ii) a method to reimburse providers for mental health services provided by telehealth.

SOURCE: 305 ILCS 5/5-5.25. (Accessed Aug. 2022).

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. (Accessed Aug. 2022).

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 Aug. 2022). 

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 Aug. 2022).

See regulations for requirements during a public health emergency.

SOURCE: IL Admin. Code, Title 89,140.403. (Accessed Aug. 2022). 


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 Aug. 2022).

See Encounter Clinic Services Appendices for billing examples.

SOURCE: Handbook for Encounter Clinic Services, Chapter D-200 – Appendices. (Accessed Aug. 2022).

Modifier 93 is a new modifier used to identify services that are provided via telephone or other real-time interactive audio-only telecommunication systems. It does not replace modifier GT, which should continue to be used to identify telehealth interactions using both audio and video telecommunications systems. When using modifier 93, the communication during the audio-only service must be of an amount or nature that meets the same key components and/or requirements of a face-to-face interaction. Modifier 93 is effective 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 Aug. 2022).

There is no reimbursement for group psychotherapy as a telepsychiatry service.

SOURCE: IL Admin. Code Title 89, 140.403. (Accessed Aug. 2022).

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). (Accessed Aug. 2022).

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 Aug. 2022).

This notice informs “Community Based Behavioral Services” providers of new billing instructions related to the use of procedure code modifier GT – Via Audio and Video Telecommunications Systems and Place of Service Code 02 – Telehealth — effective October 1, 2021.

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.

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. 23-24 (Oct., 2021). (Accessed Aug. 2022).

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 Aug. 2022).

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 Aug. 2022).

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 Aug. 2022).


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 Aug. 2022).

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); & 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 Aug. 2022).

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 Appendicies supplement for telehealth billing examples for encounter clinics.

SOURCE: IL Admin. Code Title 89, 140.403IL 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 Aug. 2022).

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 Aug. 2022)

Local education agencies may submit telehealth services as a certified expenditure.

SOURCE: IL Admin. Code Title 89, 140.403(c)(1)(B). (Accessed Aug. 2022).


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 Aug. 2022).  

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 Aug. 2022).

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 Aug. 2022).

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 Aug. 2022).

See handbook supplement for telehealth billing examples.

SOURCE: All Providers Handbook Supplement (Sept. 2020), pg. 43-45. (Accessed Aug. 2022). 

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 Appendicies supplement for telehealth billing examples for encounter clinics.

SOURCE: IL Dept. of Healthcare and Family Svcs., Expansion of Telehealth Services, Informational Notice, Jan. 1, 2010IL Dept. of Healthcare and Family Svcs., Handbook for Practitioners. (June 2021) Ch. 200, p. 25Handbook for Podiatrists, F-200, p. 27 (Oct. 2016); & Handbook for Encounter Clinic Services. Ch. D-200, pg. 17.  Aug. 2016. (Accessed Aug. 2022).


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 Aug. 2022).

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” (Accessed Aug. 2022)

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Indiana

Last updated 08/20/2022

POLICY

Indiana Code requires reimbursement for medically necessary telehealth services …

POLICY

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, provider licensed as 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 Aug. 2022).

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

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

In any telemedicine encounter, there will be the following:

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

SOURCE: IN Admin. Code, “Article 5,” Title 405, 5-38-3 & 4., p. 182 (Accessed Aug. 2022).


ELIGIBLE SERVICES/SPECIALTIES

The following services may not be provided using telehealth: surgical procedures, radiological services, laboratory services, anesthesia services, care coordination without the member present, durable medical equipment (DME)/home medical equipment (HME) services, provider-to-provider consultation, and services that require hands-on physical interaction or manipulation with the patient.

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

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

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

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

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

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

An appropriate place of service (POS) code of one of the following:

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

An appropriate modifier of one of the following: −

  • 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 ICHP Bulletin BT202249 (June 30, 2022). (Accessed Aug. 2022).

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

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

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

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

Nonhealthcare Virtual Services

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.

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.

Intensive Outpatient Treatment via Telehealth

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 Aug. 2022).


ELIGIBLE PROVIDERS

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

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

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

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

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

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

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

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

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

  • A federally qualified health center
  • A rural health clinic
  • A community mental health center
  • A critical access hospital
  • A home health agency licensed under IC 16-27-1. (Effective July 1, 2022).
  • A provider, as determined by the office to be eligible, providing a covered telehealth service.

SOURCE: IN Admin Code, “Article 5” 405 5-38-4(3) p. 183IN Code, 12-15-5-11 (Accessed Apr. 2022). Bolded items added by SB 284 (2022 Session). (Accessed Aug. 2022).

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

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

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

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

Non-Eligible Providers

IHCP does not reimburse the following provider types for telemedicine:

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

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


ELIGIBLE SITES

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 Aug. 2022).

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

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


GEOGRAPHIC LIMITS

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

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


FACILITY/TRANSMISSION FEE

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

  • 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 Aug. 2022).

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Iowa

Last updated 07/21/2022

POLICY

An in-person contact between a health care professional and …

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. 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 Jul. 2022).

Managed care plans in Iowa’s Healthy and Well Kids in Iowa (Hawki) program, may cover telehealth and telemonitoring services, but do not appear to be mandated.

SOURCE: IA Hawki Benefits. (Accessed Jul. 2022). 

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. 3 & 19. (AccessedJul. 2022).


ELIGIBLE SERVICES/SPECIALTIES

IA Medicaid covers teledentistry synchronous real time encounter.

SOURCE: IA Dep. of Human Services. Informational Letter No. 2124-MC-FFS, April 6, 2020, (Accessed Jul. 2022).


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 Mar. 2022).


ELIGIBLE SITES

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 Mar. 2022).


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 Mar. 2022).

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Kansas

Last updated 08/18/2022

POLICY

Insurers (including Medicaid) cannot exclude from coverage a service …

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 Jun. 2022). 

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.  2-31 (Jul 2022). (Accessed Aug. 2022).


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.  The GT modifier is no longer required.

See manual for list of acceptable CPT codes.  Telemedicine will be reimbursed at the same rate as face-to-face services.

SOURCE: KS Dept. of Health and Environment, Kansas Medical Assistance Program, Provider Manual, General Benefits, p. 2-30 (Jul 2022) & FQHC/RHC, 8-13 (Aug. 2022), (Accessed Aug. 2022)

Mental health assessment can be delivered by a non-physician at a professional level and delivered either face-to-face or through telemedicine. Some specialized community-based rehabilitation services can be provided face-to-face or via telemedicine.

SOURCE: KS Dept. of Health and Environment, Kansas Medical Assistance Program, Provider Manual, Mental Health, p. 8-15, 8-22 (Mar. 2022). (Accessed Aug. 2022).

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 (Jul 2022), & Rehabilitative Therapy Services, p. 8-5, (Apr. 2022). (Accessed Aug. 2022).

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. 2-32 (Jul 2022). (Accessed Aug. 2022). 

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 & 8-8 (Nov. 2021). (Accessed Aug. 2022). 

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 (Jan. 2022). (Accessed Aug. 2022). 

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. 2022), (Accessed Aug. 2022).

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, p. 8-38, (Aug. 2022), (Accessed Aug. 2022).


ELIGIBLE PROVIDERS

Telemedicine and telehealth services may be delivered by a healthcare provider, which includes:

  • Physicians
  • Licensed Physician Assistants
  • Licensed Advanced Practice Registered Nurses
  • Other persons 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. 2-30 (Jul. 2022). (Accessed Aug. 2022). 

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 (Jul 2022); Early Childhood Intervention Fee-for-Service Provider Manual, p. 8-4 to 8-5 (Apr. 2022) ; Local Education Agency Services, p. 8-7 (Jan. 2020); & Rehabilitative Therapy Services, p. 8-4, (Apr. 2022). (Accessed Aug. 2022).

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, 8-13, (Aug. 2022), (Accessed Aug. 2022).


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 (Jul. 2022), & Rehabilitative Therapy Services, p. 8-5, (Apr. 2022). (Accessed Aug. 2022).


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).

SOURCE: KS Dept. of Health and Environment, Kansas Medical Assistance Program, Provider Manual, General Benefits, p. 2-30 & 32 (Jul 2022), (Accessed Aug. 2022).

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. 8-13 (Aug. 2022), (Accessed Aug. 2022).

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 (Jul 2022), (Accessed Aug. 2022).

 

 

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Kentucky

Last updated 08/12/2022

POLICY

The department must reimburse an eligible telehealth care provider …

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.

SOURCE: KY Admin. Regs. Title, 907, 3:170. (Accessed Aug. 2022).

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 Aug. 2022).

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 Aug. 2022).

Health care providers performing a telehealth or digital health service shall, 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 Aug. 2022).


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 Aug. 2022).

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
  • Remote patient monitoring
  • Referral
  • Treatment

A service is not reimbursed if:

  • It is not medically necessary;
  • The equivalent service is not covered by the department if provided in a face-to-face setting; or
  • The provider is not enrolled, participating, or in good standing with the Medicaid program, is on an excluded or terminated provider list, or is an excluded individual or entity, as listed on the US Office of Inspector General List.

Reimbursement is not made for services that are not:

  • Medically necessary;
  • Compliant with administrative regulation;
  • Applicable to this administrative regulation; or
  • Compliant with state or federal law.

SOURCE: KY Admin. Regs. Title, 907, 3:170. (Accessed Aug. 2022).


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 Aug. 2022).

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.

SOURCE: KY Admin. Regs. Title, 907, 3:170. (Accessed Aug. 2022).

Eligible providers for services NOT in a Community Mental Health Center:

  • A psychiatrist;
  • A licensed clinical social worker directly employed by a psychiatrist if the psychiatrist also interacts with the recipient during the encounter;
  • A psychologist with a license and a doctorate degree in psychology directly employed by a psychiatrist if the psychiatrist also interacts with the recipient during the encounter;
  • A licensed professional clinical counselor directly employed by a psychiatrist if the psychiatrist also interacts with the recipient during the encounter;
  • A licensed marriage and family therapist directly employed by a psychiatrist if the psychiatrist also interacts with the recipient during the encounter;
  • A physician;
  • An APRN;
  • Speech-language pathologist;
  • Occupational therapist;
  • Physical therapist;
  • Licensed dietitian or certified nutritionist; or
  • Registered nurse or dietitian

Eligible providers for services in a Community Mental Health Center:

  • A psychiatrist;
  • A physician;
  • Psychologist with a license in accordance with KRS 319.010(6);
  • A licensed marriage and family therapist;
  • A licensed professional clinical counselor;
  • A psychiatric medical resident;
  • A psychiatric registered nurse;
  • A licensed clinical social worker;
  • An advanced practice registered nurse

Restrictions apply for all professionals.

SOURCE: KY State Plan Amendment. Attachment 3.1-B. Approved 3/9/2011 (Accessed Aug. 2022).


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 Aug. 2022).

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 Aug. 2022).


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 Aug. 2022).

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Louisiana

Last updated 08/02/2022

POLICY

Louisiana Medicaid only reimburses the distant site for services …

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.

Covered services must be identified on claims submissions by appending the modifier “95” to the applicable procedure code and indicate Place of Service (POS) 02. Both the correct POS and modifier must be present on the claim to receive reimbursement.

SOURCE: LA Dept. of Health and Hospitals, Professional Svcs. Provider Manual, Chapter Five of the Medicaid Svcs. Manual, Section 5.1, p. 161-162 (Sept. 3, 2020). (Accessed Aug. 2022).

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. 34 (Accessed Aug. 2022).


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 Aug. 2022). 

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 and Hospitals, Professional Svcs. Provider Manual, Chapter Five of the Medicaid Svcs. Manual, Section 5.1, p. 161. (Sept. 3, 2020). (Accessed Aug. 2022).

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 Aug. 2022).

Behavioral Health Services

Assessments, evaluations, individual psychotherapy, family psychotherapy, and medication management services may be reimbursed when provided via telecommunication technology. The LMHP is responsible for acting within the telehealth scope of practice as decided by their licensing board. The provider must bill the procedure code (CPT codes) with modifier “95”, as well as Place of Service “02”. Reimbursement will be at the same rate as a face-to-face service.

SOURCE: LA Dept. of Health and Hospitals, Behavioral Health Services, Chapter Two of the Medicaid Svcs. Manual, Section 2.3, p. 91-92 (As issued on Feb. 25, 2022). (Accessed Aug. 2022).

Ambulance Providers – Managed Care Organizations

Ambulance providers that are dispatched by an emergent call for service may determine upon the scene that a telehealth visit with a licensed medical professional, who is enrolled in Medicaid, is more appropriate than transportation to an emergency department. In this case, the treatment-in-place service may be rendered.

SOURCE: LA Medicaid Managed Care Organization (MCO) Manual, p. 64 (As revised 3/5/21), (Accessed Aug. 2022).

Early and Periodic Screening, Diagnostics and Treatment Health Services (EPSDT)

Telemedicine/telehealth is not a covered service, but is a service delivery method. Louisiana Medicaid encourages the use of this delivery method, when appropriate, for any and all healthcare services (i.e., not just those related to COVID-19 symptoms). Louisiana Medicaid allows for the telemedicine/telehealth mode of delivery for many common healthcare services.

All services eligible for telemedicine/telehealth may be delivered via an interactive audio/video telecommunications system.

Reimbursement for services delivered through telemedicine/telehealth is at the same level as reimbursement for in-person services.

SOURCE: LA Dept. of Health and Hospitals, EPSDT Health and IDEA Related Services, Ch. 20, Sec. 20.1, (As issued on Sept. 22, 2021), (Accessed Aug. 2022).

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

The distant site provider must be enrolled as a Louisiana Medicaid provider to receive reimbursement for covered services.

SOURCE: LA Dept. of Health and Hospitals, Professional Svcs. Provider Manual, Chapter Five of the Medicaid Svcs. Manual, Section 5.1, p. 161 (As issued on Sept. 3, 2020). (Accessed Aug. 2022).

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 Aug. 2022). 

FQHC manual refers to provider manual for billing instructions.

SOURCE: LA Dept. of Health and Hospitals, Federally Qualified Health Centers Provider Manual, Chapter 22, Sec. 22.4, pg. 33, (As issued on Mar. 10, 2022) & Rural Health Clinic Manual, Chapter 40, Sec. 40.4, pg. 33 (As issued on Mar. 17, 2022). (Accessed Aug. 2022).


ELIGIBLE SITES

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 Aug. 2022). 

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 Aug. 2022). 


GEOGRAPHIC LIMITS

A BHS provider may not provide telehealth services outside of its geographic service area.

SOURCE: LA Admin Code 48:I Sec. 5606, (Accessed Aug. 2022).


FACILITY/TRANSMISSION FEE

Louisiana Medicaid only reimburses the distant site provider.

SOURCE: LA Dept. of Health and Hospitals, Professional Svcs. Provider Manual, Chapter Five of the Medicaid Svcs. Manual, Section 5.1, p. 161 (As issued on Sept. 3, 2020). (Accessed Aug. 2022).

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Maine

Last updated 07/27/2022

POLICY

If the Member is eligible for the underlying covered …

POLICY

If the Member is eligible for the underlying covered service to be delivered, and if delivery of the covered service via telehealth is medically appropriate, as determined by the health care provider, the member is eligible for telehealth services.

Except as provided in the manual, reimbursement will not be provided for communications between Health Care Providers when the Member is not present at the Originating (Member) Site.

Except as provided in the manual, reimbursement will not be provided for communications solely between Health Care Providers and Members when such communications would not otherwise be billable.

SOURCE: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4., p. 3 & 9. (June 15, 2020). (Accessed Jul. 2022).

“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 Jul. 2022).


ELIGIBLE SERVICES/SPECIALTIES

Any medically necessary MaineCare Covered Service may be delivered via Interactive Telehealth Services, provided the following requirements are met:

  1. The Member is otherwise eligible for the Covered Service, as described in the appropriate section of the MaineCare Benefits Manual; and
  2. The Covered Service delivered by Interactive Telehealth Services is of comparable quality to what it would be were it delivered in person.

Prior authorization is required for Interactive 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 prior authorization of the mode of delivery. A face to face encounter prior to telehealth is not required.

There is a specific list of telehealth specific codes and reimbursement rates provided in the manual.

Coverage also includes the virtual check-in, which can occur telephonically or through interactive services.  See manual for requirements.

Non-Covered services include:

  • Medical equipment, supplies, orthotics and prosthetics
  • Personal care aide
  • Assistive technology services (for certain applicable sections, see manual)
  • Non-emergency medical transportation
  • 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 telehealth services.

See manual for details of the exclusions.

SOURCE: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4., p. 4-5, 7-9, 15-17. (June 15, 2020). (Accessed Jul. 2022).

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 Jul. 2022)

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, pgs. 51-52 (Aug. 19, 2020). (Accessed Jul. 2022).

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 Jul. 2022).

Durable Medical Equipment

Face-to-Face Encounter is a mandatory encounter (including encounters through a telehealth system, (as described in Chapter I, §1.06 of this manual) and other than encounters incidental to services involved) between the member and his or her physician, physician assistant, nurse practitioner or clinical nurse specialist that takes place within the six (6) months prior to a written order for Durable Medical Equipment being given. The written order may be prescribed by the physician, physician assistant, nurse practitioner, or clinical nurse specialist who performed the face-to-face encounter.

SOURCE: MaineCare Benefits Manual, Durable Medical Equipment, 60.05, Ch. 101, Ch. II, Sec. 60, p. 4, (6/13/18), (Accessed Jul. 2022).


ELIGIBLE PROVIDERS

A health care provider is an individual or entity licensed or certified under the laws of the state of Maine to provide medical, behavioral health, and related services to MaineCare Members. Health Care Providers must be enrolled as MaineCare Providers in order to be reimbursed for services.

A health care provider must also be:

  • Acting within the scope of his or her license
  • Enrolled as a MaineCare provider; and
  • Otherwise eligible to deliver the underlying Covered Service according to the requirements of the applicable section of the MaineCare Benefits Manual.

SOURCE: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4.03., p 1 & 4. (June 15, 2020). (Accessed Jul. 2022). 

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 HRSA and 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. 13. (June 15, 2020). (Accessed Jul. 2022).


ELIGIBLE SITES

The Originating (Member) Site will usually be a Health Care Provider’s office, but it may also be the Member’s residence, provided the proper equipment is available 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.

The Health Care Providers at the Receiving and Originating Sites may be part of the same organization. In addition, 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 qualified professional who is under a contractual arrangement with the Originating (Member) Site.

SOURCE: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4., p. 2 & 13 & 14. (June 15, 2020). (Accessed Jul. 2022).


GEOGRAPHIC LIMITS

No Reference Found


FACILITY/TRANSMISSION FEE

A facility fee is provided to a health care provider at the originating site.

An originating facility fee may only be billed in the event that the originating site is in a healthcare provider’s facility.

An Originating Facility Fee may not be billed for a Telephonic Service.

When an FQHC or RHC serves as the originating site, the facility fee is paid separately from the center or clinic all-inclusive rate.

The Department will not separately reimburse for any charge related to the purchase, installation, or maintenance of telehealth equipment or technology, nor any transmission fees, nor may a Member be billed for such.

SOURCE: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4. p. 2, 9-10, 13. (June 15, 2020). (Accessed Jul. 2022).

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Maryland

Last updated 08/02/2022

POLICY

Reimbursement for telehealth is required for services appropriately delivered …

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 solely because it is through telehealth.

SOURCE: MD Health General Code 15-141.2 (Accessed Aug. 2022).

Managed Care

MCOs shall provide coverage for medically necessary telemedicine services.

SOURCE: Code of Maryland Admin. Regs. Sec. 10.67.06.31. (Accessed Aug. 2022).

Maryland Medicaid provides a telehealth program that employs a “hub-and-spoke” model. This model involves real-time interactive communication between the originating and distant sites via a secure, two-way audiovisual telecommunication system. The “telepresenter,” physically located at the originating site with the participant, facilitates the telehealth communication between the participant and distant site provider by arranging, moving, or operating the telehealth equipment.

SOURCE: MD Medicaid Telehealth Program. Telehealth Program Manual, p. 1. Updated April 2020. (Accessed Aug. 2022).

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 Aug. 2022).


ELIGIBLE SERVICES/SPECIALTIES

Covered Services – Somatic and behavioral health services: Providers must contact the participant’s Healthchoice MCO or behavioral health ASO with questions regarding prior authorization requirements for telehealth services.

SOURCE: MD Medicaid Telehealth Program. Telehealth Program Manual, p. 2. Updated April 2020. (Accessed Aug. 2022).

The Department, under the Telehealth Program, covers medically necessary services covered by the Maryland Medical Assistance Program rendered by a distant site provider that are:

  • Distinct from services provided by the originating site provider;
  • Able to be delivered using technology-assisted communication; and
  • Clinically appropriate to be delivered via telehealth.

Services must be provided via telehealth to the same extent and standard of care as services provided in person; and as determined by the provider’s licensure or credentialing board, services performed via telehealth must be within the scope of a provider’s practice.

SOURCE: Code of Maryland Admin. Regs. Sec. 10.09.49.04. (Accessed Aug. 2022).

Services should be billed with the GT modifier.

SOURCE: Code of Maryland Admin. Regs. Sec. 10.09.49.10. (Accessed Aug. 2022).

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 Aug. 2022).

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 Aug. 2022).

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 June 8, 2022. (Accessed Aug. 2022).

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 Aug. 2022).

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 Aug. 2022).

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. (Accessed Aug. 2022).

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 Aug. 2022).


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 Aug. 2022).

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, 2023, 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). (Accessed Aug. 2022).

Effective October 7, 2019, all distant site providers enrolled in Maryland Medicaid may provide services via telehealth as long as telehealth is a permitted delivery model within the rendering provider’s scope of practice. Providers should consult their licensing board prior to rendering services via telehealth.

Telehealth providers must be enrolled in the Maryland Medical Assistance Program before rendering services via telehealth.

Only providers who are HIPAA compliant and meet Technical Requirements may bill for services rendered via telehealth.

SOURCE: MD Medicaid Telehealth Program. Telehealth Provider Manual, p. 1-3. Updated April 2020. MD Medical Assistance Program. Professional Services Provider Manual, p. 74. Updated Jan. 2022. (Accessed Aug. 2022).

Distant Site Providers may render services via telehealth within the provider’s scope of practice.

SOURCE:  Code of Maryland Admin. Regs. Sec. 10.09.49.06(D). (Accessed Aug. 2022).

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 Aug. 2022).

An approved distant telemental health location shall be within the State.

SOURCE: Code of Maryland Admin. Regs., Sec. 10.21.30.05(D). (Accessed Aug. 2022).


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 Aug. 2022).

Eligible originating sites may be:

  • College or university student health or counseling office
  • Community-based substance use disorder provider
  • Deaf or hard of hearing participant’s home or any other secure location approved by the participant and provider
  • Elementary, middle, high or technical school with a supported nursing, counseling or medical office
  • Local health department
  • FQHC
  • Hospital, including emergency department
  • Nursing facility
  • Private office of a physician, physician assistant, psychiatric nurse practitioner, nurse practitioner, or nurse midwife
  • Opioid treatment program
  • Outpatient mental health center
  • Renal dialysis center; or
  • Residential crisis services site

SOURCE: MD Medicaid Telehealth Program. Telehealth Provider Manual, p. 2. Updated April 2020. & Code of Maryland Admin. Regs. Sec. 10.09.49.06. (Accessed Aug. 2022).

Schools are permitted to act as originating sites under Medicaid telehealth Program regulations. All distant site providers enrolled in Maryland Medicaid may provide services via telehealth as long as telehealth is a permitted delivery model within the rendering provider’s scope of practice. Providers should consult their licensing board prior to rendering services via telehealth.

A school may still serve as the originating site for a telehealth interaction if the service is performed outside of an SBHC with an FQHC or local health department sponsor.

SOURCE: MD Medicaid Telehealth Program FAQs. p. 1-2, Updated April 2020. (Accessed Aug. 2022).

Mental Health

Eligible Originating Sites:

  • County government offices appropriate for private clinical evaluation services;
  • 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 Aug. 2022).

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. The use of audio-only telehealth services is only permitted during the Public Health State of Emergency.

SOURCE: MD Medical Assistance Program. Professional Services Provider Manual, p. 24-25, 74. Updated Jan. 2022. (Accessed Aug. 2022).

Distant site providers may use secure space/areas in the provider’s home to engage in telehealth. Telehealth providers must meet the minimum requirements for privacy as well as the minimum requirements for technology.

Other permitted places of service from where to deliver services via telehealth include: school, office, inpatient hospital, outpatient hospital, emergency room, nursing facility, independent clinic, Federally Qualified Health Center (FQHC), community mental health center, non-residential substance abuse treatment facility, end-stage renal disease treatment facility, public health clinic.

SOURCE: MD Medicaid Telehealth Program FAQs. p. 1, Updated April 2020. (Accessed Aug. 2022).


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 Aug. 2022).

The Telehealth Program serves Medicaid participants regardless of geographic location within Maryland.

SOURCE: MD Medicaid Telehealth Program. Telehealth Provider Manual. p. 1, Updated April 2020. (Accessed Aug. 2022).

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 Aug. 2022).


FACILITY/TRANSMISSION FEE

The Department may not reimburse distant site providers for a facility fee.

SOURCE: Code of Maryland Admin. Regs. Sec. 10.09.49.09(G). (Accessed Aug. 2022).

Hospital Billing Instructions

Facility charges related to the use of telemedicine services. This revenue code is payable for dates of service 10/1/13 forward.

SOURCE:  Maryland Dept. of Health Medical Assistance, UB04 Hospital Billing Instructions, 4/23/2020, p. 93 (Accessed Aug. 2022).

From July 1, 2021, to June 30, 2023, 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). (Accessed Aug. 2022)

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Massachusetts

Last updated 08/29/2022

POLICY

The division and its contracted health insurers, health plans, …

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 Aug. 2022).

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 Aug. 2022).

Access to Health Services through Telehealth Options

Given the previously referenced trends, and recognizing the continuing impacts of COVID-19, MassHealth is updating its telehealth policy to ensure continued access to telehealth modalities for delivery of medically necessary MassHealth-covered services and to promote equity in access and high quality of care. This updated policy largely aligns with the telehealth policy described in All Provider Bulletin 324 (and its predecessor bulletins), with certain exceptions described in this bulletin. In sum, pursuant to this policy, MassHealth will continue to allow MassHealth-enrolled providers to deliver a broad range of MassHealth-covered services via telehealth and, through December 31, 2022, will reimburse for such services at parity with their in-person counterparts. All providers delivering services via telehealth must comply with the policy detailed in this bulletin. This bulletin will be effective until MassHealth issues superseding guidance.

This bulletin, which is effective for DOS on or after October 16, 2021, provides that guidance, establishing MassHealth’s agency-wide rules for reimbursement of services provided via telehealth, applicable to all MassHealth programs. This bulletin applies to members enrolled in MassHealth fee-for-service, the Primary Care Clinician (PCC) plan, or a Primary Care Accountable Care Organization (ACO).

*Note:  MassHealth will continue to evaluate these telehealth rate parity and facility fee policies through December 31, 2022, and may change those policies after that date.  MassHealth does not anticipate introducing any such changes prior to January 1, 2023.

SOURCE: MassHealth All Provider Bulletin 327, Oct. 2021. (Accessed Aug. 2022).


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 Aug. 2022).

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 Aug. 2022).

The division of medical assistance shall ensure that rates of payment for in-network providers for telehealth services provided in pursuant to MA law (see text) are not less than the rate of payment for the same service delivered via in-person methods.

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 Mar. 2022).

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 Aug. 2022). 

MassHealth lists specific codes that may be used by community health centers for services delivered through telehealth. See Transmittal Letter for details.

SOURCE: MassHealth Transmittal Letter CHC-118 Community Health Center Manual (Addition of Codes) &  MassHealth Transmittal Letter CHC-118, p. 6-12 & 6-13, Jan. 1, 2022. (Accessed Aug. 2022).

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), any MassHealth-enrolled provider may deliver any medically necessary MassHealth-covered service to a MassHealth member via any telehealth modality, 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 Appendix A to this bulletin, 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 development of its telehealth policy. Based on the results of this monitoring, and its analysis of relevant data and information, MassHealth may adjust this coverage policy, including by imposing limitations on the use of certain telehealth modalities for various covered services. MassHealth does not anticipate introducing any such changes prior to January 1, 2023.

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 Services
  • Laboratory Services
  • Nursing Facility Services
  • Orthotic Services
  • Personal Care Services
  • Prosthetic Services
  • Renal Dialysis Clinic Services
  • Surgery Services
  • Transportation Services
  • X-Ray/Radiology Services

As described above, except for these categories of services, any provider may deliver any MassHealth-covered service via any telehealth modality in accordance with the standards set forth in this bulletin, provided that such services are payable under that provider type.

*Note:  MassHealth will continue to evaluate these telehealth rate parity and facility fee policies through December 31, 2022, and may change those policies after that date.  MassHealth does not anticipate introducing any such changes prior to January 1, 2023.

SOURCE: MassHealth All Provider Bulletin 327, Oct. 2021. (Accessed Aug. 2022).


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 Mar. 2022).

Consistent with All Provider Bulletin 324, and its predecessor bulletins, through December 31, 2022, MassHealth will reimburse providers delivering any telehealth-eligible covered service via any telehealth modality at parity with its in-person counterpart. Likewise, through December 31, 2022, an eligible distant site provider delivering covered services via telehealth in accordance with this bulletin may bill MassHealth a facility fee if such a fee is permitted under the provider’s governing regulations or contracts. MassHealth will continue to evaluate these telehealth rate parity and facility fee policies through December 31, 2022, and may change those policies after that date.

Providers must include the place of service (POS) code 02 when submitting a professional claim and modifier GT when submitting a facility claim for services delivered via telehealth. Additionally, for any such professional claim, providers must include

  • modifier 95 to indicate services rendered via audio-video telehealth

MassHealth will initially implement modifiers 95, V3, and GQ through a six-month informational edit period. Thus, effective for dates of service between October 16, 2021, and April 15, 2022, MassHealth will not deny claims containing POS code 02 that are missing one of these modifiers. Effective for DOS on or after April 16, 2022, MassHealth will discontinue this informational edit, and will deny claims containing POS code 02 that are missing one of these modifiers.

*Note:  MassHealth will continue to evaluate these telehealth rate parity and facility fee policies through December 31, 2022, and may change those policies after that date.  MassHealth does not anticipate introducing any such changes prior to January 1, 2023.

SOURCE: MassHealth All Provider Bulletin 327, Oct. 2021. (Accessed Aug. 2022).

Synchronous teledentistry is covered.


ELIGIBLE SITES

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 Aug. 2022).


GEOGRAPHIC LIMITS

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 Aug. 2022).


FACILITY/TRANSMISSION FEE

Through December 31, 2022, an eligible distant site provider delivering covered services via telehealth in accordance with this bulletin may bill MassHealth a facility fee if such a fee is permitted under the provider’s governing regulations or contracts. MassHealth will continue to evaluate these telehealth rate parity and facility fee policies through December 31, 2022, and may change those policies after that date.

*Note:  MassHealth will continue to evaluate these telehealth rate parity and facility fee policies through December 31, 2022, and may change those policies after that date.  MassHealth does not anticipate introducing any such changes prior to January 1, 2023.

SOURCE: MassHealth All Provider Bulletin 327, Oct. 2021. (Accessed Aug. 2022).

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Michigan

Last updated 09/03/2022

POLICY

MDHHS requires a real time interactive system at both …

POLICY

MDHHS requires a real time interactive system at both the originating and distant site, allowing instantaneous interaction between the patient and health care professional via the telecommunication system. Telemedicine should be used primarily when travel is prohibitive for the beneficiary or there is an imminent health risk justifying immediate medical need for services.

Source: Dept. of Health and Human Services, Medicaid Provider Manual, p. 1888. Jul. 1, 2022 (Accessed Sept. 2022). 

Assertive Community Treatment Program

All telepractice interactions shall occur through real-time interactions between the ACT consumer and the physician/nurse practitioner/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. 352 Jul. 1, 2022 (Accessed Sept. 2022)


ELIGIBLE SERVICES/SPECIALTIES

The following services may be provided via telemedicine:

  • ESRD-related services
  • Behavior change intervention
  • Behavioral Health and/or Substance Use Disorder Treatment
  • Education Services, Telehealth
  • Inpatient consultations
  • Nursing facility subsequent care
  • Office or other outpatient consultations
  • Office or other outpatient services
  • Psychiatric diagnostic procedures
  • Subsequent hospital care
  • Training service – Diabetes (see Diabetes Self-Management Education Training Program section in Hospital Chapter specific program requirements)

Where face-to-face visits are required (such as ESRD and nursing facility related services), the telemedicine service may be used in addition to the required face-to-face visit but cannot be used as a substitute. There must be at least one face-to-face hands-on visit (i.e., not via telemedicine) by a physician, physician’s assistant or advanced practice registered nurse per month to examine the vascular site for ESRD services. The initial visit for nursing facility services must be face-to-face.

Procedure codes and modifier information is contained in the MDHHS Telemedicine Services Database.

There is no prior authorization requirements when providing telemedicine services for fee-for-service beneficiaries.

Authorization requirements for beneficiaries enrolled in Medicaid Health Plans (MHPs) may vary. Providers must check with individual MHPs for any authorization or coverage requirements.

Providers at the distant site can only bill services listed in the Telemedicine Services database.

SOURCE: Dept. of Health and Human Services, Medicaid Provider Manual, p. 1888-9, Jul. 1, 2022 (Accessed Sept. 2022).  

Listed below are HCPCS codes being adopted by MDHHS for dates of service on and after April 1, 2022, and the provider groups allowed to bill these codes. These codes must not be reported with POS 02 nor the GT modifier and will be represented on the applicable provider fee schedules and not the telemedicine database. They are, by definition, technology enabled and do not need the telemedicine POS or modifier to identify them appropriately.  See bulletin for code list.

SOURCE: MI Dept. of Health and Human Services, Medicaid Bulletin, 7/5/22, (Accessed Sept. 2022).

Speech-Language and Audiology Services

Speech, language and hearing services may be reimbursed. Requires an annual referral from a physician. In addition to the use of the appropriate billing code, billers use the “GT modifier to identify services provided by telepractice.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 1990, Jul. 1, 2022 (Accessed Sept. 2022). 

Assertive Community Treatment Program

The telepractice modifier, 95, must be used in conjunction with ACT encounter reporting code H0039 when telepractice is used.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 351 July. 1, 2022 (Accessed Sept. 2022). 

Telepractice for BHT Services

Telepractice services must be prior authorized.  Telepractice must be obtained through real-time interaction between the child’s physical location (patient site) and the provider’s physical location (provider site). Telepractice services are provided to patients through hardwire or internet connection. It is the expectation that providers, facilitators, and staff involved in telepractice are trained in the use of equipment and software prior to servicing patients, and services provided via telepractice are provided as part of an array of comprehensive services that include in-person visits and assessments with the primary supervising BHT provider. Qualified providers of behavioral health services are able to arrange telepractice services for the purposes of teaching the parents/guardians to provide individualized interventions to their child and to engage in behavioral health clinical observation and direction (i.e. increase oversight of the provision of services to the beneficiary to support the outcomes of the behavioral plan of care developed by the primary supervising BHT provider).

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 484 Jul. 1, 2022 (Accessed Sept. 2022). 

Telemedicine/Telepractice for BHT Services

Refer to the Behavioral Health Telemedicine reporting requirements database for appropriate or allowed telemedicine services that may be covered by Medicaid. Certain qualifications and conditions will also need to be met. Use GT modifier in addition to appropriate procedure code.

It is the expectation that providers, facilitators, and staff involved in telemedicine are trained in the use of equipment and software prior to servicing patients and services provided via telemedicine are provided as part of an array of comprehensive services that include in-person visits and assessments with the primary supervising BHT provider. The provider of the telemedicine service is only able to monitor one child/family at a time.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 484, 1888-1890 Jul. 1, 2022 (Accessed Sept. 2022).

Child Therapy

A child mental health professional may provide child therapy on an individual or group basis with a family-driven, youth-guided approach. Telepractice/Telehealth is approved for Individual Therapy or Family Therapy using approved children’s evidence-based practices (i.e., Trauma Focused Cognitive Behavioral Therapy, Parent Management Training-Oregon, 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. 336 Jul. 1, 2022 (Accessed Sept. 2022). 

Psychiatric Collaborative Care Model (CoCM) Services

Provider care management services provided by a Behavioral Health Care Manager can be provided in a non-face-to-face interaction. Weekly consults with the psychiatric consultant may also be non-face-to-face. Face-to-face or non-face-to-face weekly to monthly follow-up by the behavioral health care manager that must include monthly screening with validated rating scale, monitoring of goals and/or medication, and may include recommended evidence-based therapies.

SOURCE:  MI Dept. of Health and Human Services Medicaid Provider Manual, p. 1883 Jul. 1, 2022  (Accessed Sept. 2022).

Medication Therapy Management (MTM)

In the event that the beneficiary is unable to physically access a face-to-face setting, an eligible pharmacist may provide MTM services via telepractice.  The arrangements for telepractice will be made by the pharmacist. The administration of telepractice services are subject to the same provision of services that are provided to a beneficiary in person.  For services provided through telepractice each procedure code must include the modifier GT (professional claims).

SOURCE:  MI Dept. of Health and Human Services Medicaid Provider Manual, p. 1808 Jul. 1, 2022  (Accessed Sept. 2022).

Children’s Special Health Care Services (CSHCS)

CSHCS covers services that are medically necessary, related to the beneficiary’s qualifying diagnosis(es), and ordered by the beneficiary’s CSHCS authorized specialist(s) or subspecialist(s). Services are covered and reimbursed according to Medicaid policy unless otherwise stated in this chapter.

The primary CSHCS benefits may include:

  • Telemedicine

SOURCE:  MI Dept. of Health and Human Services Medicaid Provider Manual, p. 588 Jul. 1, 2022  (Accessed Sept. 2022).


ELIGIBLE PROVIDERS

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.

SOURCE: Dept. of Health and Human Services Medicaid Provider Manual, p. 2124, Jul. 1, 2022 (Accessed Sept. 2022). 

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. The physician or practitioner at the distant site who is licensed under State law to furnish a covered telemedicine services (as described in the Telemedicine Services subsection) may bill, and receive payment for, the service when it is delivered via a telecommunication system. In order to be reimbursed for services, distant site providers must be enrolled in Michigan Medicaid.

SOURCE: Dept. of Health and Human Services Medicaid Provider Manual, p. 1889-90, Jul. 1, 2022 (Accessed Sept. 2022). 

Telepractice for BHT Services

Qualified providers include:

  • Board certified behavior analysts
  • Board certified assistant behavior analysts
  • Licensed psychologists
  • Limited licensed psychologists
  • Qualified behavioral health professionals

Occupational, physical and speech therapists are not included in this policy.

A facilitator trained in telepractice technology must be physically present with the patient during the entire telepractice session.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 484-485 Jul. 1, 2022 (Accessed Sept. 2022). 

Telemedicine for Behavioral Health Services

Behavioral health services may be provided by:

  • Licensed physician or psychiatrist;
  • LIcensed psychologist;
  • Limited licensed master’s level psychologist under the supervision of a licensed psychologist;
  • MDE-credentialed master’s level school psychologist;
  • Licensed master’s level marriage and family therapist;
  • Board-certified behavior analyst (BCBA);
  • Board-certified assistant behavior analyst (BCaBA) under the supervision of a BCBA;
  • Licensed master’s level professional counselor;
  • LImited licensed master’s level professional counselor under the supervision of a licensed master’s level professional counselor;
  • Licensed master’s level social worker;
  • Licensed master’s level school social worker;
  • LImited licensed master’s level social worker under the supervision of a licensed master’s level social worker; and
  • Temporary limited licensed psychologist under the supervision of a fully licensed psychologist.

SOURCE: Dept. of Health and Human Services, Medicaid Provider Manual, p. 1992-1993, Jul. 1, 2022 (Accessed Sept. 2022).

Medication Therapy Management (MTM)

In the event that the beneficiary is unable to physically access a face-to-face care setting, an eligible pharmacist may provide MTM services via telepractice.  Services must be provided through hardwire or internet connection.

SOURCE: Dept. of Health and Human Services, Medicaid Provider Manual, p. 1808,  Jul. 1, 2022 (Accessed Sept. 2022).

Prepaid Inpatient Health Plans/Community Mental Health (PIHP/CMH) can be either originating or distant sites. 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. 342, Jul. 1, 2022 (Accessed Sept. 2022).

Speech-Language and Audiology Services

Eligible providers:

  • A fully licensed speech-language pathologist
  • Licensed Audiologist in Michigan
  • Speech language pathologist and/or audiology candidate under the direction of a qualified SLP or audiologist. All documentation must be reviewed and signed by the appropriately licensed SLP or licensed audiologist.
  • A limited licensed speech language pathologist under the direction of a fully licensed SLP or audiologist. All documentation must be reviewed and signed by the appropriately licensed supervising SLP or licensed audiologist.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 1990, Jul. 1, 2022 (Accessed Sept. 2022).  

Federally Qualified Health Centers, Hospital, Nursing Facility, Rural Health Centers, Tribal Health Centers

An FQHC, hospital, nursing facility,  RHC or tribal health centers can be either an originating or distant site for telemedicine services.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 737, 1003, 1525, 1952 & 2022 Jul. 1, 2022 (Accessed Sept. 2022). 

Child Therapy

A child mental health professional may provide child therapy on an individual or group basis with a family-driven, youth-guided approach. It is the expectation that providers involved in telepractice/telehealth are trained in the use of equipment and software prior to servicing children/families.

SOURCE:  MI Dept. of Health and Human Services Medicaid Provider Manual, p. 336,  Jul. 1, 2022 (Accessed Sept. 2022).

School-Based Services and Caring 4 Students Providers

Telepractice specifically applies to the SBS and C4S programs.  See Medicaid manual for requirements.

SOURCE:  MI Dept. of Health and Human Services. Bulletin 20-15, School Based Services, p 1993-1994.  Jul. 1, 2022 (Accessed Sept. 2022).


ELIGIBLE SITES

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 Sept. 2022).

Tribal 638 Facilities

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 Sept. 2022)

Eligible originating sites:

  • County mental health clinics or publicly funded mental health facilities;
  • Federally Qualified Health Centers;
  • Hospitals (inpatient, outpatient, or Critical Access Hospitals);
  • Physician or other providers’ offices, including medical clinics;
  • Hospital-based or CAH-based Renal Dialysis Centers (including satellites);
  • Rural Health Clinics;
  • Skilled nursing facilities;
  • Tribal Health Centers

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 1889. Jul. 1, 2022 (Accessed Sept. 2022). 

Speech-Language and Audiology Services, Behavioral Health Therapy, School-Based Services & Caring 4 Students Provider

The patient site may be located:

  • Within the school (for speech-language and audiology services & School-Based and Caring 4 Students Provider);
  • The Center (Behavioral Health Therapy);
  • Home;
  • Any other established site deemed appropriate by the provider.

The room must be free from distractions so as not to interfere with the telepractice session.  A facilitator must be trained in the use of the telepractice technology and physically present at the patient site during the entire telepractice session to assist the patient at the direction of the SLP or audiologist.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 485(BHT), 1990 (SLP & Audiology), 1993 (BHT), 1993 (School-Based/Caring 4 Kids Providers) Jul. 1, 2022 (Accessed Sept. 2022). 

Federally Qualified Health Centers, Hospital, Nursing Facility, Rural Health Centers, Tribal Health Centers

An FQHC, hospital, nursing facility,  RHC or tribal health centers can be either an originating or distant site for telemedicine services.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 728, 958, 1428, 1848 & 2128 Jul. 1, 2022 (Accessed Sept. 2022). 

Telemedicine Coding Changes

MDHHS acknowledges the addition of POS 10-Telehealth provided in a patient’s home, the new definition of POS 02-Telehealth provided other than in a patient’s home, and the addition of modifier FQ-audio only service.

However, due to current systems processing restraints, MDHHS will continue to require POS 02 for all services provided via telemedicine. Per bulletin MSA 20-09, all telemedicine services, as allowable on the telemedicine database and submitted on the professional invoice, must be reported with POS 02-Telehealth and the GT-interactive telecommunication modifier. To distinguish patient’s home from other location, MDHHS is requesting that providers, as able, include the comment “patient’s home” in the remarks section.

MDHHS will require modifier FQ to be appended in addition to modifier GT. When a provider submits modifier FQ for an audio only service, the provider does not need to include a note in the remarks section stating that the service was provided via telephone (per bulletin MSA 20-13). Please note, modifier GT must be included for the claim to be processed correctly. For FQHCs/RHCs/THCs and Tribal FQHCs, please use modifier GT and modifier FQ as indicated above.

Further updates to telemedicine reporting will be provided in future bulletins.

SOURCE: MI Health and Aging Services Administration Bulletin HASA 22-03 (Feb. 8, 2022), (Accessed Sept. 2022).


GEOGRAPHIC LIMITS

No Reference Found


FACILITY/TRANSMISSION FEE

To be reimbursed for the originating site facility fee, the originating site provider must bill the appropriate telemedicine procedure code and modifier. MDHHS will reimburse the originating site provider the lesser of charge or the current Medicaid fee screen.

SOURCE: Dept. of Health and Human Services, Medicaid Provider Manual, p. 267, Jul. 1, 2022 (Accessed Sept. 2022).

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Minnesota

Last updated 08/02/2022

POLICY

Medical assistance covers medically necessary services and consultations delivered …

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 was delivered through in-person contact.  Services or consultations delivered through telehealth are paid at the full allowable rate.

SOURCE: MN Statute Sec. 256B.0625, Subdivision 3b(a). (Accessed Aug. 2022).

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. 14, 2022. (Accessed Aug. 2022).

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 Jul. 25, 2022. (Accessed Aug. 2022).


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. 14, 2022. (Accessed Aug. 2022).

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 telehealt 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
  • 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 Jul. 25, 2022 & Telehealth Services, As revised Jun. 14, 2022. (Accessed Aug. 2022).

Telehealth does not include:

  • Communication between health care provider and a patient that consists solely of an email or facsimile.
  • Electronic connections that are not conducted over a secure encrypted website as specified by the Health Insurance Portability and Accountability Act of 1996 Privacy and Security rules
  • Prescription renewal
  • Scheduling a test or appointment
  • Clarification of issues from a previous visit
  • Reporting test results
  • Nonclinical communication

SOURCE: MN Dept. of Human Services, Provider Manual, Telehealth Services, As revised Jun. 14, 2022. (Accessed Aug. 2022).

Non-covered services:

SOURCE: MN Dept. of Human Services, Provider Manual, Physician and Professional Services (Telehealth), As revised Jul. 25, 2022, (Accessed Aug. 2022).

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. 14, 2022. (Accessed Aug. 2022).

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 Aug. 2022).

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 Jun. 24, 2022, (Accessed Aug. 2022).

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 Aug. 2022).

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.

Use 02 place of service code. See IEP manual for specific documentation and billing requirements.

SOURCE: MN Dept. of Human Svcs., Provider Manual, IEP Services, Revised May 19, 2022, (Accessed Aug. 2022).

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, Jun. 27, 2022, (Accessed Aug. 2022).

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. Mar. 14, 2022 (Accessed Aug. 2022).

Early Intensive Developmental and Behavioral Intervention (EIDBI) services

Telehealth is an option for Early Intensive Developmental and Behavioral Intervention (EIDBI) services. Use 02 place of service code.

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

EIDBI Benefits grid also lists adaptive behavioral treatment by protocol and group adaptive behavior treatment by protocol.   See grid for more information.

SOURCE: MN Dept. of Human Svcs., EIDBI Services Benefits billing grid, Jun. 2022 (Accessed Jun. 2022) & MN Dept. of Human Services, EIDBI Benefit Policy Manual, EIDBI Telehealth Services.  Mar. 16, 2022. (Accessed Aug. 2022).

Medical assistance covers medically necessary EIDBI services and consultations delivered by a licensed health care provider via telehealth, in the same manner as if the service or consultation was delivered in person.

SOURCE: MN Statute Sec. 256B.0949, Subdivision. 13. (Accessed Aug. 2022).

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 Aug. 2022).

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:

  • Telehealth systems must be compliant with HIPAA privacy and security requirements and regulations.
  • Billing providers must submit claims with the applicable MTMS codes and telehealth (telemedicine) identifiers to signify that the service was delivered by telehealth. Billing requirements for telehealth (telemedicine) services are described in the Physician and Professional Services section of the MHCP Provider Manual.
  • Providers must submit the Telehealth Provider Assurance Statement (DHS-6806) (PDF) before billing for telehealth MTMS encounters.

SOURCE: MN Dept. of Human Svcs., Provider Manual, Medication Therapy Management Svcs. Nov. 3, 2021 (Accessed Aug. 2022).

Behavioral Health Home Services

If an individual accepts the offer for a face-to-face visit at six months, providers who are eligible to provide services via telemedicine may do so. Providers must have a valid telemedicine agreement in place with DHS and must comply with all MA telemedicine requirements for equipment, privacy and billing to serve individuals receiving BHH services through telemedicine. Refer to the following sections for requirements, billing and additional information:

SOURCE: MN Department of Human Services, Behavioral Health Home Services, Feb. 23, 2022. (Accessed Aug. 2022).

Targeted Case Management

For adult MH-TCM, interactive video may be used instead of a face-to-face contact if the client resides in a hospital, nursing facility, residential mental health facility or an intermediate care facility for persons with developmental disabilities. The use of interactive video may substitute for no more than 50 percent of the required face-to-face contacts.

SOURCE: MN Dept. of Human Services, Adult Mental Health Targeted Case Management and Children’s Mental Health Targeted Case Management, Jun. 14. 2022 (Accessed Aug. 2022).

Commissioner of Human Services; Extension of Covid-19 Human Services Program Modifications

Notwithstanding Laws 2020, First Special Session chapter 7, section 1, subdivision 2, as amended by Laws 2020, Third Special Session chapter 1, section 3, when the peacetime emergency declared by the governor in response to the COVID-19 outbreak expires, is terminated, or is rescinded by the proper authority, the following modifications issued by the commissioner of human services pursuant to Executive Orders 20-11 and 20-12, and including any amendments to the modification issued before the peacetime emergency expires, shall remain in effect until July 1, 2023:

(1) CV16: expanding access to telemedicine services for Children’s Health Insurance Program, Medical Assistance, and MinnesotaCare enrollees; and

(2) CV21: allowing telemedicine alternative for school-linked mental health services and intermediate school district mental health services.

SOURCE: MN Session Laws, 2021, 1st Special Session, Ch. 7, H.F. No. 33. (Accessed Aug. 2022).


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. 14, 2022. (Accessed Aug. 2022). 

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:

  • Physician
  • Nurse practitioner
  • Physician assistant
  • Nurse midwife
  • Clinical nurse specialist
  • Registered dietitian or nutrition professional
  • Dentist, dental hygienist, dental therapist, advanced dental therapist
  • Mental health professional, when following the requirements and service limitations listed in the Telehealth Delivery of Mental Health Services section.
  • Pharmacist
  • Certified genetic counselor
  • Podiatrist
  • Speech therapist
  • Physical therapist
  • Occupational therapist
  • Audiologist

SOURCE: MN Dept. of Human Services, Provider Manual, Physician and Professional Services (Telehealth), As revised Jul. 25, 2022, (Accessed Aug. 2022).

Medical assistance covers medically necessary services and consultations delivered by a licensed health care provider via telehealth, 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 256B.0615, subdivision 5, a mental health certified family peer specialist under section 256B.0616, subdivision 5, a mental health rehabilitation worker under section 256B.0623, subdivision 5, paragraph (a), clause (4), and paragraph (b), a mental health behavioral aide under section 256B.0943, subdivision 7, paragraph (b), clause (3), a treatment coordinator under section 245G.11, subdivision 7, an alcohol and drug counselor under section 245G.11, subdivision 5, a recovery peer under section 245G.11, subdivision 8.

Telehealth visits 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) & (f)(2). (Accessed Aug. 2022).

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 Aug. 2022).

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 Aug. 2022).

Mental Health Services

Eligible providers include any of the following:

  • Mental health professionals who are qualified under Minnesota Statute 245.462, subdivision 18
  • Mental health practitioners working under the supervision of a mental health professional
  • Mental health certified peer specialists
  • Mental health certified family peer specialists
  • Mental health rehabilitation workers
  • Mental health behavioral aides

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 Jun. 24, 2022 (Accessed Aug. 2022).

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, Jun. 27, 2022 (Accessed Aug. 2022).

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 Aug. 2022).

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. Mar. 14, 2022. (Accessed Aug. 2022).

Medical Assistance Services and Payment Rates

Effective July 1, 2022, telehealth visits provided through audio and real time video communication may be used to satisfy the face-to-face requirement for reimbursement under the payment methods that apply to federally qualified health centers, rural health centers, Indian Health Service and 638 Tribal clinics, and certified community behavioral health centers. This change extends the current telehealth reimbursement policy for these provider types beyond the federal public health emergency. This change is not expected to have a fiscal impact. Laws of Minnesota 2021, First Special Session, chapter 7, article 6, section 11.

SOURCE: MN Statute 256B.0625. (Accessed Aug. 2022).


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).

  • 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: 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.
  • Modifier 93 Audio only: Synchronous telehealth service rendered via telephone or other real-time interactive audio-only telecommunications system. MHCP requires modifier 93 when audio-only telehealth is used.

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. 14, 2022. (Accessed Aug. 2022). 

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 Jul. 25, 2022, (Accessed Aug. 2022).

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.

SOURCE: MN Dept. of Human Svcs., Provider Manual, Telehealth Delivery of Mental Health Services, Revised Jun. 24, 2022 (Accessed Aug. 2022).

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 Aug. 2022).

Medication Therapy Management Services (MTMS)

Medication therapy management services include the following:

  • Face-to-face or telehealth encounters done in any of the following:
    • Ambulatory care outpatient setting
    • Clinics
    • Pharmacies
    • Member’s home or place of residence if the member does not reside in a skilled nursing facility

See manual for privacy, equipment and reimbursement requirements.

SOURCE: MN Dept. of Human Svcs., Provider Manual, Medication Therapy Management Svcs. Nov. 3, 2021 (Accessed Aug. 2022).

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.

SOURCE: MN Dept. of Human Svcs., Provider Manual, Substance Use Disorder Telehealth, Jun 27, 2022, (Accessed Aug. 2022).

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. Mar. 14, 2022. (Accessed Aug. 2022).

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 Aug. 2022).

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 Aug. 2022).


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 Aug. 2022).

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 Jul. 25, 2022, (Accessed Aug. 2022).

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 Jun. 24, 2022 (Accessed Aug. 2022).

READ LESS

Mississippi

Last updated 08/24/2022

POLICY

Mississippi Medicaid and private payers are required to provide …

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 as amended by SB 2738 (2022 Session). (Accessed Aug. 2022).

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 Aug. 2022).


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.

Noncovered Services:

  • 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 MS 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 Aug. 2022).


ELIGIBLE PROVIDERS

Any enrolled Medicaid provider may provide telehealth services at the originating site.  The following enrolled Medicaid providers may provide telehealth services at the distant site:

  • Physicians,
  • Physician assistants,
  • Nurse practitioners,
  • Psychologists,
  • Licensed Clinical Social Workers (LCSW),
  • Licensed Professional Counselors (LPCs),
  • 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

The Division of Medicaid requires a telepresenter who meets the requirements of Miss. Admin Code Part 225, Rule 1.1.C. at the originating site as determined by the Division.

SOURCE: MS Admin. Code Title 23, Part 225, Rule. 1.3(B). (Accessed Aug. 2022).

During a state of emergency, beneficiaries may seek treatment utilizing telehealth services from a distant site provider not listed under Medicaid’s allowed distant site providers.

SOURCE: MS Admin. Code Title 23, Part 225, Rule. 1.7. (Accessed Aug. 2022).

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 Aug. 2022).

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 Aug. 2022).

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 Aug. 2022).

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 Aug. 2022).


ELIGIBLE SITES

The Division of Medicaid covers telehealth services at the following locations:

  • 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.C. at the originating site as determined by the Division.

SOURCE: MS Admin. Code Title 23, Part 225, Rule. 1.3(B) & 1.7. (Accessed Aug. 2022).

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 Aug. 2022).

During a state of emergency, beneficiaries may seek treatment utilizing telehealth services from an originating site not listed in the Medicaid State Plan, including the beneficiary’s residence and health care facilities not listed in the State Plan wishing to act as an originating sites must first be granted approval by the Division of Medicaid before rendering originating sites telehealth services.

When the beneficiary receives services in the home, the requirement for a telepresenter to be present may be waived.

SOURCE: MS Admin. Code Title 23, Part 225, Rule. 1.7. (Accessed Aug. 2022).

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 Aug. 2022).


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 Aug. 2022).

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 Aug. 2022.

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 Aug. 2022).

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 as amended by SB 2738 (2022 Session) (Accessed Aug. 2022). 

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Missouri

Last updated 08/19/2022

POLICY

Services provided through telemedicine [or telehealth, as referred to …

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, 13.69A p. 286 (Aug. 19, 2022), Provider Manual, Rural Health Clinics, Section 13, p. 165 (Aug. 19, 2022) & MO HealthNet, Provider Manual, Behavioral Services, Section 13, p. 209 (Aug. 19, 2022). (Accessed Aug. 2022).

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 Aug. 2022).

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, (Accessed Aug. 2022). 


ELIGIBLE SERVICES/SPECIALTIES

Services provided through telemedicine must meet the standard of care that would otherwise be expected should such services be provided in person. 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,13-69A p. 286-287 (Aug. 19, 2022) & MO HealthNet, Provider Manual, Behavioral Services, Section 13, p. 209-210 (Aug. 19, 2022). (Accessed Aug. 2022).

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 Statute Annotated, Title 12, Sec. 208.677, MO HealthNet, Physician Manual,13-69A p. 286 (Aug. 19, 2022), MO HealthNet, Provider Manual, Behavioral Services, Section 13, p. 209 (Aug. 19, 2022). & MO HealthNet, Provider Manual, Rural Health Clinics, Section 13, p. 166 (Aug. 19, 2022), (Accessed Aug. 2022).

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 Aug. 2022).

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.

Medication services may be provided via telehealth. See manual for code list.

SOURCE: MO HealthNet, CSTAR Manual, 13.14(K)(1), 13.14(K)(5) pgs. 201 &203 & 13.14(L)(4) p. 204 (Aug. 20, 2022). (Accessed Aug. 2022).

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, p. 240-249. (Aug. 20, 2022), (Accessed Aug. 2022).

Home Health

The face-to-face encounter may occur through telehealth, as allowed by State law.

SOURCE: MO HealthNet, Home Health Manual, p. 169. (Aug. 19, 2022), (Accessed Aug. 2022).

Dentistry

Some teledentistry is covered. See manual for codes.

SOURCE: MO HealthNet, Dental Manual, p. 259. (Aug. 18, 2022). (Accessed Aug. 2022).

MO HealthNet covers teledentistry services. MO HealthNet 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.

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 in order to communicate to the 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 American Dental Association (ADA) Dental Claim Form with the CDT code (D9995 or D9996) and any additional services provided, using place of service code 02 – Telehealth.

SOURCE: MO Department of Social Services, Provider Bulletin Vol. 44 No. 46, (May 5, 2022). (Accessed Aug. 2022).

Opioid Treatment Programs

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 Aug. 2022).

Recently Adopted Rule

A telemedicine service shall be covered only if it is medically necessary.

A telemedicine service must be performed with the same standard of care as an in-person, face-to-face service. If the same standard of care cannot be met, a telemedicine service shall not be provided.

School Services. Prior to the provision of telemedicine services in a school, the parent or guardian of the child shall provide authorization for the provision of such ser- vice. Such authorization shall include the ability for a parent or guardian to authorize services via telemedicine in the school for the remainder of the school year.

SOURCE: MO Code of State Regulations, Title 13 Sec. 70-3.330, (Accessed Aug. 2022). 


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, 13.69B p. 286 (Aug. 19, 2022), Provider Manual, Rural Health Clinics, Section 13, p. 165 (Aug. 19, 2022) & MO HealthNet, Provider Manual, Behavioral Services, Section 13, p. 210 (Aug. 19, 2022). (Accessed Aug. 2022).

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 Aug. 2022).

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). 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. Distant site services provided on school grounds should be billed with place of service 03 and a GT modifier.

SOURCE: MO HealthNet, Physician Manual, 13.69A p. 287 (Aug. 19, 2022) & MO HealthNet, Provider Manual, Behavioral Services, Section 13, p. 210 (Aug. 19, 2022). (Accessed Aug. 2022).

RHCs must bill with their non-RHC provider number when they are the originating site to receive the facility fee. RHCs may bill with either their non-RHC provider number or their RHC provider number when they are the distant site.  The provider will use the appropriate procedure code for the service along with place of service 02 (Telehealth). Distant site services provided on school grounds should be billed with place of service 03 and a GT modifier.

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. To be reimbursed for telehealth services health care providers treating patients in this state, utilizing telehealth, must be fully licensed to practice in this state and be enrolled as a MHD provider prior to rendering services.

SOURCE: MO HealthNet, Rural Health Clinic, p. 165 (Aug. 19, 2022). (Accessed Aug. 2022).

Anesthesiologist monitoring telemetry in the operating room is a non-covered service.

SOURCE: MO HealthNet, Physician Manual, p. 207 (Aug 19, 2022). (Accessed Aug. 2022).

Recently Adopted Rule

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.

Health care provider or provider shall mean a health care professional or a health care facility.

Any licensed/enrolled health care professional shall be authorized to provide telemedicine services if such services to MHD participants 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 shall not prohibit a health care entity from reimbursing 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.

A health care provider utilizing telemedicine at either a distant site or an originating site shall be enrolled as a MO Health-Net provider pursuant to 13 CSR 65-2.020 and be fully licensed for practice in the state of Missouri. A health care provider utilizing telemedicine must do so in a manner that is consistent with the provisions of all laws governing the practice of the provider’s profession and shall be held to the same standard of care as a provider employing in-person behavioral health or medical health care.

For purposes of the provision of telemedicine services in the MO HealthNet Program, the provider-patient relationship may be established by the following:

  • An in-person encounter through a medical interview and physical examination;
  • Consultation with another health care professional, or that health care professional’s delegate, who has an established relationship with the patient and an agreement with the health care professional to participate in the patient’s care; or
  • A telemedicine encounter, if the standard of care does not require an in-person encounter, and in accordance with evidence- based standards of practice and telemedicine practice guidelines that address the clinical and technological aspects of telemedicine.

SOURCE: MO Code of State Regulations, Title 13 Sec. 70-3.330, (Accessed Aug. 2022). 


ELIGIBLE SITES

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, 13-69A p. 287 (Aug. 19, 2022) & MO HealthNet, Provider Manual, Behavioral Services, Section 13, p. 210 (Aug. 19, 2022). (Accessed Aug. 2022).

The department shall not restrict the originating site through rule or payment so long as the provider can ensure services are rendered meeting the standard of care that would otherwise be expected should such services be provided in-person.

SOURCE: MO Revised Statute Ch. 208 Sec. 208.670. (Accessed Aug. 2022). 

No originating site for services or activities provided under this section shall be required to maintain immediate availability of on-site clinical staff during the telehealth services, except as necessary to meet the standard of care for the treatment of the patient’s medical condition if such condition is being treated by an eligible health care provider who is not at the originating site, has not previously seen the patient in-person in a clinical setting, and is not providing coverage for a health care provider who has an established relationship with the patient.

SOURCE: MO Revised Statute Sec. 191.1145(6). (Accessed Aug. 2022).  

RHCs must bill with their non-RHC provider number (or when the distant site, the RHC provider number can also be used) when they are the originating site to receive the facility fee.

Distant site services provided on school grounds should be billed with place of service 03 and a GT modifier.

SOURCE: MO HealthNet, Rural Health Clinic, p. 165 (Aug. 19, 2022). (Accessed Aug. 2022). 

The originating site is where the MO HealthNet participant receiving the telehealth service is physically located.  The originating site and distant site 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 Department of Social Services. Provider Bulletin. Vol. 40, No. 47. Feb. 2, 2018. (Accessed Aug. 2022).

Recently Adopted Rule

Originating site shall mean a telemedicine site where the MO HealthNet participant receives the telemedicine service. Originating sites include, but are not necessarily limited to health care provider facilities, participants’ homes, and schools. For the purposes of asynchronous store-and-forward transfer, the originating site shall also mean the location from which the referring provider transfers information to the distant site.

School Services. Prior to the provision of telemedicine services in a school, the parent or guardian of the child shall provide authorization for the provision of such ser- vice. Such authorization shall include the ability for a parent or guardian to authorize services via telemedicine in the school for the remainder of the school year.

SOURCE: MO Code of State Regulations, Title 13 Sec. 70-3.330, (Accessed Aug. 2022). 


GEOGRAPHIC LIMITS

Payment for services rendered via telehealth shall not depend on any minimum distance requirement between the originating and distant site.

SOURCE: MO Revised Statute Ch. 208 Sec. 208.670. (Accessed Aug. 2022).


FACILITY/TRANSMISSION FEE

The originating site is only eligible to receive a facility fee for the telemedicine service. Claims should be submitted with HCPCS code Q3014 (telemedicine originating site facility fee). Procedure code Q3014 is used by the originating site to receive reimbursement for the use of the facility while telehealth services are being rendered.

SOURCE: MO HealthNet, Physician Manual, 13.69A p. 287 (Aug. 12, 2022); & MO HealthNet, Provider Manual, Behavioral Services, Section 13, p. 210 (Aug. 19, 2022). (Accessed Aug. 2022).

RHCs must bill with their non-RHC provider number to receive reimbursement for a facility fee for the Telehealth services when operating as the originating site. Claims must be submitted with HCPCS code Q3014 (Telehealth originating site facility fee).

SOURCE: Provider Manual, Rural Health Clinics, Section 13, p. 165 (Aug. 19, 2022). (Accessed Aug. 2022).

FQHCs and RHCs are eligible for an originating site facility fee. Special billing instructions apply to FQHC providers.

SOURCE: MO Department of Social Services. Provider Bulletin. Vol 41, No. 44. Mar. 5, 2019. (Accessed Aug. 2022).

Hospitals

Costs and charges for the telehealth originating site fee reimbursed on a fee schedule shall be excluded when calculating the outpatient cost-to-charge ratios used to determine outpatient percentage rates starting with the calculation of the outpatient percentage rate for the SFY after the telehealth originating site fee is moved to a fee schedule.

SOURCE: MO Revised Statute Title 13, Sec. 70-15.160, (Accessed Aug. 2022).

Recently Adopted Rule

The originating site is eligible to receive an originating site/facility fee.

Reimbursement of the originating site fee will be made according to the MO HealthNet Fee Schedule.

SOURCE: MO Code of State Regulations, Title 13 Sec. 70-3.330, (Accessed Aug. 2022). 

The originating site facility fee cannot be billed to MO HealthNet when the originating site is the participant’s home.

SOURCE:  MO Medicaid Provider Tips, Telemedicine, July 18, 2022, (Accessed Aug. 2022).

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Montana

Last updated 11/17/2021

POLICY

Providers enrolled in the Medicaid program may provide medically …

POLICY

Providers enrolled in the Medicaid program may provide medically necessary services by means of telehealth if the service:

  • is clinically appropriate for delivery by telehealth as specified by the department by rule or policy;
  • comports with the guidelines of the applicable Medicaid provider manual; and
  • is not specifically required in the applicable provider manual to be provided in a face-to-face manner

Telehealth services must be provided at same rate as services delivered in person.

Department directed to adopt rules for the provision of telehealth (see statute for further details).

SOURCE: MCA 53-6-122 (Accessed Aug. 2022).

MT Medicaid reimburses for medically necessary telemedicine services to eligible members.  Providers must be enrolled as Montana Healthcare Programs providers and be licensed in the state of Montana.

Telemedicine should not be selected when face-to-face services are medically necessary. Members should establish relationships with primary care providers who are available on a face-to-face basis.

The originating and distant providers may not be within the same facility or community. The same provider may not be the “pay to” for both the originating and distance provider.

SOURCE: MT Dept. of Public Health and Human Svcs, Medicaid and Medical Assistance Programs Manual, General Information for Providers, Telemedicine (Feb. 2020). (Accessed Aug. 2022).


ELIGIBLE SERVICES/SPECIALTIES

Healthy Montana Kids

Services provided by telemedicine are allowed for non-surgical medical services and behavioral health outpatient services.

SOURCE: MT Children’s Health Insurance Plan, Healthy Montana Kids (HMK). Evidence of Coverage (Nov. 2017), p. 24 & 30. (Accessed Aug. 2022).

Telehealth services are available for Physical, Occupational and Speech Therapy when ordered by a physician or mid-level practitioner. The order is valid for 180 days. All Montana Medicaid covered services delivered via telemedicine/telehealth are reimbursable so long as such services are medically necessary and clinically appropriate for delivery via telemedicine/telehealth.

The Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services program (EPSDT) covers all medically necessary services for children age 20 and under. Therapy services for children are not restricted to a specific number of hours or units as long as the therapy services are restorative, not maintenance. All other applicable requirements apply.

SOURCE: MT Dept. of Public Health and Human Svcs., Medicaid and Medical Assistance Programs Manual, Therapies Manual, Covered Services (Mar. 2020). (Accessed Aug. 2022). 

School-Based Services

Telehealth services are allowed for Physical Therapy, Occupational Therapy and Speech Therapy. All Montana Medicaid covered services delivered via telemedicine/telehealth are reimbursable so long as such services are medically necessary and clinically appropriate for delivery via telemedicine/telehealth.

SOURCE: MT Dept. of Public Health and Human Svcs., Medicaid and Medical Assistance Programs Manual, School-Based Services Manual, Covered Services (4/14/22). (Accessed Aug. 2022).

The availability of services through telemedicine in no way alters the scope of practice of any health care provider; or authorizes the delivery of health care services in a setting or manner not otherwise authorized by law.

SOURCE: MT Dept. of Public Health and Human Svcs., Medicaid and Medical Assistance Programs Manual, Physician Related Svcs., Telemedicine (Feb. 2020). (Accessed Aug. 2022).

Durable Medical Equipment

Face-to-face assessments of the patient by the prescriber can be performed using telemedicine.

SOURCE:  MT Dept. of Public Health and Human Svcs., Medicaid and Medical Assistance Programs Manual, Durable Medical Equipment, Prosthetics, Orthotics, and Medical Supplies (DMEPOS) Manual, Covered Services (12/27/21). (Accessed Aug. 2022).


ELIGIBLE PROVIDERS

Providers must be enrolled as Montana Healthcare Programs providers and be licensed in the State of Montana in order to:

  • Treat a Montana Healthcare Programs member; and
  • Submit claims for payment to Montana Healthcare Programs

SOURCE: MT Dept. of Public Health and Human Svcs., Medicaid and Medical Assistance Programs Manual, General Information for Providers, Telemedicine (Feb. 2020). (Accessed Aug. 2022).


ELIGIBLE SITES

Telemedicine can be provided in a member’s residence; the distance provider is responsible for the confidentiality requirements. See “Originating Provider Requirements” section for list of eligible originating sites for facility fee.

SOURCE: MT Dept. of Public Health and Human Svcs., Medicaid and Medical Assistance Programs Manual, General Information for Providers, Telemedicine (Feb. 2020). (Accessed Aug. 2022).

An enrollee’s residence is not reimbursable as an enrolled originating site provider.

SOURCE: MCA 53-6-122 & MT Dept. of Public Health and Human Svcs., Medicaid and Medical Assistance Programs Manual, General Information for Providers, Telemedicine (Feb. 2020). (Accessed Aug. 2022).

“Originating site provider” means an enrolled provider who is operating a secure connection that complies with the requirements of the Health Insurance Portability and Accountability Act of 1996, 42 U.S.C. 1320d, et seq., and assisting an enrollee with the technology necessary for a telehealth visit.

An originating site provider is not required to participate in the delivery of the health care service.

SOURCE: MCA 53-6-155, (Accessed Aug. 2022).


GEOGRAPHIC LIMITS

The originating and distant providers may not be within the same facility or community. The same provider may not be the pay to for both the originating and distance provider.

SOURCE: MT Dept. of Public Health and Human Svcs., Medicaid and Medical Assistance Programs Manual, General Information for Providers, Telemedicine (Feb. 2020). (Accessed Aug. 2022).


FACILITY/TRANSMISSION FEE

The department will reimburse for all Montana Medicaid covered services delivered via telemedicine/telehealth originating site fees as long as such services are medically necessary and clinically appropriate for delivery via telemedicine/telehealth, comply with the guidelines set forth in the applicable Montana Medicaid provider manual, and are not a service specifically required to be face-to-face.

SOURCE: Administrative Rules of Montana, Sec. 37.40.330, (Accessed Aug. 2022).

The following provider types can bill the originating site fee:

  • Outpatient hospital
  • Critical access hospital*
  • Federally qualified health center*
  • Rural health center*
  • Indian health service*
  • Physician
  • Psychiatrist
  • Mid-levels
  • Dieticians
  • Psychologists
  • Licensed clinical social worker
  • Licensed professional counselor
  • Mental health center
  • Chemical dependency clinic
  • Group/clinic
  • Public health clinic
  • Family planning clinic

*Reimbursement for Q3014 is a set fee and is paid outside of both the cost to charge ratio and the all-inclusive rate.

Originating site providers must include a specific diagnosis code to indicate why a member is being seen by a distance provider and this code must be requested from the distance site prior to billing for the telemedicine appointment.

The originating site provider may also, as appropriate, bill for clinical services provided on-site the same day that a telemedicine originating site service is provided. The originating site may not bill for assisting the distant site provider with an examination, including for any services that would be normally included in a face-to-face visit.

FQHCs and RHCs can bill a telehealth originating site procedure code Q3014 if applicable.

SOURCE: MT Dept. of Public Health and Human Svcs., Medicaid and Medical Assistance Programs Manual, General Information for Providers, Telemedicine (Feb. 2020). (Accessed Aug. 2022).

No reimbursement for infrastructure or network use charges.

SOURCE: MT Dept. of Public Health and Human Svcs., Medicaid and Medical Assistance Programs Manual, Physician Related Svcs., Billing Procedures (March 2021). (Accessed Aug. 2022).

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Nebraska

Last updated 08/25/2022

POLICY

Nebraska Medicaid provides coverage for telehealth at the same …

POLICY

Nebraska Medicaid provides coverage for telehealth at the same rate as in-person services when the technology meets industry standards and is HIPAA compliant.

Medicaid will reimburse a consulting health care provider if the following are met:

  • After obtaining and analyzing the transmitted information, the consulting provider reports back to the referring health care practitioner;
  • The consulting health care practitioner must bill for services using the appropriate modifier;
  •  Payment is not made to the referring health care practitioner who sends the medical documentation. Reimbursement is at the same rate as in-person services.

Practitioner consultation is not covered for behavioral health when the client has an urgent psychiatric condition requiring immediate attention by a licensed mental health practitioner.

SOURCE: NE Admin. Code Title 471 Sec. 1-004.08-.09, Ch. 1,  (Accessed Aug. 2022).

In-person contact is not required for reimbursable services under the Medicaid program, subject to reimbursement policies developed.  This policy also applies to managed care plans who contract with the Department only to the extent that:

  • Services delivered via telehealth are covered and reimbursed under the fee-for-service program and
  • Managed care contracts are amended to add coverage of services delivered via telehealth and appropriate capitation rate adjustments are incorporated.

Reimbursement shall, at a minimum, be set at the same rate as a comparable in-person consult and the rate must not depend on the distance between the health care practitioner and the patient.

The department shall establish rates for transmission cost reimbursement for telehealth consultations, considering, to the extent applicable, reductions in travel costs by health care practitioners and patients to deliver or to access health care services and such other factors as the department deems relevant. Such rates shall include reimbursement for all two-way, real-time, interactive communications, unless provided by an Internet service provider, between the patient and the physician or health care practitioner at the distant site which comply with the federal Health Insurance Portability and Accountability Act of 1996 and rules and regulations adopted thereunder and with regulations relating to encryption adopted by the federal Centers for Medicare and Medicaid Services and which satisfy federal requirements relating to efficiency, economy, and quality of care.

SOURCE: NE Revised Statutes Sec. 71-8506. (Accessed Aug. 2022).


ELIGIBLE SERVICES/SPECIALTIES

Federally Qualified Health Centers & Rural Health Clinics

FQHC and RHC payment for telehealth services is the Medicaid rate for a comparable in-person service. FQHC & RHC core services provided via telehealth are not covered under the encounter rate.

SOURCE: NE Admin. Code Title 471, Sec. 29-004.05, Ch. 29, & NE Admin. Code Title 471, Sec. 34-007, Ch. 34, Manual Letter #11-2010. (Accessed Aug. 2022).

Assertive Community Treatment (ACT)

ACT Team Interventions may be provided via telehealth when provided according to certain regulations.

SOURCE: NE Admin. Code Title 471 Sec. 35-013.11, Ch. 35,  (Accessed Aug. 2022).

Indian Health Service (IHS) Facilities

Encounter: A face-to-face visit, including telehealth services provided in accordance with 471 NAC 1-006, between a health care professional and an individual eligible for the provision of medically necessary Medicaid-defined services in an IHS or Tribal (638) facility within a 24-hour period ending at midnight, as documented in the client’s medical record.

SOURCE: NE Admin. Code Title 471 Sec. 11-001, Ch. 11, (Accessed Aug. 2022).

Services for Individuals with Developmental Disabilities

Providers may conduct observations in-person or by telehealth.

SOURCE: NE Admin. Code Title 403 Sec. 004.04, Ch. 4, p. 5 & Sec. 004.04, Ch. 5, p. 5  (Accessed Mar. 2022).

Children’s Behavioral Health

The Department of Health and Human Services shall adopt and promulgate rules and regulations providing for telehealth services for children’s behavioral health. The rules and regulations required shall include, but not be limited to:

An appropriately trained staff member or employee familiar with the child’s treatment plan or familiar with the child shall be immediately available in person to the child receiving a telehealth behavioral health service in order to attend to any urgent situation or emergency that may occur during provision of such service. This requirement may be waived by the child’s parent or legal guardian; and

In cases in which there is a threat that the child may harm himself or herself or others, before an initial telehealth service the health care practitioner shall work with the child and his or her parent or guardian to develop a safety plan. Such plan shall document actions the child, the health care practitioner, and the parent or guardian will take in the event of an emergency or urgent situation occurring during or after the telehealth session. Such plan may include having a staff member or employee familiar with the child’s treatment plan immediately available in person to the child, if such measures are deemed necessary by the team developing the safety plan.

SOURCE: NE Statute Sec. 71-8509, (Accessed Aug. 2022).

An appropriately trained staff member or employee familiar with the child’s treatment plan or familiar with the child must be immediately available in person to the child receiving a telehealth behavioral consultation in order to attend to any urgent situation or emergency that may occur.  This requirement may be waived by a legal guardian.  In cases where there is a threat that the child may harm themselves or others, a safety plan must be developed before the telehealth interaction takes place.

SOURCE: NE Admin. Code Title 471, Sec. 1-004.05, Ch. 1, (Accessed Aug. 2022).

Teledentistry follows the requirements of telehealth in accordance with 471 NAC 1. Services requiring hands on professional care are excluded.

SOURCE: NE Admin Code Title 471, Ch. 6, Sec. 006. (Accessed Aug. 2022).

 


ELIGIBLE PROVIDERS

Health care practitioner means a Nebraska medicaid-enrolled provider who is licensed, registered, or certified to practice in this state by the department.

SOURCE: NE Rev. Statute, 71-8503(2) (Accessed Aug. 2022).


ELIGIBLE SITES

Health care practitioners must ensure that the originating sites meet the standards for telehealth services.  Originating sites must provide a place where the client’s right to receive confidential and private services is protected.

SOURCE: NE Admin. Code Title 471 Sec. 1-004.03, Ch. 1, (Accessed Aug. 2022).


GEOGRAPHIC LIMITS

No Reference Found


FACILITY/TRANSMISSION FEE

Telehealth services and transmission costs are covered by Medicaid when:

  • The technology used meets industry standards;
  •  The technology is Health Insurance Portability and Accountability Act of 1996 (HIPAA) compliant; and
  • The telehealth technology solution in use at both the originating and the distant site must be sufficient to allow the health care practitioner to appropriately complete the service billed to Medicaid

An originating site fee is paid to the Medicaid-enrolled facility hosting the client at a rate set forth in the Medicaid fee schedule or under arrangement with the Managed Care Organization (MCO).

SOURCE: NE Admin. Code Title 471 Sec. 1-004.06 & 1-004.010, Ch. 1, (Accessed Aug. 2022).

Federally Qualified Health Centers & Rural Health Clinics

Telehealth transmission cost related to non-core services will be the lower of:

  • The provider’s submitted charge; or
  • The maximum allowable amount

The Department will pay for transmission costs for line charges when directly related to a covered telehealth service. The provider must be in compliance with the standards for real time, two way interactive audiovisual transmissions (see 471 NAC 1-006).

SOURCE:  NE Admin. Code Title 471, Sec. 29-004.05A, Ch. 29, Manual Letter #11-2010, & NE Admin. Code Title 471, Sec. 34-007.01, Ch. 34, Manual Letter #11-2010, (Accessed Aug. 2022).

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Nevada

Last updated 08/17/2022

POLICY

The State Plan for Medicaid must include:

  • A requirement

POLICY

The State Plan for Medicaid must include:

  • A requirement that the State, and, to the extent applicable, any of its political subdivisions, shall pay for the nonfederal share of expenses for services provided to a person through telehealth to the same extent and, except for services provided through audio-only interaction, in the same amount as though provided in person or by other means; and
  • A provision prohibiting the State from:
    • Requiring a person to obtain prior authorization that would not be required if a service were provided in person or through other means, establish a relationship with a provider of health care or provide any additional consent to or reason for obtaining services through telehealth as a condition to paying for services as described in paragraph (a). The State Plan for Medicaid may require prior authorization for a service provided through telehealth if such prior authorization would be required if the service were provided in person or through other means.
    • Requiring a provider of health care to demonstrate that it is necessary to provide services to a person through telehealth or receive any additional type of certification or license to provide services through telehealth as a condition to paying for services.
    • Refusing to pay for services because of the distant site from which a provider of health care provides services through telehealth or the originating site at which a person who is covered by the State Plan for Medicaid receives services through telehealth; or the technology used to provide the services.
    • Requiring services to be provided through telehealth as a condition to paying for such services.
    • Categorizing a service provided through telehealth differently for purposes relating to coverage or reimbursement than if the service had been provided in person or through other means.

The provisions of this section do not:

  • Require the Director to include in the State Plan for Medicaid coverage of any service that the Director is not otherwise required by law to include; or
  • Require the State or any political subdivision thereof to:
    • Ensure that covered services are available to a recipient of Medicaid through telehealth at a particular originating site; or
    • Provide coverage for a service that is not included in the State Plan for Medicaid or provided by a provider of health care that does not participate in Medicaid.

Various other version of these provisions become effective under various circumstances, including:

  • 1 year after the date on which the Governor terminates the emergency described in the Declaration of Emergency for COVID-19 issued on March 12, 2020, only if the Governor terminates that emergency before July 1, 2022.
  • On July 1, 2023, only if the Governor terminates the emergency described in the Declaration of Emergency for COVID-19 issued on March 12, 2020, before July 1, 2022.
  • On June 30, 2023, only if the Governor terminates the emergency described in the Declaration of Emergency for COVID-19 issued on March 12, 2020, on or after July 1, 2022.

See bill for alternate versions and accompanying effective dates.

SOURCE: NV Revised Statute 422.2721, (Accessed Aug. 2022).

Services provided via telehealth must be clinically appropriate and within the health care professional’s scope of practice as established by its licensing agency. Services provided via telehealth have parity with in-person health care services. Health care professionals must follow the appropriate Medicaid Services Manual (MSM) policy for the specific service they are providing.

  • Photographs must be specific to the patient’s condition and adequate for rendering or confirming a diagnosis or a treatment plan. Dermatologic photographs (e.g., photographs of a skin lesion) may be considered to meet the requirement of a single media format under this instruction.
  • Reimbursement for the DHCFP covered telehealth services must satisfy federal requirements of efficiency, economy and quality of care.
  • All participating providers must adhere to requirements of the Health Insurance Portability and Accountability Act (HIPAA). The DHCFP may not participate in any medium not deemed appropriate for protected health information by the DHCFP’s HIPAA Security Officer.

Telehealth services follow the same prior authorization requirements as services provided in-person. Utilization of telehealth services does not require prior authorization. However, individual services may require prior authorization when delivered by telehealth.

ESRD visits must include at least one in-person visit to examine the vascular access site by a provider; however, an interactive audio/video telecommunications system may be used for providing additional visits.

SOURCE: NV Dept. of Health and Human Svcs., Medicaid Services Manual, Telehealth Services Chapter 3400 Section 3403, p. 1; 3403.5, p. 3; & 3403.7, p. 4 (Jun. 1, 2022). (Accessed Aug. 2022).

Effective December 1, 2015, telehealth may be used by any Nevada Medicaid and Nevada Check Up provider working within their scope of practice to provide services that can be appropriately provided via telehealth.  The telecommunications system used must be an interactive audio and video system. Standard telephones, facsimile machines or electronic mail do not meet this criteria.

SOURCE: Nevada Dept. of Health and Human Services Billing Guidelines Telehealth Billing Instructions, p. 1 (Nov. 18, 2020). (Accessed Aug. 2022).

Medicaid Managed Care plans must include coverage for services provided through telehealth to the same extent as through provided in-person or by other means.

Medicaid Managed Care plans shall not:

  • Require an enrollee to establish an in-person relationship with a provider or provide any additional consent to or reason for obtaining services through telehealth as a condition to providing the coverage;
  • Require a provider of health care to demonstrate that it is necessary to provide services to an enrollee through telehealth or receive any additional type of certification or license;
  • Refuse to provide coverage for telehealth because of the type of the distant site or originating site in which the provider/enrollee provides/receives services via telehealth; or
  • Require covered services to be provided through telehealth as a condition of providing coverage for such services.

A Medicaid Managed Care plan may not require an enrollee to obtain prior authorization for any service provided through telehealth that is not required for the service when provided in-person.

Medicaid Managed Care plans are not required to:

  • Ensure that covered services are available to an enrollee through telehealth at a particular originating site
  • Provide coverage for a service that is not a covered service or that is not provided by a covered provider of health care; or
  • Enter into a contract with any provider of health care or cover any service if the insurer is not otherwise required by law to do so.

SOURCE: NV Revised Statute Sec. 695G.162. (Accessed Aug. 2022).


ELIGIBLE SERVICES/SPECIALTIES

Telehealth services are also covered by Nevada Medicaid. See MSM Chapter 3400, Telehealth Services for the complete coverage and limitations for Telehealth.  Medical Nutrition Therapy may be provided through Telehealth services. See MSM Chapter 3400 for the Telehealth policy.

SOURCE: NV Dept. of Health and Human Svcs., Section 603, p. 4; Sec. 609, pg. 3 (Jul. 13, 2022) (Accessed Aug. 2022).

A licensed professional operating within the scope of their practice under state law may provide the following Telehealth services for Medicaid recipients:

  • Annual wellness visits;
  • Diabetic outpatient self-management;
  • Documented psychiatric treatment in crisis intervention (e.g., threatened suicide); and
  • Office or other outpatient visits

SOURCE: NV Dept. of Health and Human Svcs., Provider Type 20, 24, and 77 (Physician), (Osteopath) and (APRN) Billing Guide, pgs. 9 & 10 (3/4/22). (Accessed Aug. 2022).

Services NOT Covered:

  • Basic Skills Training and Psychosocial Rehabilitation services, whether authorized, provided, and billed as stand-alone services or as components of Intensive Outpatient Program, Partial Hospitalization, and Day Treatment must be provided in person
  • Personal care services provided by a Personal Care Attendant
  • Home Health Services provided by a RN, occupational therapist, physical therapist, speech therapist, respiratory therapist, dietician or Home Health Aide
  • Private Duty Nursing services provided by a RN

SOURCE: NV Dept. of Health and Human Svcs., Medicaid Services Manual, Telehealth Services Chapter 3400 Section 3403.6, p. 3 (Jun. 1, 2022). (Accessed Aug. 2022).

 


ELIGIBLE PROVIDERS

Telehealth may be used by any Nevada Medicaid and Nevada Check Up provider working within their scope of practice.

SOURCE: Nevada Dept. of Health and Human Services Billing Guidelines Telehealth Billing Instructions, p.1 (Nov. 18, 2020) (Accessed Aug. 2022).

Indian Health Services and Tribal Clinics should follow the guidelines in the Telehealth Chapter 3400.

SOURCE: Nevada Dept. of Health and Human Svcs., Medicaid Services Manual, Indian Health Services and Clinics, pg. 1, (5/1/20), (Accessed Aug. 2022).

A distant site provider must be an enrolled Medicaid provider.

Facilities that are eligible for encounter reimbursement (e.g. Indian Health (IH) programs, Federally Qualified Health Centers (FQHCs), Rural Health Centers (RHCs)) may bill for an encounter in lieu of an originating site facility fee, if the distant site is for ancillary services (i.e. consult with specialist). If, for example, the originating site and distant site are two different encounter sites, the originating encounter site may only bill the telehealth facility fee, and the distant encounter site may bill the encounter code.

SOURCE: NV Dept. of Health and Human Svcs., Medicaid Services Manual, Telehealth Services Chapter 3400, Section 3403.1 p. 2, 3403.2, p. 1-2 (Jun. 1, 2022). (Accessed Aug. 2022).

Telehealth originating site services can be provided within a community paramedicine provider’s scope of practice as part of a community paramedicine visit when requested in plan of care.

SOURCE: NV Dept. of Health and Human Services, Medicaid Services Manual, Physician Services Chapter 600 Section 604.2, pg. 2 (July 1, 2021), (Accessed Aug. 2022).

A provider is not eligible for payment as both the originating and distant site for the same patient, same date of service.

SOURCE: NV Dept. of Health and Human Svcs., Medicaid Services Manual, Telehealth Services Chapter 3400 Section 3403.6, p. 1 (Jun. 1, 2022). (Accessed Aug. 2022).


ELIGIBLE SITES

In order to receive coverage for a telehealth facility fee, the originating site must be an enrolled Medicaid provider.

A provider is not eligible for payment as both the originating and distant site for the same patient, same date of service.

If a patient is receiving telehealth services at an originating site not enrolled in Medicaid, the originating site is not eligible for a facility fee from the DHCFP. Examples of this include, but are not limited to, cellular devices, home computers, kiosks and tablets.

Facilities that are eligible for encounter reimbursement (e.g. Indian Health (IH) programs, Federally Qualified Health Centers (FQHCs), Rural Health Centers (RHCs)) may bill for an encounter in lieu of an originating site facility fee, if the distant site is for ancillary services (i.e. consult with specialist). If, for example, the originating site and distant site are two different encounter sites, the originating site may only bill the telehealth facility fee, and the distant encounter site may bill the encounter code.

SOURCE: NV Dept. of Health and Human Svcs., Medicaid Services Manual, Telehealth Services Chapter 3400, Section 3403.1 p. 1-2, (Jun. 1, 2022). (Accessed Aug. 2022).

Eligible sites:

  • Office of provider
  • Critical Access Hospital (CAH)
  • Rural Health Clinic (RHC)
  • Federally Qualified Health Center (FQHC)
  • Hospital
  • End Stage Renal Disease (ESRD) Facility
  • Skilled Nursing Facility (SNF)
  • Community Mental Health Centers (CMHC)
  • Indian Health Services/Tribal Organization/Urban Indian Organization
  • School-Based Health Centers
  • Schools
  • Family Planning Clinics
  • Public Health Clinics
  • ·Comprehensive Outpatient Rehabilitation Facilities
  • Community Health Clinics (State Health Division)
  • Special Children’s Clinics
  • Human Immunodeficiency Virus (HIV) Clinics
  • Therapy offices
  • Chiropractic offices
  • Emergency Medical Services (EMS) performing Community Paramedic Services
  • Recipient’s smart phone (no facility fee)
  • Recipient’s home computer (no facility fee)

SOURCE: Nevada Dept. of Health and Human Services Billing Guidelines Telehealth Billing Instructions, p. 1-2 (Nov. 18, 2020) (Accessed Jun. 2022). Community Paramedicine, p. 1 (Nov. 4, 2019). (Accessed Aug. 2022).

Specific encounter service limits apply for distant site providers at Indian Health Service, Tribal clinics, or Tribal FQHCs. See billing guide for Nevada AI/AN providers.

SOURCE: Nevada Dept. of Health and Human Services Billing Guidelines, Indian Health Services (IHS) and Tribal Clinics, p. 1. (05/01/2020) (Accessed Aug. 2022).


GEOGRAPHIC LIMITS

The originating site must be located in the state of Nevada.

SOURCE: NV Dept. of Health and Human Svcs., Medicaid Services Manual, Telehealth Services Chapter 3400, Section 3403.1 p. 1, (Jun. 1, 2022). (Accessed Aug. 2022).

A Medicaid Managed Care Organization may not refuse to provide coverage of telehealth services because where the distant or originating site providing/receiving services via telehealth is located.

SOURCE: NV Revised Statute Sec. 695G.162.  (Accessed Aug. 2022).


FACILITY/TRANSMISSION FEE

Originating site is qualified to receive a facility fee if they are an enrolled Medicaid provider. If a patient is receiving telehealth services at a site not enrolled in Medicaid, the originating site is not eligible to receive a facility fee.

Facilities that are eligible for encounter reimbursement (e.g. Indian Health (IH) programs, Federally Qualified Health Centers (FQHCs), Rural Health Centers (RHCs)) may bill for an encounter in lieu of an originating site facility fee, if the distant site is for ancillary services (i.e. consult with specialist). If the originating site and distant site are two different encounter sites, the originating site may only bill the telehealth facility fee, and the distant encounter site may bill the encounter code.

SOURCE: NV Dept. of Health and Human Svcs., Medicaid Services Manual, Telehealth Services Chapter 3400, Section 3403.1, pg. 1 & 2 (Jun. 2022). (Accessed Aug. 2022).

A facility fee is not billable if the telecommunication system used is a recipient’s smart phone or home computer.

SOURCE: Nevada Dept. of Health and Human Services Billing Guidelines Telehealth Billing Instructions, p. 2 (Nov. 18, 2020) (Accessed Aug. 2022).

Some provider types that may bill for an originating site facility fee include:

  • Some Special Clinic provider types
  • Some Applied Behavior Analysis provider types
  • Therapists
  • Chiropractors
  • Providers at End-Stage Renal Disease Facilities

SOURCE: NV Dept. of Health and Human Svcs. Announcement 1048 & 1202. (Accessed Aug. 2022).

Sites eligible for an originating site facility fee include:

  • Office of provider
  • Critical Access Hospital (CAH)
  • Rural Health Clinic (RHC)
  • Federally Qualified Health Center (FQHC)
  • Hospital
  • End Stage Renal Disease (ESRD) Facility
  • Skilled Nursing Facility (SNF)
  • Community Mental Health Centers (CMHC)
  • Indian Health Services/Tribal Organization/Urban Indian Organization
  • School-Based Health Centers
  • Schools
  • Family Planning Clinics
  • Public Health Clinics
  • Comprehensive Outpatient Rehabilitation Facilities
  • Community Health Clinics (State Health Division)
  • Special Children’s Clinics
  • Human Immunodeficiency Virus (HIV) Clinics
  • Therapy offices
  • Chiropractic offices
  • Emergency Medical Services (EMS) performing Community Paramedic Services

SOURCE: Nevada Dept. of Health and Human Services Billing Guidelines Telehealth Billing Instructions, p. 1-2 (Nov. 18, 2020) (Accessed Aug. 2022).

If the originating site is enrolled as a Nevada Medicaid provider, they may bill HCPCS code Q3014. If the telecommunication system used is a recipient’s smart phone or home computer, the facility fee may not be billed.

SOURCE: Nevada Dept. of Health and Human Services, School Health Services, pg. 58 (1/20/22), (Accessed Aug. 2022).

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New Hampshire

Last updated 08/18/2022

POLICY

The Medicaid program shall provide coverage and reimbursement for …

POLICY

The Medicaid program shall provide coverage and reimbursement for health care services provided through telemedicine on the same basis as the Medicaid program provides coverage and reimbursement for health care services provided in person.

The Medicaid program shall provide reimbursement for all modes of telehealth, including video and audio, audio-only, or other electronic media provided by medical providers to treat all members for all medically necessary services.

NH Medicaid is required by statute to cover Medicaid-covered services provided within the scope of practice of a physician or other health care provider as a method of delivery of medical care. The appropriate application of telehealth services provided by physicians and other health care providers is determined by the department based on the Centers for Medicare and Medicaid Services regulations, and also includes persons providing psychotherapeutic services.

NH Medicaid is not prohibited from providing coverage for only those services that are medically necessary and subject to all other terms and conditions of the coverage.

Telemedicine services for primary care, remote patient monitoring and substance use disorder services are covered only when the patient has established care at an originating site via face-to-face in-person service.  Exceptions include:

  • The provider is a Department of Veteran Affairs (VA) practitioner or VA-contracted practitioner not required to obtain a special registration pursuant to 21 U.S.C. section 831(h);
  • The patient is being treated by, and is physically located in a correctional facility administered by the state of New Hampshire or a New Hampshire county;
  • The patient is being treated by, and is physically located in a doorway as defined in RSA 167:4-d, II(c);
  • The patient is being treated by and is physically located in a state designated community mental health center pursuant to RSA 135; or
  • The patient is being treated by, and physically located in, a hospital or clinic registered in a manner fully consistent with 21 U.S.C. section 823(f)

SOURCE: NH Revised Statutes 167:4-d (Accessed Aug. 2022).


ELIGIBLE SERVICES/SPECIALTIES

“Telehealth services” shall comply with 42 C.F.R. section 410.78, except for 42 C.F.R. section 410.78(b)(4).  This section limits telehealth services to specific CPT/HCPCS codes.

New Hampshire Medicaid is required by statute to provide coverage for Medicaid-covered services provided within the scope of practice of a physician or other health care provider.  It must be an appropriate application of telehealth services, as determined by the department based on CMS regulations and also includes psychotherapeutic services.

Coverage under this section shall include the use of telehealth or telemedicine for Medicaid-covered services provided within the scope of practice of a physician or other health care provider as a method of delivery of medical care:

(1) Which is an appropriate application of telehealth services provided by physicians and other health care providers, as determined by the department based on the Centers for Medicare and Medicaid Services regulations, and also including persons providing psychotherapeutic services as provided in He-M 426.08 and 426.09;

(2) Primary care, remote patient monitoring & substance use disorder shall only be covered in the event that the patient has already established care at an originating site via face-to-face in-person service.  Exceptions include:

  • The provider is a Department of Veteran Affairs (VA) practitioner or VA-contracted practitioner not required to obtain a special registration pursuant to 21 U.S.C. section 831(h);
  • The patient is being treated by, and is physically located in a correctional facility administered by the state of New Hampshire or a New Hampshire county;
  • The patient is being treated by, and is physically located in a doorway as defined in RSA 167:4-d, II(c);
  • The patient is being treated by and is physically located in a state designated community mental health center pursuant to RSA 135; or
  • The patient is being treated by, and physically located in, a hospital or clinic registered in a manner fully consistent with 21 U.S.C. section 823(f); and

(3) By which an individual shall receive medical services from a physician or other health care provider who is an enrolled Medicaid provider without in-person contact with that provider.

The Medicaid program shall provide reimbursement for all modes of telehealth, including video and audio, audio-only, or other electronic media provided by medical providers to treat all members for all medically necessary services.  The combined amount of reimbursement that the Medicaid program allows for the compensation to the distant site and the originating site shall not be less that the total amount allowed for health care services provided in person.

With written consent of the patient receiving medication assisted treatment through telehealth services provided under this section, the health care provider shall provide notification of the patient’s medication assisted treatment to the doorway.

The department shall adopt rules to carry out this section.

SOURCE: NH Revised Statutes 167:4-d (Accessed Aug. 2022).

Medicaid to Schools Program

Medical services delivered via telehealth including those services in a school setting are reimbursable pursuant to RSA 167:4-D. Claims should be submitted with the appropriate procedure code and TM modifier along with modifier GT and place of service (02 for telehealth).

SOURCE: NH Medicaid to Schools Billing Guidelines and Billable Procedure Codes Companion to the Technical Assistance Guide, pg. 2 ( Mar. 1, 2022), ( Accessed Aug. 2022). 

Any direct service that would have previously been rendered and Medicaid covered as face-to-face may now be rendered via telehealth. This includes both medical services as well as behavioral health services. Follow up with students on home activities that normally would have been done face-to-face would be considered direct services. Work that Rehabilitation Assistants are doing remotely in support of students such as sensory exercises, teaching communication skills or other such medically related activities in support of the student’s plan of care would be billable. Notification to NH Medicaid to transition an individual from face- to- face direct treatment to telehealth visits is not required.

NH Medicaid pays the same rate as if the service was provided face-to-face. Billing for the service delivered should identify the CPT codes typically used for in-person visits with the addition of the GT modifier and place of service 02 (telehealth) to the claim form. The use of the GT modifier and the 02 place of service are for all Medicaid to Schools covered procedure codes both medical and behavioral health. Medicaid is not adopting a different set of procedure codes specific to telehealth.

SOURCE: NH Department of Health and Human Services, Medicaid to Schools Program Medicaid to Schools Technical Assistance Guide pgs. 91 & 92, (May 2, 2022), (Accessed Aug. 2022).

The following new modifiers listed below have been added to MMIS:

  • FQ – the service was furnished using audio-only communication technology
  • FR – the supervising practitioner was present through two-way, audio/video communication technology
  • FS – split (or shared) Evaluation and Management service
  • FT- unrelated Evaluation and Management (E/M) visit during a postoperative period, or on the same day as a procedure or another E/M visit

These modifiers are effective 4/1/2022 and are informational only.

SOURCE: NH Medicaid Provider Bulletin, New Modifiers and Telehealth POS (Mar. 25, 2022), (Accessed Aug. 2022).


ELIGIBLE PROVIDERS

“Telehealth services” shall comply with 42 C.F.R. section 410.78, except for 42 C.F.R. section 410.78(b)(4).  This sections limits providers that can be reimbursed for telehealth to the following:

  • Physician
  • Physician assistant
  • Nurse practitioner
  • Clinical nurse specialist
  • Nurse-midwife
  • Clinical psychologist and clinical social worker (may not seek payment for medical evaluation and management services)
  • Registered dietician or nutrition professional
  • Certified registered nurse anesthetist

Medical providers below shall be allowed to perform health care services through the use of all modes of telehealth, including video and audio, audio-only, or other electronic media. Medical providers include, but are not limited to, the following:

  • Physicians and physician assistants, governed by RSA 329 and RSA 328- D;
  • Advanced practice nurses, governed by RSA 326-B and registered nurses under RSA 326-B employed by home health care providers
  • Midwives
  • Psychologists
  • Allied Health Professionals
  • Dentist
  • Mental health practitioners
  • Community mental health providers employed by community mental health programs
  • Alcohol and other drug use professionals
  • Dietitians
  • Professionals certified by the national behavior analyst certification board or persons performing services under the supervision of a person certified by the national behavior analyst certification board.

SOURCE: NH Revised Statutes 167:4-d & 42 CFR Sec. 410.78(b)(2), (Accessed Aug. 2022).

Medicaid to Schools Program

All services provided via telehealth must be within the provider’s professional scope of practice and He-W 589.04. The following provider types are eligible to provide telehealth services:

  • Occupational Therapists (OTs)
  • Physical Therapists (PTs)
  • Speech and Language Pathologists (SLPs)
  • Rehabilitation Assistants
  • Psychologists
  • Board Certified Behavior Analysts (BCBAs)
  • School Physicians
  • Psychiatrists
  • Advanced Registered Nurse Practitioners (APRNs) and Registered Nurses (RNs)
  • Licensed alcohol and drug counselors (LADC) and master licensed alcohol and drug counselors (MLADC) per He-W 513
  • Psychotherapists and Mental Health Practitioners

SOURCE: NH Department of Health and Human Services, Medicaid to Schools Program Medicaid to Schools Technical Assistance Guide pg. 91, (May 3, 2022), (Accessed Aug. 2022).


ELIGIBLE SITES

There shall be no restriction on eligible originating or distant sites for telehealth services. An originating site means the location of the member at the time the service is being furnished via a telecommunication system. A distant site means the location of the provider at the time the service is being furnished via a telecommunication system.

SOURCE: NH Revised Statutes Annotated, 167:4-d, (Accessed Aug. 2022).

“Originating site” means the location of the patient, whether or not accompanied by a health care provider, at the time services are provided by a health care provider through telemedicine, including, but not limited to, a health care provider’s office, a hospital, or a health care facility, or the patient’s home or another nonmedical environment such as a school-based health center, a university-based health center, or the patient’s workplace.

SOURCE: NH Revised Statutes 167:4-d (Accessed Aug. 2022).

Effective as of 4/1/2022 place of service 10, telehealth provided in a patient’s home has been added to MMIS.

SOURCE: NH Medicaid Provider Bulletin, New Modifiers and Telehealth POS (Mar. 25, 2022), (Accessed Aug. 2022).

Medicaid to Schools Program

Medical services delivered via telehealth including those services in a school setting are reimbursable pursuant to RSA 167:4-D. Claims should be submitted with the appropriate procedure code and TM modifier along with modifier GT and place of service (02 for telehealth).

SOURCE: NH Medicaid to Schools Billing Guidelines and Billable Procedure Codes Companion to the Technical Assistance Guide, pg. 2 ( Mar. 1, 2022), ( Accessed Aug. 2022). 


GEOGRAPHIC LIMITS

New Hampshire Medicaid does not follow 42 CFR 410.78(b)(4), listing geographic and site restrictions on originating sites.

SOURCE: NH Revised Statutes 167:4-d (Accessed Aug. 2022).


FACILITY/TRANSMISSION FEE

New Hampshire Medicaid complies with the Centers for Medicare and Medicaid Service requirements for telehealth. Based on the Medicare requirements, originating sites are eligible for a facility fee.

SOURCE: NH Revised Statutes 167:4-d, (Accessed Aug. 2022).

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New Jersey

Last updated 09/06/2022

POLICY

The State Medicaid and NJ FamilyCare programs shall provide …

POLICY

The State Medicaid and NJ FamilyCare programs shall provide coverage and payment for health care services delivered to a benefits recipient through telemedicine or telehealth, on the same basis as, and at a provider reimbursement rate that does not exceed the provider reimbursement rate that is applicable, when the services are delivered through in-person contact and consultation in New Jersey, provided the services are otherwise covered when delivered through in-person contact and consultation in New Jersey.  Reimbursement payments under this section may be provided either to the individual practitioner who delivered the reimbursable services, or to the agency, facility, or organization that employs the individual practitioner who delivered the reimbursable services, as appropriate.

The State Medicaid and NJ FamilyCare programs may limit coverage to services that are delivered by participating health care providers, but may not charge any deductible, copayment, or coinsurance for a health care service, delivered through telemedicine or telehealth, in an amount that exceeds the deductible, copayment, or coinsurance amount that is applicable to an in-person consultation.

In no case shall the State Medicaid and NJ FamilyCare Programs:

  • Impose any restrictions on the location or setting of the distant site used by a health care provider to provide services using telemedicine and telehealth or on the location or setting of the originating site where the patient is located when receiving services using telemedicine and telehealth, except to ensure that the services provided using telemedicine and telehealth meet the same standard of care as would be provided if the services were provided in person;
  • Restrict the ability of a provider to use any electronic or technical platform to provide services using telemedicine or telehealth, including but not limited to interactive, real-time, two-way audio, which may be used in combination with asynchronous store-and-forward technology without video capabilities including audio-only telephone conversations, to provide services using telemedicine or telehealth, provided that the platform used:
    • Allows the provider to meet the same standard of care as would be provided if the services were provided in person’
    • Is compliant with the requirements of the federal health privacy rule set forth at 45 CFR Parts 160 and 164.
  • Deny coverage for or refuse to provide reimbursement for routine patient monitoring performed using telemedicine and telehealth, including remote monitoring of a patient’s vital signs and routine check-ins with the patient to monitor the patient’s status and condition, if coverage and reimbursement would be provided if those services are provided in person, and the provider is able to meet the same standard of care as would be provided if the services were provided in person; or
  • Limit coverage only to services delivered by select third party telemedicine or telehealth organizations.

SOURCE: NJ Statute C.30:4D-6K. (Accessed Sept. 2022).


ELIGIBLE SERVICES/SPECIALTIES

The offsite provider is responsible for determining that the billable service meets all required standards of care. If the provider cannot meet that standard of care via telehealth, the provider shall notify the patient to seek a face-to-face appointment. When a physical evaluation is required, the telehealth provider may utilize an individual licensed to provide physical evaluations (e.g. RN) who is onsite.

SOURCE: NJ Division of Medical Assistance and Health Services. Newsletter Vol. 28, No. 17, Sept. 2018, p. 2 (Accessed Sept. 2022).

Psychiatric Services

Telepsychiatry may be utilized by mental health clinics and/or hospital providers of outpatient mental health services to meet their physician related requirements including but not limited to intake evaluations, periodic psychiatric evaluations, medication management and/or psychotherapy sessions for clients of any age.

Before any telepsychiatry services can be provided, each participating program must establish policies and procedures, regarding elements noted in the newsletter, such as confidentiality requirements, technology requirements and consent.

Mental health clinics and hospital providers are limited to billing for services permitted by the Division of Medical Assistance and Health Services.

SOURCE: NJ Division of Medical Assistance and Health Services. Newsletter. Vol. 23, No. 21, December 2013. (Accessed Sept. 2022).

For the Screening and Outreach Program, the psychiatric assessment maybe completed through the use of telepsychiatry, provided that the screening service has a Division-approved plan setting forth its policies and procedures for providing a psychiatric assessment via telepsychiatry that meets the following criteria (see regulation).

SOURCE: NJAC 10:31-2.3. (Accessed Apr. 2022).

A provider may use interactive, real-time, two-way audio in combination with asynchronous store-and-forward technology, without video communication, if the provider has determined that the provider is able to meet the accepted standard of care provided if the visit was face-to-face.

SOURCE: NJ Division of Medical Assistance and Health Services. Newsletter Vol. 28, No. 17, Sept. 2018, p. 2. (Accessed Sept. 2022).

The State Medicaid and NJ FamilyCare programs shall provide coverage and payment for health care services delivered to a benefits recipient through telemedicine or telehealth, on the same basis as, and at a provider reimbursement rate that does not exceed the provider reimbursement rate that is applicable, when the services are delivered through in-person contact and consultation in New Jersey, provided the services are otherwise covered when delivered through in-person contact and consultation in New Jersey.  Reimbursement payments under this section may be provided either to the individual practitioner who delivered the reimbursable services, or to the agency, facility, or organization that employs the individual practitioner who delivered the reimbursable services, as appropriate.

The State Medicaid and NJ FamilyCare programs may limit coverage to services that are delivered by participating health care providers, but may not charge any deductible, copayment, or coinsurance for a health care service, delivered through telemedicine or telehealth, in an amount that exceeds the deductible, copayment, or coinsurance amount that is applicable to an in-person consultation.

SOURCE: NJ Statute C.30:4D-6K. (Accessed Sept. 2022).  


ELIGIBLE PROVIDERS

  • Psychiatric Services
  • Psychiatrist
  • Psychiatric Advanced Practice Nurse

The practitioner may be offsite but must be a practitioner currently licensed to practice within the State of New Jersey.  When consumers receiving telepsychiatry services are under the care of a multidisciplinary treatment team, the psychiatrist or psychiatric APN providing telepsychiatry services must have regular communication with them and be available for consultation.

The clinician cannot bill for services directly.

SOURCE: NJ Division of Medical Assistance and Health Services. Newsletter. Vol. 23, No. 21, December 2013. (Accessed Sept. 2022).

In no case shall the State Medicaid and NJ FamilyCare Programs:

  • Impose any restrictions on the location or setting of the distant site used by a health care provider to provide services using telemedicine and telehealth or on the location or setting of the originating site where the patient is located when receiving services using telemedicine and telehealth, except to ensure that the services provided using telemedicine and telehealth meet the same standard of care as would be provided if the services were provided in person.

SOURCE: NJ Statute C.30:4D-6K. (Accessed Sept. 2022).


ELIGIBLE SITES

For the provision of services, providers are expected to follow the same rules they would follow if the patient visit was face-to-face. This includes instances when a license is for an entity such as an independent clinic. This license is for a specific address and is not tied to specific personnel. In this instance, the service may only be billed when provided at the address listed on the license. When billed by the clinic, the service provider (for example a physician) may provide services from a remote location but the patient must receive those services while physically present at the independent clinic (licensed location). Independent practitioners have a person specific license that is not tied to a specific address. Services billed by independent practitioners do not have location restrictions. The patient and/or the provider may be at any location as long as the provider is licensed to practice in New Jersey.

SOURCE: NJ Division of Medical Assistance and Health Services. Newsletter Vol. 28, No. 17, Sept. 2018, p. 2 (Accessed Sept. 2022).

Psychiatric Services

A patient must receive services at the mental health clinic or outpatient hospital program and the mental health clinic/hospital must bill for all services under their Medicaid provider number. The clinician cannot bill for services directly.

SOURCE: NJ Division of Medical Assistance and Health Services. Newsletter. Vol. 23, No. 21, December 2013 (Accessed Sept. 2022).

In no case shall the State Medicaid and NJ FamilyCare Programs:

  • Impose any restrictions on the location or setting of the distant site used by a health care provider to provide services using telemedicine and telehealth or on the location or setting of the originating site where the patient is located when receiving services using telemedicine and telehealth, except to ensure that the services provided using telemedicine and telehealth meet the same standard of care as would be provided if the services were provided in person;

SOURCE: NJ Statute C.30:4D-6K. (Accessed Sept. 2022). 


GEOGRAPHIC SITES

No Reference Found


FACILITY/TRANSMISSION FEE

All costs associated with the provision of telehealth services, including but not limited to the contracting of professional services and the telecommunication equipment, are the responsibility of the provider and are not directly reimbursable by NJFC.

SOURCE: NJ Division of Medical Assistance and Health Services. Newsletter Vol. 28, No. 17, Sept. 2018, p. 4 (Accessed Sept. 2022).

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New Mexico

Last updated 08/03/2022

POLICY

New Mexico Medicaid will reimburse for professional services at …

POLICY

New Mexico Medicaid will reimburse for professional services at the originating-site and the distant-site at the same rate as when the services are furnished without the use of a telecommunication system.

SOURCE: NM Administrative Code 8.310.2.12(M)(d). (Accessed Aug. 2022).

Telemedicine is also covered by NM Managed Care.

SOURCE: NM Medical Assistance Division Managed Care Policy Manual, p. 311. Oct. 2020.  (Accessed Aug. 2022).

Applied Behavior Analysis

Telemedicine applies to multiple Family Sets joining each other in a virtual meeting. MAD encourages AP agencies to use this delivery system to meet the needs of Family Set members who cannot attend during regular business hours groups. A parent who travels for work, could easily keep engaged by participating in during their lunch or dinner time.

SOURCE: NM Applied Behavior Analysis Agency Manual Instructions, pg. 3, (Accessed Aug. 2022).

Managed Care Program

The benefits package includes telemedicine services.  See Admin. Code 8.308.9.18 for requirements of MCOs related to telemedicine services.

SOURCE: NM Admin Code Sec. 8.309.4.16 & 8.308.9.18. (Accessed Aug. 2022).

Provision of telemedicine services does not require that a certified Medicaid healthcare provider be physically present with the patient at the originating site unless the telemedicine consultant at the distant site deems it necessary.

SOURCE: NM Administrative Code 8.310.2.12 (M). (Accessed Aug. 2022).

The MCO is encouraged to use technology, such as telemedicine, to ensure access and availability of services statewide.

SOURCE: NM Administrative Code 8.308.2.12 (Q). (Accessed Aug. 2022).

The alternative benefits package includes telemedicine services.

SOURCE: NM Centennial Care Managed Care Policy Manual, Oct. 1. 2020, (Accessed Aug. 2022).


ELIGIBLE SERVICES/SPECIALTIES

Applied Behavior Analysis

MAD pays for telemedicine communication system per recipient/per service for the delivery of ABA services.  See manual for specific services and supervision requirements.

SOURCE: NM Applied Behavior Analysis Agency Manual Instructions, pg. 12, (Accessed Aug. 2022).

School-Based Services

Telemedicine services provided in accordance with 8.210.2 NMAC [section may be referencing 8.310.2 NMAC instead]. The modifier “GT” should be utilized when billing for services provided via telemedicine.

SOURCE: NM Medicaid Guide for School-Based Services, pg. 15. (Accessed Aug. 2022).

Noncovered telemedicine services: 

A service provided through telemedicine is subject to the same program restrictions, limitations and coverage which exist for the service when not provided through telemedicine. Telemedicine services are not covered when audio/video technology is used in furnishing a service when the MAP eligible recipient and the practitioner are in the same institutional or office setting.

SOURCE: NM Administrative Code 8.310.2.12 M(4). (Accessed Aug. 2022).

MAD covers service plan updates through the participation of interdisciplinary teams.

The six elements of teaming may be performed by using a variety of media (with the person’s knowledge and consent) e.g., texting members to update them on an emergent event; using email communications to ask or answer questions; sharing assessments, plans and reports; conducting conference calls via telephone; using telehealth platforms conferences; and, conducting face-to-face meetings with the person present when key decisions are made. Only the last element, that is, conducting the final face-to-face meeting with the recipient present when key decisions that result in the updates to the service plan, is a billable event.

SOURCE: NM Administrative Code 8.321.2.9 (L) & (L)(3c). (Accessed Aug. 2022).

Medication Assisted Treatment for Buprenorphine (MAT) services are reimbursable with telemedicine.

See manual for additional requirements, including online prescribing requirements.

SOURCE: NM Behavioral Health Policy and Billing Manual for Providers, 2021, (Accessed Aug. 2022).


ELIGIBLE PROVIDERS

Reimbursement for professional services at the originating-site and the distant-site are made at the same rate as when the services provided are furnished without the use of a telecommunication system. In addition, reimbursement is made to the originating-site for a real-time interactive audio/video technology telemedicine system fee (where the MAP eligible recipient is located, if another eligible provider accompanies the patient) at the lesser of the provider’s billed charge, or the maximum allowed by MAD for the specific service of procedure. If the originating site is the patient’s home, the originating site fee should not be billed if the eligible provider does not accompany the MAP eligible recipient. The MAP eligible recipient is not reimbursed for their computer/internet.

SOURCE: NM Administrative Code 8.310.2.12 (M)(d). (Accessed Aug. 2022).

Reimbursement for services at the originating-site (where the MAP eligible recipient is located) and the distant-site (where the provider is located) are made at the same amount as when the services provided are furnished without the use of a telecommunication system.  In addition, reimbursement is made to the originating-site for an interactive telemedicine system fee at the lesser of the provider’s billed charge; or the maximum allowed by MAD for the specific service or procedure.

SOURCE: NM Administrative Code 8.310.3.11. (Accessed Aug. 2022). 


ELIGIBLE SITES

School-based services provided via telemedicine are covered.

SOURCE: NM Administrative Code 8.320.6.13(I). (Accessed Aug. 2022).

When the originating-site is in New Mexico and the distant-site is outside New Mexico, the provider at the distant-site must be licensed for telemedicine to the extent required by New Mexico state law and NMAC rules or meet federal requirements for providing services to IHS facilities or tribal contract facilities.

SOURCE: NM Administrative Code 8.310.3.9  (F). (Accessed  Aug. 2002).

An interactive HIPAA compliant telecommunication system must include both interactive audio and video and be delivered on a real-time basis at the originating and distant sites. If real-time audio/video technology is used in furnishing a service when the MAP eligible recipient and the practitioner are in the same institutional or office setting, then the practitioner should bill for the service furnished as if it was furnished in person as a face to face encounter. Coverage for services rendered through telemedicine shall be determined in a manner consistent with medicaid coverage for health care services provided through in person consultation. For telemedicine services, when the originating-site is in New Mexico and the distant-site is outside New Mexico, the provider at the distant-site must be licensed for telemedicine to the extent required by New Mexico state law and regulations or meet federal requirements for providing services to IHS facilities or tribal contract facilities. Provision of telemedicine services does not require that a certified medicaid healthcare provider be physically present with the MAP eligible recipient at the originating site unless the telemedicine consultant at the distant site deems it necessary.

SOURCE: NM Administrative Code 8.310.2.12 (M). (Accessed Aug. 2022).

Telemedicine originating-site

The location of a MAP eligible recipient at the time the service is being furnished via an interactive telemedicine communications system. The origination-site can be any of the following medically warranted sites where services are furnished to a MAP eligible recipient.

  • The office of a physician or practitioner.
  • A critical access hospital (as described in section 1861 (mm)(1) of the Act).
  • A rural health clinic (as described in 1861 (mm)(2) of the Act).
  • A federally qualified health center (as defined in section 1861 (aa)(4) of the Act).
  • A hospital (as defined in section 1861 (e) of the Act).
  • A hospital-based or critical access hospital-based renal dialysis center (including satellites).
  • A skilled nursing facility (as defined in section 1819(a) of the Act).
  • A community mental health center (as defined in section 1861(ff)(3)(B) of the Act).
  • A renal dialysis facility (only for the purposes of the home dialysis monthly ESRD-related clinical assessment in section 1881(b)(3)(B) of the Act).
  • The home of an individual (only for purposes of the home dialysis ESRD-related clinical assessment in section 1881(b)(3)(B) of the Act).
  • A mobile stroke unit (only for the purposes of diagnosis, evaluation, or treatment of symptoms of an acute stroke provided in accordance with section 1834(m)(6) of the Act).
  • The home of an individual (only for the purposes of treatment of a substance use disorder or a co-occurring mental health disorder), furnished on or after July 1, 2019, to an individual with a substance use disorder diagnosis.
  • The home of an individual when an interactive audio and video telecommunication system that permits real-time visit is used between the eligible provider and the MAP eligible recipient.
  • A School Based Health Center (SBHC) as defined by section 2110(c)(9) of the Act.

SOURCE: NM Administrative Code 8.310.2.12 (M)(a). (Accessed Aug. 2022).

 Telemedicine distant-site

The location where the telemedicine provider is physically located at the time of the telemedicine service.  All services are covered to the same extent the service and the provider are covered when not provided through telemedicine.  For these services, use of the telemedicine communications system fulfills the requirement for a face-to-face encounter.

SOURCE: NM Administrative Code 8.310.2.12 (M)(b). (Accessed Aug. 2022).


GEOGRAPHIC LIMITS

No Reference Found


FACILITY/TRANSMISSION FEE

Reimbursement is made to the originating site for an interactive telemedicine system fee at the lesser of the following:

  • Provider’s billed charge; or
  • Maximum allowed by MAD for the specific service or procedure.

SOURCE: NM Administrative Code 8.310.2.12 M(d). (Accessed Aug. 2022).

A telemedicine originating-site communication system fee is covered if the MAP eligible recipient was present at and participated in the telemedicine visit at the originating-site and the system that is used meets the definition of a telemedicine system.

SOURCE: NM Administrative Code 8.310.2.12 M(e). (Accessed Aug. 2022).

Indian Health Services

Originating Site Fee:

A telemedicine originating site fee is covered when the requirements of 8.310.2 NMAC are met;

  • Both the originating and distant sites may be IHS or tribal facilities at two different locations or if the distant site is under contract to the IHS or tribal facility and would qualify to be an enrolled provider;
  • A telemedicine originating site fee is not payable if the telemedicine technology is used to connect an employee or staff member of a facility to the eligible recipient being seen at the same facility;

However, even if the service does not qualify for a telemedicine originating site fee, the use of telemedicine technology may be appropriate thereby allowing the service provided to meet the standards to qualify as an encounter by providing the equivalent of face-to-face contact.

SOURCE: NM Administrative Code 8.310.12.12. (8) (Accessed Aug. 2022).

Indian Health Services

A telemedicine communication fee is paid for the originating site at fee schedule rates using the CMS 1500 format; not the OMB rate. The originating clinical service fee is billed on a UB claim form at the OMB rate. Both the originating and distant sites may be IHS or tribal facilities with two different locations; or a distant site can be under contract to the IHS or tribal facility. If the distant site is an IHS or tribal facility, the distant site may also bill the OMB rate when the service is typically paid at OMB rates.

SOURCE: NM Behavioral Health Policy and Billing Manual for Providers, pg. 30, (Accessed Aug. 2022).

FQHC

A telemedicine communication fee is paid for the originating site at fee schedule rates using the CMS 1500 format; not the encounter rate. The originating clinical service fee is billed on a UB claim form if for evaluation or therapy and on a CMS 1500 if for a special service and reimbursed at the encounter rate.

SOURCE: NM Behavioral Health Policy and Billing Manual for Providers, pg. 30, (Accessed Aug. 2022).

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New York

Last updated 08/25/2022

POLICY

Reimbursement policy applies to fee-for-service and Medicaid Managed Care …

POLICY

Reimbursement policy applies to fee-for-service and Medicaid Managed Care plans.

New York reimburses for two-way electronic audio-visual communications to deliver clinical health care services to a patient at an originating site by a telehealth provider located at a distant site. The totality of the communication of information exchanged between the physician or other qualified health care practitioner and the patient during the course of the synchronous telemedicine service must be of an amount and nature that would be sufficient to meet the key components and/or requirements of the same service when rendered via face-to-face interaction.

Telehealth should not be used by a provider if it may result in any reduction to the quality of care required to be provided to a Medicaid member or if such service could adversely impact the member.

NY Medicaid does not reimburse for telehealth used solely for the convenience of the practitioner when a face-to-face visit is more appropriate and/or preferred by the member.

New York Medicaid does not reimburse the acquisition, installation, and maintenance of telecommunication devices or systems.

SOURCE: NY Dept. of Health, Medicaid Update, Vol. 35, Number 2, February 2019 (Special Edition), p. 1-4. (Accessed Aug. 2022).

Recent Legislation Effective until April 1, 2024

Health care services delivered by means of telehealth shall be entitled to reimbursement on the same basis, at the same rate, and to the same extent the equivalent services, as may be defined in regulations promulgated by the commissioner, are reimbursed when delivered in person; provided, however, that health care services delivered by means of telehealth shall not require reimbursement to a telehealth provider for certain costs, including but not limited to facility fees or costs reimbursed through ambulatory patient groups or other clinic reimbursement methodologies, if such costs were not incurred in the provision of telehealth services due to neither the originating site nor the distant site occurring within a facility or other clinic setting.

For services licensed, certified or otherwise authorized, such services provided by telehealth, as deemed appropriate by the relevant commissioner, shall be reimbursed at the applicable in person rates or fees established by law, or otherwise established or certified by the office for people with developmental disabilities, office of mental health, or the office of addiction services and supports.

Both temporary and permanent statute state that while services delivered by means of telehealth shall be entitled to reimbursement, reimbursement for additional modalities, provider categories, originating sites and audio-only telephone communication defined in regulations shall be contingent upon federal financial participation.

SOURCE: NY Public Health Law Article 29 – G Section 2999-dd, as amended by A 9007 (2022 Session). (Accessed Aug. 2022).

Mental Health

A program applying to utilize telemental health must complete a “Telemental Health Services Standards Compliance Attestation” form (Appendix 1) and attach it to the Administrative Action request, or to the email request for designated providers, for approval by OMH. The attestation assures OMH that the provider’s plan for the use of telemental health conforms to the technological and clinical standards. See guidance for further requirements.

SOURCE: NY Office of Mental Health, Telemental Health Guidance, 2019, pg. 2. (Accessed Aug. 2022).


ELIGIBLE SERVICES/SPECIALTIES

Federally Qualified Health Centers (FQHCs)

FQHCs that have “opted into” Ambulatory Patient Groups (APGs) should follow the billing guidance outlined for sites billing under APGs.

FQHCs that have not opted into APGs:

  • When services are provided via telemedicine to a patient located at an FQHC originating site, the originating site may bill only the FQHC offsite services rate code (4012) to recoup administrative expenses associated with the telemedicine encounter.
  • When a separate and distinct medical service, unrelated to the telemedicine encounter, is provided by a qualified practitioner at the FQHC originating site, the originating site may bill the Prospective Payment System (PPS) rate in addition to the FQHC offsite services rate code (4012).
  • If a provider who is onsite at an FQHC is providing services via telemedicine to a member who is in their place of residence or other temporary location, the FQHC should bill the FQHC off-site services rate code (4012) and report the applicable modifier (95 or GT) on the procedure code line.
  • If the FQHC is providing services as a distant site provider, the FQHC may bill their PPS rate.

SOURCE: NY Dept. of Health, Medicaid Update, Vol. 35, Number 2, February 2019, p. 11. (Accessed Aug. 2022).

Telemental Health Services may be authorized by the office for licensed or designated services provided by Telemental Health Practitioners.

Under the Medicaid program, Telemental Health Services are covered when medically necessary and under the following circumstances:

  • The person receiving services is located at the originating/spoke site and the Telemental Health Practitioner is located at the distant/hub site;
  • The person receiving services is present during the encounter;
  • The request for Telemental Health Services and the rationale for the request are documented in the individual’s clinical record;
  • The clinical record includes documentation that the encounter occurred; and
  • The Telemental Health Practitioner at the distant/hub site is (1) authorized in New York State; (2) practicing within his/her scope of specialty practice; (3) affiliated with the originating/spoke site facility; and (4) if the originating/spoke site is a hospital, credentialed and privileged at the originating/spoke site facility.

SOURCE: NY Code of Rules and Regs.  Title 14, Sec. 596.5 & 596.7 (Accessed Aug. 2022).

Teledentistry

Services provided by means of telehealth must be in compliance with the Health Insurance Portability and Accountability Act (HIPAA) and all other relevant laws and regulations governing confidentiality, privacy, and consent.

Reimbursement for teledentistry be made in accordance with existing Medicaid policy related to supervision and billing rules and requirements.  See manual for billing procedures.

SOURCE: NY Dental Policy and Procedure Code Manual January 1, 2022, page 85-87 (Accessed Aug. 2022).

Telemental Health

As the final step in the approval process, though not required, OMH Field Office licensing staff may conduct a remote readiness review to either or both the originating and/or distant sites to review the use of Telemental Health Services as part of the routine certification process.  See guidance for details.

SOURCE: NY Office of Mental Health, Telemental Health Guidance, 2019, pg. 3 (Accessed Aug. 2022).

Office of Alcoholism and Substance Abuse Services

Telepractice services, as defined in this Part, may be authorized by the office for the delivery of certain addiction services provided by practitioners employed by, or pursuant to a contract or memorandum of understanding (MOU) with a program certified by the office.

For purposes of billing for Medicaid reimbursement, both the practitioner and/or facility employing the practitioner, and the designated program must be Medicaid enrolled and in good standing. For Medicaid reimbursement the practitioner, as defined in this Part, must be defined as a telehealth provider in subdivision two of Public Health Law section 2999-cc.  For purposes of this subdivision, telepractice services shall be considered face-to-face contacts.

To be eligible for Medicaid reimbursement, telepractice services must meet all requirements applicable to assessment and treatment services of Part 841 and the part pursuant to which the designated program operating certificate is issued and must exercise the same standard of care as services delivered on-site or in-community.

Telepractice services will be reimbursed at the same rates for identical procedures provided by practitioners on-site or in-community; an additional administrative fee for transmission may be billed pursuant to applicable rules or directives issued by the NYS Department of Health.  The designated program is the primary billing entity; reimbursement for practitioners at a distant/hub site must be pursuant to a contract or MOU. Delivery of services via telepractice are covered when medically necessary and under the following circumstances:

  • the patient is located at an originating/spoke site and the practitioner is located at a distant/hub site;
  • the patient is located at another designated program, an additional location of a designated program or at an in-community location approved by the office; and the practitioner is located in another designated program;
  • the patient is present during the telepractice session;
  • the request for a telepractice session and the rationale for the request are documented in the patient’s case record; or
  • the case record includes documentation that the telepractice session occurred and the results and findings were communicated to the designated provider.

If the person receiving services is not present during the telepractice service, the service is not eligible for third party reimbursement and any incurred costs may remain the responsibility of the designated provider.Telepractice services may only be delivered via technological means approved by the Federal Center for Medicaid and Medicare Services (CMS), provided such means are compliant with Federal confidentiality requirements. If all or part of a telepractice service is undeliverable due to a failure of transmission or other technical difficulty, reimbursement shall not be provided.


ELIGIBLE PROVIDERS

For purposes of medical assistance reimbursement, all Medicaid providers authorized to provide in-person services are authorized to provide such services via telehealth, as long as such telehealth services are appropriate to meet a patient’s health care needs and are within a provider’s scope of practice.

SOURCE: NY Code of Rules and Regs. Title 18, Sec. 538.1. (Accessed Aug. 2022).

Providers who may deliver telemedicine services include:

  • Licensed physician
  • Licensed physician assistant
  • Licensed dentist
  • Licensed nurse practitioner
  • Licensed registered professional nurse (only when such nurse is receiving patient- specific health information or medical data at a distant site by means of RPM)
  • Licensed podiatrist
  • Licensed optometrist
  • Licensed psychologist
  • Licensed social worker
  • Licensed speech language pathologist or audiologist
  • Licensed midwife
  • Physical Therapists
  • Occupational Therapists
  • Certified diabetes educator
  • Certified asthma educator
  • Certified genetic counselor
  • Hospital (including residential health care facilities serving special needs populations)
  • Home care services agency
  • Hospice
  • Credentialed alcoholism and substance abuse counselor
  • Providers authorized to provide services and service coordination under the early intervention program
  • Clinics licensed or certified under Article 16 of the MHL
  • Certified and Non-certified day and residential programs funded or operated by the OPWDD
  • Care manager employed by or under contract to a health home program, patient centered medical home, office for people with developmental disabilities Care Coordination Organization (CCO), hospice or a voluntary foster care agency certified by the office of children and family services. (in Public Health Law only)
  • Certified peer recovery advocate services providers certified by the commissioner of addiction services and supports pursuant to section 19.18-b of the mental hygiene law, peer providers credentialed by the commissioner of addiction services and supports and peers certified or credentialed by the office of mental health (in Public Health Law only)
  • Or any other provider as determined by the Commissioner of Health pursuant to regulation or in consultation with the Commissioner, by the Commissioner of OMH, the Commissioner of OASAS, or the Commissioner of OPWDD pursuant to regulation.

SOURCE: NY Public Health Law Article 29 – G Section 2999-cc & NY Dept. of Health, Medicaid Update, Vol. 35, Number 2, February 2019, p. 5-6. (Accessed Aug. 2022).

Effective until April 1, 2024

Additional providers who may deliver telemedicine services include mental health practitioners licensed pursuant to article one hundred sixty-three of the education law.

SOURCE: NY Public Health Law Article 29 – G Section 2999-cc, as amended by A 9007 (2022 Session). (Accessed Aug. 2022).

Telemental Health

Telemental Health Services may be authorized by the office for licensed or designated services provided by Telemental Health Practitioners, as defined in section 596.4 of this Part, from a site distant from the location of a recipient, where the recipient is physically located at a provider site licensed by the office, or the recipient’s place of residence or other temporary location within or outside the state of New York.

‘Telemental health practitioner’ means a physician, nurse practitioner in psychiatry, psychologist, mental health counselor, social worker, marriage and family therapist, creative arts therapist, or psychoanalyst who is providing Telemental Health Services from a distant or hub site.

SOURCE: NY Code of Rules and Regs.  Title 14, Sec. 596.4(q) & 596.5(a) (Accessed Aug. 2022).

Home Telehealth

Subject to the approval of the state director of the budget, the commissioner may authorize the payment of medical assistance funds for demonstration rates or fees established for home telehealth services and subject to federal financial participation shall not exclude from the payment of medical assistance funds the delivery of health care services through telehealth as defined in Section 2999-cc.

SOURCE: NY Statute, Social Services Law SOS §367-u. (Accessed Aug. 2022).

Teledentistry

Dentists providing services via telehealth must be licensed and currently registered in accordance with NYS Education Law or other applicable law and enrolled in NYS Medicaid. Telehealth services must be delivered by dentists acting within their scope of practice.

SOURCE: NY Dental Policy and Procedure Code Manual January 1, 2022, page 85 (Accessed Aug. 2022).


ELIGIBLE SITES

“Originating site” means a site at which a patient is located at the time health care services are delivered to him or her by means of telehealth

“Distant site” means a site at which a telehealth provider is located while delivering health care services by means of telehealth. Any site within the United States or United States’ territories is eligible to be a distant site for delivery and payment purposes.

SOURCE: NY Public Health Law Article 29 – G Section 2999- cc, (Accessed Aug. 2022).

Originating and distant sites must be a secure location within the fifty United States or United States’ territories where the telehealth provider is located while delivering health care services by means of telehealth and may include:

  • Facilities licensed under Article 28 of the Public Health Law (PHL): hospitals, nursing homes and diagnostic and treatment centers;
  • Facilities licensed under Article 40 of the PHL: hospice programs;
  • Facilities as defined in subdivision 6 of Section 1.03 of the Mental Hygiene Law (MHL): clinics certified under Articles 16, 31 and 32;
  • Certified and non-certified day and residential programs funded or operated by the Office of People with Developmental Disabilities (OPWDD);
  • Private physician or dentist offices located within the State of New York;
  • Adult care facilities licensed under Title 2 of Article 7 of the Social Security Law (SSL);
  • Public, private and charter elementary and secondary schools located within the State of New York;
  • School-age child care programs located within the State of New York;
  • Child daycare centers located within the State of New York; and,
  • The member’s place of residence in New York State, or other temporary location in or out of state.

SOURCE: NY Dept. of Health, Medicaid Update, Vol. 35, Number 2, February 2019 (Special Edition), p. 3; Dental Procedure Manual. 1/1/22. P. 85; (Accessed Aug. 2022).

The commissioner may specify in regulation acceptable modalities for the delivery of health care services via telehealth, including but not limited to audio-only or video-only telephone communications, online portals and survey applications, and may specify additional categories of originating sites at which a patient may be located at the time health care services are delivered to the extent such additional modalities and originating sites are deemed appropriate for the populations served.

SOURCE: NY Public Health Law Article 29 – G Section 2999-ee. (Accessed Aug. 2022).

Teledentistry

When services are provided by an Article 28 facility, the telehealth dentist must be credentialed and privileged at both the originating and distant sites in accordance with Section 2805-u of PHL.

SOURCE: Dental Procedure Manual. 1/1/22. P. 85 (Accessed Aug. 2022).

Telemental Health

The recipient can be physically located at a provider site licensed by the office, or the recipient’s place of residence or other temporary location within or outside the state of New York.

SOURCE: NY Code of Rules and Regs.  Title 14, Sec. 596.5(a) (Accessed Aug. 2022).

As the final step in the approval process, though not required, OMH Field Office licensing staff may conduct a remote readiness review to either or both the originating and/or distant sites to review the use of Telemental Health Services as part of the routine certification process.  See guidance for details.

SOURCE: NY Office of Mental Health, Telemental Health Guidance, 2019, pg. 3 (Accessed Aug. 2022).


GEOGRAPHIC LIMITS

No Reference Found


FACILITY/TRANSMISSION FEE

When services are provided via telemedicine to a member located at an Article 28 originating site (outpatient department/clinic, emergency room), the originating site may bill only CPT code Q3014 (telehealth originating-site facility fee) through APGs to recoup administrative expenses associated with the telemedicine encounter.

When a separate and distinct medical service, unrelated to the telemedicine encounter, is provided by a qualified practitioner at the originating site, the originating site may bill for the medical service provided in addition to Q3014. The CPT code billed for the separate and distinct service must be appended with the 25 modifier.

When a telemedicine service is being provided by a distant-site practitioner to a member located in a private practitioner’s office (originating site), the originating-site practitioner may bill CPT code Q3014 to recoup administrative expenses associated with the telemedicine encounter.

When a telemedicine service is being provided by a distant-site practitioner to a member located in a private practitioner’s office (originating site) and the originating-site practitioner provides a separate and distinct medical service unrelated to the telemedicine encounter, the originating- site practitioner may bill for the medical service provided in addition to Q3014. The CPT code billed for the separate and distinct medical service must be appended with the 25 modifier.

Only one clinic payment will be made when both the originating site and the distant site are part of the same provider billing entity. In such cases, only the originating site should bill Medicaid for the telemedicine encounter.

SOURCE: NY Dept. of Health, Medicaid Update, Vol. 35, Number 2, February 2019 (Special Edition), p. 8-10. (Accessed Aug. 2022).

Telemental Health

The originating site can bill for administrative expenses only when a telemental health service connection is being provided and a qualified mental health professional is not present at the originating site with the patient at the time of the encounter.

SOURCE: NY Code of Rules and Regs.  Title 14, Sec. 596.7(e) (Accessed Aug. 2022).

When services are provided via telemedicine to a member located at an Article 28 originating site (outpatient department/clinic, emergency room), the originating site may bill only CPT code Q3014 (telehealth originating-site facility fee) through APGs to recoup administrative expenses associated with the telemedicine encounter.

When a separate and distinct medical service, unrelated to the telemedicine encounter is provided by a qualified practitioner at the originating site, the originating site may bill for the medical service provided in addition to Q3014. The CPT code billed for the separate and distinct service must be appended with the 25 modifier.

SOURCE: NY Office of Mental Health, Telemental Health Guidance, 2019, pg. 8-9 (Accessed Aug. 2022).

Teledentistry

Procedure code Q3014 may be used by the provider at the originating site. Must be reported on claim line #1. Report all services rendered on subsequent lines.

SOURCE:  Dental Procedure Manual. 1/1/22. P. 87; NY Dept. of Health, (Accessed Aug. 2022).

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North Carolina

Last updated 08/16/2022

POLICY

All telehealth services must be provided over a secure …

POLICY

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

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

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, p. 3 & 8, Nov. 15, 2020. (Accessed Aug. 2022).


ELIGIBLE SERVICES/SPECIALTIES

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

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, p. 6, Nov. 15, 2020. (Accessed Aug. 2022).

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

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

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

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

Services NOT Covered

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

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

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, p. 5 & 7, Nov. 15, 2020 & NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 8C, Outpatient Behavioral Health Services, p. 4 & 7-8, Sept. 1, 2021. (Accessed Aug. 2022).

Additional Criteria not covered under NC Health Choice

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

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

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

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

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, p. 3-8, Nov. 15, 2020. (Accessed Aug. 2022).

Telehealth, including:

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

Virtual communication, including:

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

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

Hybrid Telehealth with Supporting Home Visit (Hybrid Model)

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

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

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

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

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

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, p. 6 , 13 &14 Nov. 15, 2020. (Accessed Aug. 2022).

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

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

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

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, p. 17-18, Nov. 15, 2020. (Accessed Aug. 2022).

Outpatient Behavioral Health

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

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

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

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

FQHCs/RHCs

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

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

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

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

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

Office Based Opioid Treatment (OBOT)

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

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

Independent Practitioners

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

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

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

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

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

SOURCE: NC Div. of Medical Assistance, Independent Practitioners, Clinical Coverage Policy No: 10B, Amended July 1, 2021, pg. 3, 12 & 47 (Accessed Mar. 2022).

Outpatient Specialized Therapies – Local Education Agencies

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

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

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

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

Speech and Language Evaluation and Treatment

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

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

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

See Speech Language codes for eligible services via telehealth.

SOURCE: NC Div. of Medical Assistance, Independent Practitioners, Clinical Coverage Policy, Amended July 1, 2021, pg. 12 & 44 (Accessed Aug. 2022).

Family Planning Services

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

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

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

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

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

Home Health Services

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

SOURCE: NC Div. of Medical Assistance, Clinical Coverage Policies 3A Home Health Services, Amended Mar. 1, 2021, pg. 13, (Accessed Aug. 2022).

Dietary Evaluation and Counseling and Medical Lactation Services 

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

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

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

Dialysis Services

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

See manual for service codes.

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

Diabetes Outpatient Self-Management Education

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

See manual for service codes.

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

Independent Practitioners Respiratory Therapy Services

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

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

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

See manual for codes.

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

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

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

Pregnancy Medical Home

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

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

Enhanced Mental Health and Substance Abuse Services

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

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

Facility-Based Crisis Service for Children and Adolescents

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

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

Diagnostic Assessment

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

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

Children’s Developmental Service Agencies (CDSAs)

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

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

North Carolina Innovations

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

Specialized Consultation Services

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

Activities covered include:

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

See manual for complete list of covered activities.

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

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


ELIGIBLE PROVIDERS

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

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

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, p. 9, Nov. 15, 2020 & NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 8C, Outpatient Behavioral Health Services, p. 13, Sept. 1, 2021. (Accessed Aug. 2022).

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

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

Eligible providers that can bill for telehealth services:

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

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

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, p. 2, 13-16, Nov. 15, 2020. (Accessed Aug. 2022).

Early and Periodic Screening, Diagnostic and Treatment (EPSDT)

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

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

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

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, p. 4, Nov. 15, 2020. (Accessed Aug. 2022).

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

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, p. 12, Nov. 15, 2020. (Accessed Aug. 2022).

FQHCs/RHCs

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

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


ELIGIBLE SITES

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

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, p. 2, Nov. 15, 2020. (Accessed Aug. 2022).

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

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, p. 17, Nov. 15, 2020. (Accessed Aug. 2022).

Dietary Evaluation

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

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

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

Lactation Consultation Services

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

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

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

Dialysis Services

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

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

Diabetes Outpatient Self-Management Education

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

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

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

Independent Practitioners

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

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

SOURCE: NC Div. of Medical Assistance, Independent Practitioners, Clinical Coverage Policy, Amended July 1, 2021, pg. 48 (Accessed Aug. 2022).

FQHCs/RHCs

Core Services

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

Hybrid Telehealth with Supporting Home Visit

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

See manual for additional guidance.

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

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

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

Pregnancy Medical Home

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

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1E-6, Telehealth, Pregnancy Medical Home, pg. 14, Dec. 1, 2020. (Accessed Aug. 2022).


GEOGRAPHIC LIMITS

There are no restrictions on the originating or distant sites.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, p. 2, Nov. 15, 2020. (Accessed Aug. 2022).


FACILITY/TRANSMISSION FEE

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

Providers must bill Q3014 for the originating site facility fee.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, p. 9 & 16, Nov. 15, 2020. (Accessed Aug. 2022).

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

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

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, p. 14, Nov. 15, 2020, (Accessed Aug. 2022).

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North Dakota

Last updated 08/08/2022

POLICY

The totality of the communication of the information exchanged …

POLICY

The totality of the communication of the information exchanged between the physician or other qualified healthcare professional and the patient during the course of the synchronous telemedicine service must be of an amount and nature that would be sufficient to meet the key components and/or requirements of the same service when rendered via a face-to-face interaction.

SOURCE: ND Div. of Medical Assistance, General Information Provider Manual, Telemedicine, p. 156, (July 2022), (Accessed Aug. 2022).

Teledentistry

Synchronous teledentistry is reimbursable and reported in addition to other ND Medicaid-covered procedures provided to the patient, when applicable. Dentists and dental offices must report the appropriate CDT Code for these procedures.

The patient record must include the CDT codes that reflect the teledentistry encounter. ND Medicaid reimburses for CDT code D9995 once per date of service. Submissions must be billed using place of service code 02. Service authorization is not required for CDT code D9995.

SOURCE:  North Dakota Department of Human Services: Teledentistry Policy. (July 2019).  (Accessed Aug. 2022).


ELIGIBLE SERVICES/SPECIALTIES

Qualified services for telemedicine must:

  • Maintain actual visual contact (face-to-face) between the practitioner and patient.
  • Be medically appropriate and necessary with supporting documentation included in the patient’s clinical medical record.
  • Be provided via secure and appropriate equipment to ensure confidentiality and quality in the delivery of the service.
  • The service must be provided using a HIPAA compliant platform.

See manual for appropriate coding.

All service limits set by ND Medicaid apply to telemedicine services.

Except for non-covered services noted below, telemedicine can be used for services covered by Medicaid, and otherwise allowed, per CPT, to be rendered via telemedicine.

Noncovered Services:

  • Therapies provided in a group setting
  • Store and Forward
  • Targeted Case Management for High Risk Pregnant Women and Infants
  • Targeted Case Management for Individuals in need of Long-Term Care Services

SOURCE: ND Div. of Medical Assistance, General Information Provider Manual, Telemedicine, p. 156-157, (Jul. 2022), (Accessed Aug. 2022).

Indian Health Services and Tribally Operated 638 Facilities

Coverage and payment of services provided through telemedicine is on the same basis as those provided through face-to-face contact.

SOURCE: ND Div. of Medical Assistance, General Information Provider Manual, IHS, p. 77, (Jul. 2022), (Accessed Aug. 2022).

Medicaid Services Rendered in Schools

Services rendered in schools may be delivered via telemedicine. See the Telemedicine chapter for additional information on services rendered via telemedicine.

SOURCE: ND Div. of Medical Assistance, General Information Provider Manual, Schools, p. 90, (Jul. 2022), (Accessed Aug. 2022).

Home Health Services

Telemonitoring is a covered service. See remote patient monitoring section.

Dentistry

See manual for service codes that can be delivered utilizing synchronous real-time teledentistry.

SOURCE: ND Div. of Medical Assistance, Dental Services Provider Manual, p. 38, (Jul. 2022), (Accessed Aug. 2022).

Medication Assisted Treatment

The member must require at least one face to face or by telemedicine check‐in per month for prescribing or dispensing of OBOT/OTP medication.

Telemedicine must be provided in accordance with applicable federal and state laws and policies and follow the Controlled Substances Act (CSA)(28 USC 802) for prescribing and administration of controlled substances.

SOURCE: ND Div. of Medical Assistance, General Information Provider Manual, MAT, p. 94 & 96, (Jul. 2022), (Accessed Aug. 2022).


ELIGIBLE PROVIDERS

Payment will be made only to the distant practitioner during the telemedicine session. No payment is allowed to a practitioner at the originating site if his/her sole purpose is the presentation of the patient to the practitioner at the distant site.

Payment is made for services provided by licensed professionals enrolled with ND Medicaid and within the scope of practice per their licensure only.

Telemedicine services provided by an Indian Health Service (IHS) facility or a Tribal 638 Clinic functioning as the distant site, are reimbursed at the All-Inclusive Rate (AIR), regardless whether the originating site is outside the “four walls” of the facility or clinic.

SOURCE: ND Div. of Medical Assistance, General Information Provider Manual, Telemedicine, p. 157, (Jul. 2022), (Accessed Aug. 2022).

Rural Health Clinics

Coverage and payment of services provided through telemedicine is on the same basis as those provided through face-to-face contact.  See Telemedicine chapter for additional information on services rendered via telemedicine.

SOURCE: ND Div. of Medical Assistance, General Information Provider Manual, RHCs, p. 77-78, (Jul. 2022), (Accessed Aug. 2022).


ELIGIBLE SITES

Payment will be made to the originating site as a facility fee only in place of service office, inpatient hospital, outpatient hospital, or skilled nursing facility/nursing facility. There is no additional payment for equipment, technicians or other technology or personnel utilized in the performance of the telemedicine service.

SOURCE: ND Div. of Medical Assistance, General Information Provider Manual, Telemedicine, p. 157, (Jul. 2022), (Accessed Aug. 2022).

Health Services billed by schools can be delivered via telemedicine; however, no originating site fee is allowed. See Services Rendered via Telemedicine chapter for additional information.

SOURCE: ND Div. of Medical Assistance, General Information Provider Manual, Telemedicine, p. 80, (Jul. 2022), (Accessed Aug. 2022).


GEOGRAPHIC LIMITS

No Reference Found


FACILITY/TRANSMISSION FEE

Payment will be made to the originating site as a facility fee only in place of service office, inpatient hospital, outpatient hospital, or skilled nursing facility/nursing facility. There is no additional payment for equipment, technicians or other technology or personnel utilized in the performance of the telemedicine service.

Payment will be made only to the distant practitioner during the telemedicine session. No payment is allowed to a practitioner at the originating site if his/her sole purpose is the presentation of the patient to the practitioner at the distant site.

SOURCE: ND Div. of Medical Assistance, General Information Provider Manual, Telemedicine, p. 157, (Jul. 2022), (Accessed Aug. 2022).

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Ohio

Last updated 09/07/2022

POLICY

Ohio Medicaid covers live video telehealth for certain eligible …

POLICY

Ohio Medicaid covers live video telehealth for certain eligible providers wherever the covered individual is located.

SOURCE: The Ohio Department of Medicaid.  Telehealth Billing Guide.  Revised 7/15/2022. & OAC 5160-1-18.  (Accessed Sept. 2022).

The department of medicaid shall establish standards for medicaid payments for health care services the department determines are appropriate to be covered by the medicaid program when provided as telehealth services. The standards shall be established in rules adopted under section 5164.02 of the Revised Code.

In accordance with section 5162.021 of the Revised Code, the medicaid director shall adopt rules authorizing the directors of other state agencies to adopt rules regarding the medicaid coverage of telehealth services under programs administered by the other state agencies. Any such rules adopted by the medicaid director or the directors of other state agencies are not subject to the requirements of division (F) of section 121.95 of the Revised Code.

SOURCE: OH Revised Code, Sec. 5164.95.(B) (Accessed Sept. 2022).

Inmates of a penal facility or a public institution are not eligible for reimbursement for telehealth services.

SOURCE: OH Admin Code 5160-1-18(E). (Accessed Sept. 2022).

Mental Health

No initial in person visit is necessary to initiate services using telehealth modalities. The decision of whether or not to provide initial or occasional in-person sessions shall be based upon client choice, appropriate clinical decision-making, and professional responsibility, including the requirements of professional licensing, registration or credentialing boards.

SOURCE: OAR 5122-29-31 (Accessed Sept. 2022).

Office of Mental Health and Addiction Services

OhioMHAS-certified behavioral health centers are not subject to the Ohio Medicaid Telehealth rule 5160-1-18. However, if you are a behavioral health provider or other health care entity and are not certified by OhioMHAS, you are/or may be required to follow Ohio Medicaid rule 5160-1-18.

SOURCE: Office of Mental Health and Addiction Services, Guidance for Providing Behavioral Health Services via Telehealth. March. 2020, (Accessed Sept. 2022).

Teledentistry

The department is required to establish standards for Medicaid payment for services provided through teledentistry.

SOURCE: OH Revised Code, Sec. 5164.951. (Accessed Sept. 2022).


ELIGIBLE SERVICES/SPECIALTIES

See Medicaid guidance document and appendix to new rule 5160-1-18 for eligible services for telehealth delivery on or after November 15, 2020.

If the practitioner site does not bill the Ohio Department of Medicaid (ODM) directly (i.e., holds a contractual agreement with the practice), the patient site or practice who holds the contractual agreement may instead bill for the service delivered using telehealth.

SOURCE: The Ohio Department of Medicaid. Telehealth Billing Guide.  Revised 7/15/2022.  (Accessed Sept. 2022).

The following services are eligible for payment when delivered through telehealth from the practitioner site:

  • When provided by a patient centered medical home, or behavioral health providers, evaluation and management of a new patient described as “office or other outpatient visit” with medical decision making not to exceed moderate complexity.
  • Evaluation and management of an established patient described as “office or other outpatient visit” with medical decision making not to exceed moderate complexity.
  • Inpatient or office consultation for a new or established patient when providing the same quality and timeliness of care to the patient other than by telehealth is not possible
  • Mental health or substance use disorder services described as “psychiatric diagnostic evaluation” or “psychotherapy”
  • Remote evaluation of recorded video or images submitted by an established patient.
  • Virtual check-in by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient.
  • Online digital evaluation and management service for an established patient.
  • Remote patient monitoring.
  • Audiology, speech-language pathology, physical therapy, and occupational therapy services, including services provided in the home health setting.
  • Medical nutrition services.
  • Lactation counseling provided by dietitians.
  • Psychological and neuropsychological testing.
  • Smoking and tobacco use cessation counseling.
  • Developmental test administration.
  • Limited or periodic oral evaluation.
  • Hospice services.
  • Private duty nursing services.
  • State plan home health services.
  • Dialysis related services.
  • Services under the specialized recovery services (SRS) program as defined in rule 5160-43-01 of the Administrative Code.
  • Notwithstanding paragraph (D)(2) of this rule, behavioral health services covered under Chapter 5160-27 of the Administrative Code.
  • Optometry services.
  • Pregnancy education services.
  • Diabetic self-management training (DSMT) services.
  • Other services if specifically authorized in rule promulgated under agency 5160 of the Administrative Code.

SOURCE: OH Admin Code 5160-1-18(D). (Accessed Sept. 2022).

Mental Health

The following are the services that may be provided via telehealth:

  • General services
  • CPST service
  • Therapeutic behavioral services and psychosocial rehabilitation service
  • Peer recovery services
  • SUD case management service
  • Crisis intervention service
  • Assertive community treatment service
  • Intensive home-based treatment service
  • Mobile response and stabilization service

Individuals receiving residential and withdrawal management substance use disorder services as defined in rule 5122-29-09 of the Administrative Code or mental health day treatment service as defined in rule 5122-29-06 of the Administrative Code may receive any of the component services listed in paragraph (E) of this rule through telehealth.

SOURCE: OAC 5122-29-31. (Accessed Sept. 2022).

Services are allowed to be provided through telehealth pursuant to rule 5122-29-31 of the Administrative Code, and these services are to be documented in accordance with paragraph (G) of rule 5122-29-31 of the Administrative Code. Telehealth services including induction of any form of medication assisted treatment will only be allowed in accordance with federal and state standards.

SOURCE: OAC 5122-40-09. (Accessed Sept. 2022).

Mobile Response and Stabilization Service

MRSS is intended to be delivered in-person where the young person or family is located, such as their home or a community setting. There are instances where MRSS can be delivered using a telehealth modality. Common times that telehealth would be appropriate are:

  • When the young person or family requests MRSS service delivery using telehealth modalities,
  • There is a contagious medical condition present in the home, or
  • Inclement weather that prevents or makes it dangerous for the MRSS team to travel to the young person or family.

SOURCE: OAC 5122-29-14 (Accessed Sept. 2022).

Managed Care

Many clinically appropriate services that can be delivered virtually will be eligible for telehealth coverage, including but not limited to: sick visits, well visits, prenatal and postpartum care, behavioral health, and monitoring of chronic conditions. This is especially important for Medicaid members who experience a variety of access related barriers to care and social determinants of health.  All Telemedicine/Telehealth services must be medically necessary and documented and in the applicable medical record in order to be reimbursable. Documentation may be requested to support medical necessity reviews.  See guide for telehealth visit code set.

SOURCE: Managed Care Plan Provider Telehealth Resource Guide, pg. 3-7, (Accessed Sept. 2022).

Office of Mental Health and Addiction Services

Services that may be provided using real-time, interactive videoconferencing as a certified community behavioral health center are:

  • Telehealth
  • General Services
  • Assessments
  • Counseling and therapy including groups up to 12
  • Medical Activities including prescribing as allowed by the State of Ohio Medical Board and practitioner’s
    licensure
  • CPST Services
  • Therapeutic behavioral services and psychosocial rehabilitation services

SOURCE: Office of Mental Health and Addiction Services, Guidance for Providing Behavioral Health Services via Telehealth. March. 2020, (Accessed Sept. 2022).

Intensive Home Based Treatment (IHBT) Service

IHBT is an intensive service that consists of multiple in person contacts per week with the child/adolescent and family, which includes collateral contacts related to the behavioral health needs of the child/adolescent as documented in the individual client record (ICR) as required by Chapter 5122-27 of the Administrative Code. IHBT can be provided via telehealth in accordance with rule 5122-29-31 of the Administrative Code.

SOURCE: OH Administrative Code 5122-29-28. (Accessed Sept. 2022).

Payment may be made for IHBT services rendered face-to-face in person or via telehealth in accordance with rule 5122-29-31 of the Administrative Code.

SOURCE: OH Administrative Code 5160-59-03.3. (Accessed Sept. 2022).

Outpatient hospital behavioral health services (OPHBH)

Hospitals are eligible to provide outpatient behavioral health services via telehealth to the extent they appear on the OPHBH fee schedule.

SOURCE: The Ohio Department of Medicaid.  Telehealth Billing Guide.  Revised 7/15/2022.  (Accessed Sept. 2022).

Federally Qualified Health Center and Rural Health Clinics

Medical nutrition therapy and lactation services rendered by eligible FQHC and RHC practitioners will be paid under the PPS.

Group therapy will continue to be paid through FFS as a covered non-FQHC/RHC service under the clinic provider type 50 (using ODM’s payment schedules).

Services under the Specialized Recovery Services (SRS) program are not currently covered FQHC or RHC services.

SOURCE: The Ohio Department of Medicaid.  Telehealth Billing Guide.  Revised 7/15/2022.  (Accessed Sept. 2022).

Federally Qualified Health Center

A visit may be conducted through telehealth if the service is rendered in accordance with rule 5160-1-18 of the Administrative Code.

SOURCE: OH Administrative Code 5160-28-01. (Accessed Sept. 2022).

Dental

Dentists may provide a limited problem-focused oral exam (CDT D0140) or periodic oral evaluation (D0120) through telehealth during this state of emergency.  Dental services furnished through telehealth at FQHCs are covered under 5160-1-18 and are paid as covered FQHC dental services.

SOURCE: The Ohio Department of Medicaid.  Telehealth Billing Guide.  Revised 7/15/2022.  (Accessed Sept. 2022).

Hospice

Hospice services can be provided using telehealth when clinically appropriate.

SOURCE: The Ohio Department of Medicaid.  Telehealth Billing Guide.  Revised 7/15/2022.  (Accessed Sept. 2022).

Home Health Services

Home health services, the RN assessment service and the RN consultation service can be provided using telehealth when clinically appropriate.

SOURCE: The Ohio Department of Medicaid.  Telehealth Billing Guide.  Revised 7/15/2022.  (Accessed Sept. 2022).

Nursing Facilities

In accordance with rule 5160-1-18 of the Administrative Code, physician visits may be provided via telehealth.

SOURCE: Ohio Administrative Code 5160-3-19(4). (Accessed Sept. 2022).

Hospice

Hospice providers that deliver any component of services via telehealth will add the GT modifier on those claims, in addition to the appropriate procedure code listed in the administrative code. Ohio Department of Medicaid will allow telehealth services to be provided where in-person visits are mandated. Services billed with T2044 and T2045 are not eligible to be provided via telehealth.

SOURCE: Ohio Administrative Code 5160-56-06. (Accessed Sept. 2022).

Home Health and Private Duty Nursing

Reimbursement of home health or private duty nursing (PDN) services in accordance with this chapter are on a per visit basis. A “visit” is the duration of time that a covered home health service or private duty nursing (PDN) service is provided during an in-person or telehealth encounter to one or more individuals receiving medicaid at the same residence on the same date during the same time period.

A visit begins with the provision of a covered service and ends when the in-person or telehealth encounter ends.

SOURCE: Ohio Administrative Code 5160-12-04, (Accessed Sept. 2022).

Registered Nurse Assessment and Registered Nurse Consultation Services

The RN assessment may be completed using telehealth.

SOURCE: Ohio Administrative Code 5160-12-08, (Accessed Sept. 2022).

Home Health Services

The face-to-face encounter may be completed using telehealth.

SOURCE: Ohio Administrative Code 5160-12-01, (Accessed Sept. 2022).

Teledentistry

“Teledentistry” means the delivery of dental services through the use of synchronous, real-time communication and the delivery of services of a dental hygienist or expanded function dental auxiliary pursuant to a dentist’s authorization as defined in section 4715.43 of the Revised Code.

In order to qualify as teledentistry activities, both the originating site(s) (location of the patient) and the approved practice site(s) must be located in dental health resource shortage areas.

All teledentistry activities must be conducted at the practice site(s) specified in the dentist’s contract.

SOURCE: OAC 3701-56-03. (Accessed Sept. 2022).


ELIGIBLE PROVIDERS

Eligible providers:

  • Physicians, Psychiatrists
  • Ophthalmologist (in billing guide only)
  • Podiatrist (in billing guide only)
  • Psychologist
  • Physician Assistant
  • Dentist
  • Advanced Practice Registered Nurses:
    • Clinical Nurse Specialists
    • Certified Nurse Midwives
    • Certified Nurse Practitioners
  • Licensed Independent Social Workers
  • Licensed Independent Chemical Dependency Counselors, Supervised practitioners, trainees, residents, and interns
  • Licensed Independent Marriage and Family Therapists
  • Licensed Professional Clinical Counselors
  • Dietitians
  • Audiologist, speech-language pathologists, speech-language pathology aides, audiology aides, and individuals holding a conditional license
  • Occupational and physical therapists and occupational and physical therapist assistants
  • Speech-Language Pathologist
  • Home health aide and hospice aides (in admin code only)
  • Practitioners who are supervised or cannot practice independently (see billing guide for list but many are listed above as well (i.e. physical therapist assistant)
  • Non-Agency Nurses (in billing guide only)
  • Medicaid school program (MSP) practitioners
  • Behavioral health practitioners (in admin code only)
  • Optometrists
  • Pharmacists
  • Chiropractors (in billing guide only)
  • Other practitioners if specifically authorized in rule promulgated under Agency 5160 of the Administrative Code.

Types of providers able to bill: Rendering practitioners listed above, except:

  • Supervised practitioners
  • Occupational therapy assistant
  • Physical therapist assistant
  • Speech-language pathology and audiology aides
  • Individuals holding a conditional license
  • Registered Nurses (RN) and Licensed Practical Nurses (LPN) working in a hospice or home health setting (in billing guide only)

Other providers able to bill include:

  • Professional Medical or Dental Group
  • Federally Qualified Health Center
  • Rural Health Clinic
  • Ambulatory health care clinics
  • Outpatient hospitals on behalf of licensed psychologists and independent practitioners not eligible to separately bill when practicing in an outpatient hospital setting.
  • Psychiatric Hospitals providing OPHBH services
  • Medicaid school program (MSP)
  • Private duty  or non-Agency nurses
  • Pharmacies (submitted on a professional claim)
  • Chiropractors (in billing guide only)
  • Home health and hospice agencies (in admin code only)
  • Behavioral health providers (in admin code only)
  • Hospitals operating an outpatient hospital behavioral health program (in admin code only)

SOURCE: The Ohio Department of Medicaid. Telehealth Billing Guide.  Revised 7/15/2022 & OH Administrative Code 5160-1-18, (Accessed Sept. 2022).

Outpatient Hospitals

Hospital providers are eligible to bill for telehealth services provided by licensed psychologists and independent practitioners not eligible to separately bill a professional claim. Ohio Medicaid will pay according to the Enhanced Ambulatory Patient Grouping (EAPG) pricing as described in OAC rule 5160-2-75.

Federally Qualified Health Center and Rural Health Clinics

For a covered telehealth service that is also an FQHC or RHC service, the face-to-face requirement is waived.

Nursing Facilities

Nursing facilities (NF) are reimbursed for all telehealth related services through the NF per diem rate. Nursing Facilities do not bill for the telehealth related services they provide. Per the telehealth rule 5160-1-18, physicians and other eligible providers may bill for the services they provide to nursing facility residents from the practitioner’s site in accordance with the rule.  When nursing facilities provide telehealth related services to their residents, they report the costs they incur for those services on the Medicaid NF cost report.

SOURCE: The Ohio Department of Medicaid.  Telehealth Billing Guide.  Revised 7/15/2022.  (Accessed Sept. 2022).

Hospice

Hospice providers that deliver any component of services via telehealth will add the GT modifier on those claims, in addition to the appropriate procedure code above. Ohio Department of Medicaid will allow telehealth services to be provided where in-person visits are mandated.

SOURCE: Ohio Administrative Code 5160-56-06. (Accessed Sept. 2022).

Teledentistry

“Teledentistry” means the delivery of dental services through the use of synchronous, real-time communication and the delivery of services of a dental hygienist or expanded function dental auxiliary pursuant to a dentist’s authorization as defined in section 4715.43 of the Revised Code.

In order to qualify as teledentistry activities, both the originating site(s) (location of the patient) and the approved practice site(s) must be located in dental health resource shortage areas.

All teledentistry activities must be conducted at the practice site(s) specified in the dentist’s contract.

SOURCE: OAC 3701-56-03. (Accessed Sept. 2022).


ELIGIBLE SITES

“Patient site” is the physical location of the patient at the time a health care service is provided through the use of telehealth.

A modifier as identified in Appendix B of this rule if the physical location of the patient is one of the following locations:

  • The patient’s home (including homeless shelter, assisted living facility, group home, and temporary lodging);
  • School;
  • Inpatient hospital;
  • Outpatient hospital;
  • Nursing facility;
  • Intermediate care facility for individuals with an intellectual disability.

The “practitioner site” is the physical location of the treating practitioner at the time a health care service is provided through the use of telehealth.

SOURCE: Ohio Administrative Code 5160-1-18. &  Appendix B (Accessed Sept. 2022).

If the patient is at one of the following locations, a specific modifier identifying the type of location is
required:

  • The patient’s home
  • School
  • Inpatient hospital
  • Outpatient hospital
  • Nursing facility
  • Intermediate care facility for individuals with an intellectual disability

Medicaid covered individuals can access telehealth services wherever they are located. Locations include, but are not limited to:

  • Home
  • School
  • Temporary housing
  • Homeless shelter
  • Nursing Facility
  • Hospital
  • Group home
  • Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IIDs)

Penal facility or public institution such as a jail or prison are excluded places of service.

In most cases, the “GT” modifier is required to identify the service delivery through telehealth. See instructions for your specific program area or provider type for further clarification.

In most cases, the place of service code reported on the claim must be the location of the practitioner. See instructions for your specific program area or provider type for further clarification.

Telehealth place of service codes 02 and 10 will not be accepted unless stated otherwise in provider specific billing guidelines.

See billing guidance for appropriate modifiers depending on the place of service.

SOURCE: The Ohio Department of Medicaid.  Telehealth Billing Guide.  Revised 7/15/2022.  (Accessed Sept. 2022).

Teledentistry

All teledentistry activities must be conducted at the practice site(s) specified in the dentist’s contract.

SOURCE: OAC 3701-56-03. (Accessed Sept. 2022).


GEOGRAPHIC LIMITS

There is no limitation on the practitioner or patient site.

SOURCE: The Ohio Department of Medicaid.  Telehealth Billing Guide.  Revised 7/15/2022.  (Accessed Sept. 2022)..


FACILITY/TRANSMISSION FEE

No Reference Found

READ LESS

Oklahoma

Last updated 09/06/2022

POLICY

SoonerCare (Oklahoma’s Medicaid program) reimburses for live video when:…

POLICY

SoonerCare (Oklahoma’s Medicaid program) reimburses for live video when:

  • Be contracted with SoonerCare and appropriately licensed,
  • Bill for services using the appropriate modifier (GT), and
  • Maintain documentation of services, to include: service rendered, location at which service was rendered, and that service was provided via telehealth. (Documentation of services must follow all other SoonerCare documentation guidelines as well.)

NOTE: While this webpage is still active, CCHP cannot locate navigation to the page from Oklahoma Health Care Authority’s website and are therefore unsure if this information is still valid.

SOURCE: OK Health Care Authority, Telehealth. (Accessed Sept. 2022).


ELIGIBLE SERVICES/SPECIALTIES

To participate, a member:

  • May receive telehealth services outside of Oklahoma when medically necessary;
  • Retains right to withdraw from telehealth services at any time; and
  • Should be aware that all telehealth activities must comply with the Health Insurance Portability and Accountability Act (HIPAA) Security Rule, OHCA policy and all other applicable state and federal laws and regulations.

Also, if member is a minor child, a parent or legal guardian must present the child for services unless exempted by state or federal law. The parent or guardian need not attend the session unless attendance is therapeutically appropriate.

NOTE: While this webpage is still active, CCHP cannot locate navigation to the page from Oklahoma Health Care Authority’s website and are therefore unsure if this information is still valid.

SOURCE: OK Health Care Authority, Telehealth. (Accessed Sept. 2022).

OHCA has discretion and final authority to approve or deny telehealth services based on agency and/or SoonerCare members’ needs.

SOURCE: OK Admin. Code Sec. 317:30-3-27 (Accessed Sept. 2022).

A telehealth service is subject to the same SoonerCare program restrictions, limitations, and coverage which exist for the service when not provided through telehealth; provided, however, that only certain telehealth codes are reimbursable by SoonerCare. For a list of the SoonerCare-reimbursable telehealth codes, refer to the OHCA’s Behavioral Health Telehealth Services and Medical Telehealth Services, available on OHCA’s website, www.okhca.org.

Where there are established service limitations, the use of telehealth to deliver those services will count towards meeting those noted limitations. Service limitations may be set forth by Medicaid and/or other third-party payers.

SOURCE: OK Admin. Code Sec. 317:30-3-27. (Accessed Sept. 2022).

Physical, Occupational and Speech and Hearing Services

For physical therapy, occupational therapy, and/or speech and hearing services that are provided in a primary or secondary school setting, but that are not school-based services (i.e., not provided pursuant to an IEP), providers must adhere to all State and Federal requirements relating to prior authorization and prescription or referral.

SOURCE: OK Admin. Code Sec. 317:30-3-27(d). (Accessed Sept. 2022).

Psychiatric Services

Psychiatric services performed via telemedicine are subject to the requirements found in Oklahoma Administrative Code (OAC) 317:30-3-27.

SOURCE: OK Admin. Code Sec. 317:30-5-11 (Accessed Sept. 2022).

Certified Community Behavioral Health Clinics

Care coordination

Transitional care will be provided by the facility for consumers who have been hospitalized or placed in other non-community settings, such as psychiatric residential treatment facilities. The CCBHC will provide care coordination while the consumer is hospitalized as soon as it becomes known. A team member will go to the hospital setting to engage the consumer in person and/or will connect through telehealth as a face to face meeting. Reasonable attempts to fulfill this important contact shall be documented. In addition, the facility will make and document reasonable attempts to contact all consumers who are discharged from these settings within 24 hours of discharge.

SOURCE: OK Admin. Code Sec. 450:17-5-183. (Accessed Sept. 2022).

Crisis services

Facilities shall make crisis services available, through clearly defined arrangements, for behavioral health emergencies during hours when the facility is closed. The Facility will also provide crisis services that are available and accessible twenty-four (24) hours a day and delivered within one (1) hour from the time services are requested. The facility will make available, either directly or through a qualified DCO, the following co-occurring capable services:

  • Twenty-four (24) hour mobile crisis teams that are available via telehealth/secure tablet, or if an in-person response is required, arrival within one (1) hour from the time requested.

SOURCE: OK Admin. Code Sec. 450:17-5-184. (Accessed Sept. 2022).


ELIGIBLE PROVIDERS

To participate, a provider must:

  • Be contracted with SoonerCare and appropriately licensed
  • Bill for services using the appropriate modifier (GT)
  • Maintain documentation of services, to include: service rendered, location at which service was rendered, and that service was provided via telemedicine. (Documentation of services must follow all other SoonerCare documentation guidelines as well.)

Additionally, out-of-state providers must comply with all laws and regulations of the provider’s location, including health care and telehealth requirements.

NOTE: While this webpage is still active, CCHP cannot locate navigation to the page from Oklahoma Health Care Authority’s website and are therefore unsure if this information is still valid.

SOURCE: Oklahoma Health Care Authority, Telehealth.  (Accessed Sept. 2022).

The provider must be contracted with SoonerCare and appropriately licensed or certified, in good standing. Services that are provided must be within the scope of the practitioner’s license or certification. If the provider is outside of Oklahoma, the provider must comply with all laws and regulations of the provider’s location, including health care and telehealth requirements.

SOURCE: OK Admin. Code Sec. 317:30-3-27. (Accessed Sept. 2022).

Indian Health Service/Tribal 638

An I/T/U encounter means a face to face or telehealth contact between a health care professional and an IHS eligible SoonerCare member for the provision of medically necessary Title XIX or Title XXI covered services through an IHS or Tribal 638 facility or an urban Indian clinic within a 24-hour period ending at midnight, as documented in the patient’s record.

SOURCE: OK Admin. Code Sec. 317:30-5-1098. I/T/U outpatient encounters. (Accessed Sept. 2022).

 


ELIGIBLE SITES

The medical or behavioral health related service must be provided at an appropriate site for the delivery of telehealth services. An appropriate telehealth site is one that has the proper security measures in place; the appropriate administrative, physical, and technical safeguards should be in place that ensures the confidentiality, integrity, and security of electronic protected health information. The location of the room for the encounter at both ends should ensure comfort, privacy, and confidentiality. Both visual and audio privacy are important, and the placement and selection of the rooms should consider this. Appropriate telehealth equipment and networks must be used considering factors such as appropriate screen size, resolution, and security. Providers and/or members may provide or receive telehealth services outside of Oklahoma when medically necessary; however, prior authorization may be required.

SOURCE: OK Admin. Code Sec. 317:30-3-27(c)(3). (Accessed Sept. 2022).

School Setting

In order for OHCA to reimburse medically necessary telehealth services provided to SoonerCare members in a primary or secondary school setting, all of the requirements in (c) above must be met, with the exception of (c)(5), as well as all of the requirements shown below, as applicable.  There are special consent and notification requirements for school-based sites.  See Oklahoma Code.

Physical therapy, occupational therapy, and/or speech and hearing services that are provided in a primary or secondary school setting, but that are not school-based services (i.e., not provided pursuant to an IEP), providers must adhere to all State and Federal requirements relating to prior authorization and prescription or referral.

SOURCE: OK Admin. Code Sec. 317:30-3-27(d). (Accessed Sept. 2022).


GEOGRAPHIC LIMITS

No Reference Found


FACILITY/TRANSMISSION FEE

The cost of telehealth equipment and transmission is not reimbursable by SoonerCare.

SOURCE: OK Admin. Code Sec. 317:30-3-27(e)(4). (Accessed Sept. 2022).

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Oregon

Last updated 08/23/2022

POLICY

To encourage the efficient use of resources and to …

POLICY

To encourage the efficient use of resources and to promote cost-effective procedures in accordance with ORS 413.011 (1)(L), the Oregon Health Authority shall reimburse the cost of health services delivered using telemedicine, including but not limited to:

  • Health services transmitted via landlines, wireless communications, the Internet and telephone networks;
  • Synchronous or asynchronous transmissions using audio only, video only, audio and video and transmission of data from remote monitoring devices; and
  • Communications between providers or between one or more providers and one or more patients, family members, caregivers or guardians.

The authority shall pay the same reimbursement for a health service regardless of whether the service is provided in person or using any permissible telemedicine application or technology.

SOURCE: OR Statute 414.723. (Accessed Aug. 2022).

“Synchronous” means an interaction between a provider and a member that occurs at the same time using an interactive technology.  This may include audio only, video only, or audio and video and may include transmission of data from remote monitoring.

Communications may be between providers, or be between one or more providers and one or more patients, family members /caregivers /guardians.

SOURCE: OAR 410-141-3566, Health Systems Division: Medical Assistance, Oregon Health Plan, Telehealth Service and Reimbursement Requirements. (Accessed Aug. 2022) & OAR 410-120-1990 Health Systems Division: Medical Assistance Programs, Telehealth. (Accessed Aug. 2022).

Patient consultations using videoconferencing, a synchronous (live two-way interactive) video transmission resulting in real time communication between a provider located in a distant site and the recipient being evaluated and located in an originating site, is covered when billed services comply with the billing requirements. See OAR for billing requirements.

SOURCE: OR OAR 410-172-0850, Health Systems Division: Medical Assistance Programs, Medicaid Payment for Behavioral Health Services, Telemedicine for Behavioral Health. (Accessed Aug. 2022).

Telehealth for School Based Health Services (SBHS) is a real time interactive and synchronous audio/video technology from site to site regarding a Medicaid-eligible child’s health-related service. Telehealth is the equivalent to face-to-face therapy/treatment between a licensed practitioner/clinician or under the supervision of a practitioner/clinician within the scope of practice.

SOURCE: OR OAR 410-133-0040, Health Systems Division: Medical Assistance Programs, School-Based Health Services (Accessed Aug. 2022).

Coordinated Care Organizations

CCOs shall provide reimbursement for telemedicine or telehealth services and reimburse Certified and Qualified Health Care Interpreters (HCIs) as defined in OAR 333-002-0010 for interpretation services provided via telemedicine at the same reimbursement rate as if it were provided in person. This requirement does not supersede the CCOs direct agreement(s) with providers, including but not limited to, alternative payment methodologies, quality and performance measures or Value Based Payment methods described in the CCO contract. However, nothing either in this requirement or within CCO direct agreement(s) with providers referenced herein supersedes any federal or state requirements with regard to the provision and coverage of health care interpreter services.

SOURCE: OAR 410-141-3566. Health Systems Division: Medical Assistance Programs, Oregon Health Plan, Telemedicine and Telehealth Delivered Health Service and Reimbursement Requirements. (Accessed Aug. 2022).


ELIGIBLE SERVICES/SPECIALTIES

Teledentistry

Teledentistry is allowed. All billing requirements apply to all modalities (live video, store and forward, remote patient monitoring and mobile communication devices). Payment for dental services may not distinguish between services performed using teledentistry, real time, or store-and-forward and services performed in-person.  The dentist who completes diagnosis and treatment planning and the oral evaluation documents these services using the traditional CDT codes, and also reports D9995 or D9996 as appropriate.  An assessment-D0191 is a limited inspection performed to identify possible signs of oral or systemic disease, malformation or injury, and the potential need for referral for diagnosis and treatment. This code may be billed using the modality of teledentistry:

  • When D0191 is reported in conjunction with an oral evaluation (D0120-D0180) using teledentistry, D0191 shall be disallowed even if done by a different provider;
  • The assessment and evaluation may not be billed or covered by both the originating site dental care provider and a distant site dentist using the modality of teledentistry, even if due to store-and-forward review, if the dates of services are on different days.

SOURCE: OR OAR 410-123-1265, Health Systems Division: Medical Assistance Programs, Oregon Health Plan, Teledentistry. (Accessed Aug. 2022).

Behavioral Health

Behavioral health services identified as allowable for telephonic delivery are listed in the fee schedule. See fee schedule for list of covered telehealth services.

For purposes of behavioral health services, the Authority shall provide coverage for telemedicine services to the same extent that the services would be covered if they were provided in person.

SOURCE: OR OAR 410-172-0850, Health Systems Division: Medical Assistance Programs, Medicaid Payment for Behavioral Health Services, Telemedicine for Behavioral Health, (Accessed Aug. 2022).

Behavioral Health Resource Networks

A comprehensive BHRN must include at minimum the required services below to be funded by the OAC. These services may be provided by one or more entities who refer between and collaborate with each other. To be a BHRN, a BHRN must provide, and maintain sufficient capacity to provide, the following services and supports to individuals who use substances that cause harm or have a substance use disorder in the BHRN’s county or region:

  • Services must be offered face-to-face or through telehealth. The modality must be based on the needs and preference of the individual as well as any safety concerns identified by the individual or the BHRN.

See rule for additional information.

SOURCE: OR OAR 944-001-0020, Oversights and Accountability Council, Behavioral Resource Networks, (Accessed Aug. 2022). 

School Based Health Services

Oregon Health Authority reimburses for all the same covered services outlined in OAR 410-133-0080 when furnished through telehealth (See OAR 410-133-0080):

The Authority may reimburse telehealth, tele-electronic/telephonic School-Based Health Services (SBHS) provided to the same extent the services would be covered if they were provided in person and billed to Medicaid using appropriate SBHS procedure codes and modifiers.

For services covered using synchronous audio and video with modifiers GT, the Division will cover the same services provided by synchronous audio (e.g. telephone), when billed with the same codes but without modifier GT when provision of the same service via synchronous audio and video is not available or feasible, when the patient declines to enable video, or necessary consents cannot reasonably be obtained with appropriate documentation in the child/student’s plan of care.

SOURCE: OR OAR 410-133-0080, Health Systems Division: Medical Assistance Programs, School-Based Health Services, Coverage (Accessed Aug. 2022).

Reproductive Health Access Program

Covered services provided by telehealth technology may be billed to the RH Program, as appropriate. The CVR must indicate that the visit was conducted via telehealth. All telehealth visits must adhere to applicable state and federal telehealth regulations.

SOURCE: OR OAR 333-004-3110, RH Access Fund Billing and Claims (Accessed Aug. 2022).

Coordinated Care Organizations

CCOs shall ensure that telemedicine or telehealth services provided are culturally and linguistically appropriate as described in the relevant standards:

  • National Culturally and Linguistically Appropriate Services (CLAS) Standards;
  • Tribal based practice standards;
  • Trauma-informed approach to care as defined in 410-141-3500.

CCOs shall ensure that providers offer meaningful access to health care services for members and their families who experience LEP or hearing impairments by working with qualified or certified health care interpreters to provide language access services as described in OAR 333-002-0040. Such services shall not be significantly restricted, delayed, or inferior as compared to programs or activities provided to English proficient individuals.

CCOs shall ensure that providers collaborate with members to identify modalities for delivering health care services which best meets the needs of the member and considers the member’s choice and readiness for the modality of service selected.

SOURCE: OAR 410-141-3566. Health Systems Division: Medical Assistance Programs, Oregon Health Plan, Telemedicine and Telehealth Delivered Health Service and Reimbursement Requirements. (Accessed Aug. 2022).

Newborn Nurse Home Visiting Service Requirements

If a family declines home visiting services in their home, an alternate location may be offered, and telemedicine services must be offered and delivered in accordance with ORS 743A.058. Declination of home visiting services in the home must be documented in the client’s medical record.

SOURCE: OAR 333-006-0120, Health Systems Division: Public Health Division, Universally Offered Newborn Nurse Home Program, (Accessed Aug. 2022).


ELIGIBLE PROVIDERS

Telehealth providers shall meet the following requirements:

Shall be enrolled with the Authority as an Oregon Health Plan (OHP) provider, per 410-120-1260.

Shall provide services via telehealth that are within their respective certification or licensing board’s scope of practice and comply with telehealth requirements including, but not limited to:

  • Documenting patient and provider agreement of consent to receive services;
  • Allowed physical location of provider and patient;
  • Establishing or maintaining an appropriate provider-patient relationship.

SOURCE: OAR 410-120-1990, Health Systems Division: Medical Assistance Programs, Telehealth.  (Accessed Aug. 2022).

Dentists providing Medicaid services must be licensed to practice dentistry within the State of Oregon or within the contiguous area of Oregon and must be enrolled as a Health Systems Division (Division) provider.  Providers billing covered teledentistry/telehealth services are responsible for complying with specific standards.  See rule for teledentistry/telehealth services requirements for providers billing.

SOURCE: OR OAR 410-123-1265, Health Systems Division: Medical Assistance Programs, Oregon Health Plan, Teledentistry. (Accessed Aug. 2022).

See rule for requirements for providers billing behavioral health services.

SOURCE: OAR 410-172-0850, Health Systems Division: Medical Assistance Programs, Medicaid Payment for Behavioral Health Services, Telemedicine for Behavioral Health). (Accessed Aug. 2022).

School Based Health Services

Must be provided by a licensed practitioner/clinician employed by or contracted by an Oregon public school district or Education Service District, enrolled with Oregon Health Authority (OHA) as a “school medical (SM)” provider with authority to provide SBHS to Oregon Medicaid beneficiaries. Must also be performed by or under a supervising licensed practitioner/clinician within the scope of practice governed by their licensing board, who meet the federal requirements as described in medically qualified staff in OAR 410-133-0120, and who hold a current and valid license without restriction from a state licensing board where the provider is located. See OAR 410-133-0140 for additional provider requirements.

SOURCE: OR OAR 410-133-0080, Health Systems Division: Medical Assistance Programs, School-Based Health Services, Definitions (Accessed Aug. 2022).

CCOs shall provide reimbursement for telemedicine or telehealth services and reimburse Certified and Qualified Health Care Interpreters (HCIs) as defined in OAR 333-002-0010 for interpretation services provided via telemedicine at the same reimbursement rate as if it were provided in person. This requirement does not supersede the CCOs direct agreement(s) with providers, including but not limited to, alternative payment methodologies, quality and performance measures or Value Based Payment methods described in the CCO contract. However, nothing either in this requirement or within CCO direct agreement(s) with providers referenced herein supersedes any federal or state requirements with regard to the provision and coverage of health care interpreter services.

CCOs shall ensure that providers offer meaningful access to telemedicine/telehealth services by completing a capacity assessment of members in the use of specific approved methods of telemedicine or telehealth delivery that comply with accessibility standards including alternate formats, and provides the optimal quality of care for the member given considerations of member access to necessary devices, access to a private and safe location, adequate internet, digital literacy, cultural appropriateness of telemedicine or telehealth services, and other considerations of member readiness to use telemedicine or telehealth.

SOURCE: OAR 410-141-3566, Health Systems Division: Medical Assistance Programs, Oregon Health Plan, Telemedicine and Telehealth Delivered Health Service and Reimbursement Requirements. (Accessed Aug. 2022).


ELIGIBLE SITES

The patient may be in the community or in a health care setting.

The provider may be in any location in which appropriate privacy and confidentiality can be ensured.

SOURCE: OAR 410-120-1990, Health Systems Division: Medical Assistance Programs, Telehealth. (Accessed Aug. 2022).

The authority shall include the costs of telemedicine services in its rate assumptions for payments made to clinics or other providers on a prepaid capitated basis.

SOURCE: OR Statute Ch. 414 & House Bill 2508 (2021 Session), (Accessed Jan. 2022).

School-Based Health Services

Telehealth may occur between an alternate site such as the child/student’s home, childcare facility, or other public education programs and settings, and the distant site setting of the practitioner/clinician. Telehealth can be interactive audio/telephonic services provided to a child/student in a geographical area where synchronous audio and video is not available or consent for audio/video is refused for services provided to a child/student. Telehealth may include coordinated care defined in Definitions 410-133-0040(16).

SOURCE: OR OAR 410-133-0040, Health Systems Division: Medical, School-Based Services.  (Accessed Aug. 2022).

The originating site may bill a CDT code only if a separately identifiable service is performed within the scope of practice of the practitioner providing the service. The service must meet all criteria of the CDT code billed.

SOURCE: OR OAR 410-123-1265, Health Systems Division: Medical Assistance Programs, Oregon Health Plan, Teledentistry. (Accessed Aug. 2022).


GEOGRAPHIC LIMITS

No Reference Found


FACILITY/TRANSMISSION FEE

The originating site code Q3014 is covered only when the patient is present in an appropriate health care setting and receiving services from a provider in another location.

SOURCE: Oregon Health Authority, Health Evidence Review Commission, Guideline Note Changes for the January 1, 2022 Prioritized List of Health Services, p. AD-3. (8/2/22). (Accessed Aug. 2022).

 

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Pennsylvania

Last updated 09/06/2022

POLICY

For FQHCs & RHCs

Telepsychiatry Services – Only applicable …

POLICY

For FQHCs & RHCs

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

SOURCE: PA PROMISe, 837 Professional/CMS-1500 Claim Form, Provider Handbook, Appendix E – FQHC/RHC. p. 10 (Apr. 22, 2014). (Accessed Sept. 2022).

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

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

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


ELIGIBLE SERVICES/SPECIALTIES

Effective, September 30, 2021, the MA Program will pay for MA covered services rendered to beneficiaries via telemedicine when clinically appropriate and allowable according to the provider’s scope of practice. Services rendered via telemedicine must be provided according to the same standard of care as if delivered in-person. Providers are encouraged to establish protocols for the use of telemedicine.

Limited English Proficiency

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

SOURCE: PA Department of Human Services, Medical Assistance Bulletin 99-22-02, p. 3-4, May 6, 2022  & PA Department of Human Services, Office of Mental Health and Substance Abuse Services Bulletin OMHSAS-22-02, p. 6, July 1, 2022, (Accessed Sept. 2022).

MA covered services rendered via telemedicine in the FFS delivery system will be paid at the same rate as if they were rendered in-person. Providers are to use Place of Service (POS) 02 (telemedicine) to identify services that are rendered via telemedicine. Providers are to indicate in the beneficiary’s medical record when telemedicine services are rendered via audio-only.

When the beneficiary accesses services at an enrolled originating site, the provider serving as the originating site may bill for the technology service using the telehealth originating site procedure code Q3014 only. MA Providers may not bill procedure code Q3014 in addition to an office visit that is provided at the originating site.

PA Medical Assistance Program has a fee schedule that lists codes eligible to be performed using interactive telecommunication technology.

SOURCE: PA Department of Human Services, Medical Assistance Bulletin 99-22-02, p. 4-5, May 6, 2022, (Accessed Sept. 2022).

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

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

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

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

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

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

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


ELIGIBLE PROVIDERS

Licensed Practitioners

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

Provider Agencies

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

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

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

SOURCE:  PA PROMISe, 837 Professional/CMS-1500 Claim Form, Provider Handbook, Appendix E – FQHC/RHC. p. 10 (Apr. 22, 2014). (Accessed Sept. 2022).

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

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

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

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


ELIGIBLE SITES

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

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

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

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

The originating site is where the beneficiary is located at the time the MA covered service is rendered to them via telemedicine. The originating site can be, but is not limited to the beneficiary’s home, a provider’s office, clinic, nursing facility, or other medical facility site. When the originating site is a provider’s office, clinic, nursing facility or other medical facility, staff at the originating site should be trained to assist beneficiaries with the use of the telemedicine equipment and available to provide in-person clinical intervention, if needed. The provider may bill the telehealth originating site facility fee (procedure code Q3014) for the use of their office if no other MA covered service is provided at the originating site.

Providers should obtain the location of the beneficiary at the time each service is rendered via telemedicine should there be a need for emergency medical services.

SOURCE: PA Department of Human Services, Medical Assistance  Bulletin 99-22-02 (May 6, 2022), (Accessed Sept. 2022).

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

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

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

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


GEOGRAPHIC LIMITS

Access to Services Delivered In-Person

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

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

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

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


FACILITY/TRANSMISSION FEE

The provider may bill the telehealth originating site facility fee (procedure code Q3014) for the use of their office if no other MA covered service is provided at the originating site.

SOURCE: PA Department of Human Services, Medical Assistance Bulletin 99-22-02, p. 4, May 6, 2022, (Accessed Sept. 2022).

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Rhode Island

Last updated 07/20/2022

POLICY

Each health insurer [includes Medicaid] that issues individual or …

POLICY

Each health insurer [includes Medicaid] that issues individual or group accident and sickness insurance policies for healthcare services and/or provides a healthcare plan for healthcare services shall provide coverage for the cost of such covered healthcare services provided through telemedicine services, as provided in this section.

SOURCE: Rhode Island General Laws Sec. 27-81-4. (Accessed Jul. 2022).


ELIGIBLE SERVICES/SPECIALTIES

 A health insurer [includes Medicaid] shall not exclude a healthcare service for coverage solely because the healthcare service is provided through telemedicine and is not provided through in-person consultation or contact, so long as such healthcare services are medically necessary and clinically appropriate to be provided through telemedicine services.

“Medically necessary” means medical, surgical, or other services required for the prevention, diagnosis, cure, or treatment of a health-related condition, including services necessary to prevent a decremental change in either medical or mental health status.

SOURCE: Rhode Island General Laws Sec. 27-81-3 & 27-81-4, (Accessed Jul. 2022).

Rhode Island Medicaid’s fee schedule lists several telehealth service CPT codes for outpatient visits and limited emergency department inpatient telehealth consultations under procedure/professional services.  Reimbursement is available for initial inpatient telehealth consultation and follow-up inpatient telehealth consultation.  See their fee schedule look-up tool and telehealth specific codes, including G0406, G0407, G0408, G0425, G0426, G0427.

SOURCE: RI Department of Health. Medicaid Fee Schedule Look-Up. (Accessed Jul. 2022).


ELIGIBLE PROVIDERS

All medically necessary and clinically appropriate telemedicine services delivered by in-network primary care providers, registered dietitian nutritionists, and behavioral health providers shall be reimbursed at rates not lower than services delivered by the same provider through in-person methods.

SOURCE: Rhode Island General Laws Sec. 27-81-4, (Accessed Jul. 2022).


ELIGIBLE SITES

“Originating site” means a site at which a patient is located at the time healthcare services are provided to them by means of telemedicine, which can include a patient’s home where medically necessary and clinically appropriate.

SOURCE: Rhode Island General Laws Sec. 27-81-3, (Accessed Jul. 2022).

New Place of Service Code

Due to recent changes made by Medicare, effective as of April 4, 2022 the Rhode Island Executive Office of Health & Human Services (EOHHS) is adding Place of Service Code 10 (Telehealth Provided in Patient’s Home) as a telehealth place of service for Fee-for-Service and Managed Care. Please submit telehealth claims with Place of Service Code 02 (Telehealth Provided Other than in Patient’s Home) or Place of Service Code 10 (Telehealth Provided in Patient’s Home) as applicable.

Fee-for-Service Providers should submit telehealth claims with the applicable Place of Service Code 10 for dates of service of April 4, 2022 forward.

SOURCE: Rhode Island Medicaid Program, Provider Update, Jul. 2022 . (Accessed Jul. 2022).


GEOGRAPHIC LIMITS

No Reference Found


TRANSMISSION FEE

No Reference Found

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South Carolina

Last updated 08/12/2022

POLICY

South Carolina Medicaid will reimburse for live video and …

POLICY

South Carolina Medicaid will reimburse for live video and covers telemedicine when the service is medically necessary and under the following circumstances:

  • The medical care is individualized, specific, and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the beneficiary’s need; and
  • The medical care can be safely furnished, and no equally effective and more conservative or less costly treatment is available statewide.

SOURCE: SC Health and Human Svcs. Dept. Physicians Provider Manual, p. 31 (July 2022). (Accessed Aug. 2022).

If there are technological difficulties in performing a medical assessment or problems in a beneficiaries’ understanding of telemedicine, face-to-face care must be provided instead.

SOURCE: SC Health and Human Svcs. Dept. Physicians Provider Manual, p. 30 (July 2022). (Accessed Aug. 2022).

Telemedicine equipment and transmission must permit encrypted transmission and the speed and image resolution must be technically sufficient to support the service billed. Staff involved in a telemedicine visit must be trained in the use of the telemedicine equipment and component in its operation.

Reimbursement to the health professional delivering the medical service is the same as the current fee schedule amount for the service provided. See appropriate professional manuals for CPT codes. Codes must be billed along with the telemedicine GT modifier.

Telepsychiatry

To qualify for reimbursement, interactive audio and video equipment that permits two-way real-time or near real-time communication with the client, consultant, interpreter, and referring clinician.

Additional requirements include:

  • Reimbursement requires the “real-time” presence of a client.
  • Reimbursement is available for psychiatric diagnosis assessment with Medicaid and medical evaluation and management codes.
  • GT modifier must be used when billing the for telepsychiatric services.
  • All equipment must operate at a minimum communication transfer rate of 384 kbps.
  • Telepsychiatry reimbursement is not available for the following MH services; injectable, NS, CI Individual Family, Group and Multiple FP and Psychological Testing which require “hands on” encounters, Mental Health Assessment by Non-Physician and SPD.

SOURCE: SC Health and Human Svcs. Dept. Community Mental Health Services Provider Manual, p. 20. (July 2022). (Accessed Aug. 2022). 


ELIGIBLE SERVICES/SPECIALTIES

Eligible services include consultation, diagnostic, and treatment services:

  • Office or other outpatient visits;
  • Inpatient consultation;
  • Individual psychotherapy;
  • Psychiatric diagnostic interview examination;
  • Neurobehavioral status examination;
  • Electrocardiogram interpretation and report only;
  • Echocardiography.

Services provided by allied health professionals are not covered.

Telemedicine services are not an expansion of covered services, but an option for the delivery of certain covered services.

SOURCE: SC Health and Human Svcs. Dept. Physicians Provider Manual, p. 31, 32 & 159 (July 2022). (Accessed Aug 2022).

Local education manual refers providers to the physician Services Provider Manual for information regarding coverage and billing for telemedicine.

SOURCE: SC Health and Human Svcs. Dept. Local Education Provider Manual, p. 21. (July 2022). (Accessed Aug. 2022).

Medicaid Targeted Case Management
Electronic visual encounters (e.g., Skype, teleconferencing or other media) with the beneficiary are not considered a face-to-face contact and will be reimbursed at the T1016 MTCM encounter rate.

SOURCE: SC Health and Human Svcs. Dept., Medicaid Targeted Case Management Provider Guide, p. 21 (Apr. 2021). (Accessed Aug 2022).

Telepsychiatry
Psychiatric Diagnostic assessment with medical services to assess or monitor the client’s psychiatric and/or physiological status may be provided via live video telepsychiatry. See manual for specific requirements.

SOURCE:  SC Health and Human Svcs. Dept. Community Mental Health Services Provider Manual, p. 20 (July 2022). (Accessed Aug. 2022). 

Autism Spectrum Disorder
Telehealth is not covered.

SOURCE: SC Health and Human Svcs. Autism Spectrum Disorder Provider Manual, p. 19 (Apr. 2021). (Accessed Aug. 2022).

Dental Telephonic or Telehealth Encounters
As of July 1, 2021, patient triage and care coordination via telephonic or telehealth encounter, along with oral evaluations performed in conjunction with the telehealth encounters, will no longer be allowed.

SOURCE: SC Health and Human Svcs. Dental Services Provider Manual. (Jan. 2022), Pg. 82. (Accessed Aug. 2022).


ELIGIBLE PROVIDERS

Distant site eligible, reimbursed providers:

  • Physicians;
  • Nurse practitioners;
  • Physician Assistants.

A consultant site means the site at which the specialty physician or practitioner providing the medical care is located at the time the service is provided via telemedicine. The health professional providing the medical care must be currently and appropriately licensed in South Carolina and located within the South Carolina Medical Service Area (SCMSA), which is defined as the State of South Carolina and areas in North Carolina and Georgia within 25 miles of the South Carolina State border.

SOURCE: SC Health and Human Svcs. Dept. Physicians Provider Manual, p. 30. (July 2022) (Accessed Aug 2022).

The RHCs and FQHCs would bill an encounter code when operating as the consulting site. Only one encounter code can be billed for a DOS. Both provider types will use the appropriate encounter code for the service along with the “GT” modifier (via interactive audio and video telecommunications system) indicating interactive communication was used.

SOURCE: SC Health and Human Svcs. Dept. Physicians Provider Manual, p. 215. (July 2022). (Accessed Aug. 2022).


ELIGIBLE SITES

Eligible originating (referring) sites:

  • Practitioner offices (physician, NP, CNM or PA);
  • Hospitals (inpatient and outpatient);
  • Rural Health Clinics;
  • Federally Qualified Health Centers;
  • Community Mental Health Centers;
  • Public Schools;
  • Act 301 Behavioral Health Centers.

Referring sites (also known as originating sites) must be located in the South Carolina Medical Service Area, which is the state of SC and areas in NC and GA within 25 miles of the SC border.

SOURCE: SC Health and Human Svcs. Dept., Physicians Provider Manual, p. 30 (July 2022). (Accessed Aug 2022).

Local Education Agency Manual refers providers to the Physician Manual Policy.

SOURCE: Local Education Manual, p. 21. (July 2022). (Accessed Aug. 2022).

An appropriate certified or licensed health care professional at the referring site is required to present (patient site presenter) the beneficiary to the physician or practitioner at the consulting site and remain available as clinically appropriate.

SOURCE: SC Health and Human Svcs. Dept. Physicians Provider Manual, p. 32 (July 2022). (Accessed Aug 2022).


GEOGRAPHIC LIMITS

A consultant site means the site at which the specialty physician or practitioner providing the medical care is located at the time the service is provided via telemedicine. The health professional providing the medical care must be currently and appropriately licensed in South Carolina and located within the South Carolina Medical Service Area (SCMSA), which is defined as the State of South Carolina and areas in North Carolina and Georgia within 25 miles of the South Carolina State border.


FACILITY/TRANSMISSION FEE

The referring site is only eligible to receive a facility fee for telemedicine services. Claims are submitted with HCPCS code. If a provider from the referring site performs a separately identifiable service for the beneficiary on the same day as telemedicine, documentation for both services must be clearly and separately identified in the beneficiary’s medical record, and both services are eligible for full reimbursement.

RHCs and FQHCs are eligible to receive a facility fee for telemedicine services when operating as the referring site. They may not bill the encounter code if these are the only services being rendered.

Hospital providers are eligible to receive a facility fee for telemedicine when operating as the referring site. Claims must be submitted with the appropriate telemedicine revenue code.

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South Dakota

Last updated 08/19/2022

POLICY

Services provided via telemedicine are subject to the same …

POLICY

Services provided via telemedicine are subject to the same service requirements and limitations as in-person services.

These coverage requirements apply for telemedicine services in SD Medicaid:

  • The provider must be properly enrolled;
  • Services must be medically necessary;
  • The recipient must be eligible; and
  • If applicable, the service must be prior authorized.

The manual also includes non-discrimination requirements providers must abide by.

Providers must bill for services at their usual and customary charge. Providers are reimbursed the lesser of their usual and customary charge or the fee schedule rate.  Reimbursement for distant site telemedicine services is limited to the individual practitioner’s professional fees or the encounter rate if the service qualifies as an FQHC/RHC or IHS/Tribal 638 clinic service. The maximum allowable amount for services provided via telemedicine is the same as services provided in-person.

See Appendix of manual for complete list of CPT codes, but please note that current version of this manual includes services that are only being covered on a temporary basis.

SOURCE: SD Medicaid Billing and Policy Manual: Telemedicine, p. 3, 11 & 13 (May. 2022) (Accessed Aug. 2022).


ELIGIBLE SERVICES/SPECIALTIES

See manuals for specific CPT codes in Appendix.  Services not specifically listed as covered in the procedure code table in the Appendix are considered non-covered.

SOURCE: SD Medicaid Billing and Policy Manual: Telemedicine, p. 8, 13-22 (May. 2022) (Accessed Aug. 2022).

Community health worker services can be provided via telemedicine.

SOURCE: SD Medicaid Billing and Policy Manual: Community Health Worker, pg. 9-10, (Jun. 2022). (Accessed Aug. 2022).

Speech language pathologist services can be provided via telemedicine for adults, in schools, and for infants ages 0-3.

SOURCE: SD Medicaid Billing and Policy Manual:  Birth to Three Non-School District Providers, p. 3, (Oct. 2021), School Districts, pg. 4, (Jun. 2022), & Therapy Services pg. 4 (Aug. 2022). (Accessed Aug. 2022)

Psychotherapy is allowed to be provided via telehealth.

SOURCE: SD Medicaid Billing and Policy Manual: Independent Mental Health Practitioners, pg. 13, (Dec. 2021), (Accessed Aug. 2022).

An encounter for the initial ordering of durable medical equipment may occur through telehealth.

SOURCE: SD Medicaid Billing and Policy Manual: Durable Medical Equipment, Prosthetics, Orthotics and Supplies, pg. 2. Jul. 2022. (Accessed Aug. 2022).

Speech therapy services may be provided via telemedicine after an initial face-to-face contact and once every 90 days thereafter.

SOURCE: SD Medicaid Billing and Policy Manual: Telemedicine, p. 4 (May. 2022). (Accessed Aug. 2022).

A face-to-face encounter for physician recertification for hospice may occur via telemedicine.

SOURCE: SD Medicaid Billing and Policy Manual: Hospice, p. 2 (Aug. 2022), (Accessed Aug. 2022).

Telemedicine consultations are covered as outpatient hospital services.

SOURCE: SD Medicaid Billing and Policy Manual: Outpatient Hospital Services, p. 2 (Mar. 2022), (Accessed Aug. 2022).

Applied Behavior Analysis

South Dakota Medicaid has added temporary coverage of ABA services provided via telemedicine for recipients and providers at high risk for COVID-19, under quarantine, or social distancing during a declared emergency for COVID-19.

SOURCE: SD Medicaid Billing and Policy Manual: Applied Behavior Analysis, p. 7 (Apr. 2022). (Accessed Aug. 2022).

Therapy Services

South Dakota Medicaid has added temporary coverage of therapy services provided via telemedicine for recipients and providers at a high risk for COVID-19, under quarantine, or social distancing during a declared emergency for COVID-19, only if the recipient and provider have previously met for in-person services.

SOURCE: SD Medicaid Billing and Policy Manual: Therapy Services, p. 8 (Aug. 2021). (Accessed Aug. 2022).

Teledentistry

Services provided via teledentistry must meet the applicable standard of care. When reporting a service completed via teledentistry, providers are certifying the services rendered to the recipient were functionally equivalent to services provided through a face-to-face visit. Services provided via teledentistry must be provided in accordance with the coverage criteria in the dental provider manuals. Synchronistic services must be of sufficient audio and visual fidelity and clarity to be functionally equivalent to a face-to-face encounter.  See manual for limitations and covered CDT codes.

SOURCE: SD Medicaid Billing and Policy Manual, Teledentistry Services, p. 2, (Oct. 2021), & Telemedicine and Telephonic Services Updates Bulletin July 2, 2021, (Accessed Aug. 2022).

Home Health

For the initial order for home health services, a physician or other licensed practitioner must document a face-to-face encounter related to the primary reason the beneficiary requires the services. The encounter may occur through telehealth.

SOURCE: SD Medicaid Billing and Policy Manual: Home Health Agency Services, p. 2-3 (Mar 2022). (Accessed Aug. 2022).


ELIGIBLE PROVIDERS

The following providers can provide services via telemedicine at a distant site:

  • Certified Social Worker (PIP or PIP Candidate)
  • Clinical Nurse Specialist
  • Community Health Worker
  • Community Mental Health Centers (CMHC)
  • Dentists
  • Diabetes Education Programs
  • Dietitians
  • Federally Qualified Health Centers (FQHC)
  • Indian Health Services Clinics
  • Licensed Marriage and Family Therapists
  • Licensed Professional Counselor (MH or working toward MH designation)
  • Nurse Practitioners
  • Nutritionists
  • Physicians
  • Physician Assistants
  • Podiatrists
  • Psychologist
  • Rural Health Clinic (RHC)
  • Speech Language Pathologists
  • Substance Use Disorder Agencies
  • Tribal 638 facilities

* Audiologists, occupational therapists, physical therapists and optometrists are listed as temporarily allowed during COVID-19 PHE in the provider manual, but are not permanent eligible providers.

Unless prohibited by law or regulation the distant site location may be a provider’s home. South Dakota Medicaid does not require the distant site location be listed on their provider enrollment record. All services provided via telemedicine at a distant site must be billed with the GT modifier in the first modifier position to indicate the service was provided via telemedicine.

SOURCE: SD Medicaid Billing and Policy Manual: Telemedicine, p. 1 – 4 (Aug. 2022). (Accessed Aug. 2022).

Speech therapy services may be provided via telemedicine once an initial in-person contact has been completed. An in-person contact must occur every 90 days thereafter. The telemedicine service must be provided by means of “real-time” interactive telecommunications system.

SOURCE: SD Medicaid Billing and Policy Manual: Therapy Services, pg. 7-8,  (Aug. 2022), (Accessed Aug. 2022).

Indian Health Services and Tribal 638 Providers

IHS/Tribal 638s may also provide distant site telemedicine services. The services rendered by the contracted provider are reimbursed through their contract with IHS and may not be billed directly to Medicaid.

“Encounter,” a face-to-face or telemedicine contact between a health care professional and a Medicaid recipient for the provision of Medicaid or CHIP services through an IHS or Tribal 638 facility within a 24-hour period ending at midnight.

SOURCE: SD Medicaid Billing and Policy Manual:  IHS and Tribal 638 Providers, p. 5 & 12 & 14, (Jun. 2022), (Accessed Aug. 2022).

FQHC/RHCs are eligible to serve as an originating site for telemedicine services and may also provide distant site telemedicine services. An originating site is the physical location of the Medicaid recipient at the time the service is provided. A distant site is the physical location of the practitioner providing the service via telemedicine.

SOURCE: SD Medicaid Billing and Policy Manual:  FQHC and RHC Services, pg. 6, (Jun. 2022)  (Accessed Aug. 2022).


ELIGIBLE SITES

Effective July 1, 2021, South Dakota Medicaid removed the same community restrictions for telemedicine services. Previously if a provider and recipient were both located in the same community, services were not covered via telemedicine unless one of the stated exceptions was met. The decision of whether it is appropriate to deliver the service via telemedicine should be determined by the provider and the recipient.

Originating sites listed in the eligible provider section are eligible to receive a facility fee for each completed telemedicine transaction for a covered distant site telemedicine service. Sites not listed may also serve as an originating site but are not eligible for a facility fee reimbursement. Originating site are not reimbursed for any additional costs associated with equipment, technicians, technology, or personnel utilized in the performance of the telemedicine service. Originating sites must be enrolled with South Dakota Medicaid.

A home can be an originating site but is not eligible for reimbursement of the originating site fee.

For distant site services billed on a CMS 1500 or 837P providers must bill;

  • “02” for telemedicine services provided other than in patient’s home;
  • “10” for telemedicine services provided in the patient’s home; or
  • “77” for audio-only services.

SOURCE: SD Medicaid Billing and Policy Manual: Telemedicine, p. 1, 3 & 11 (May 2022). (Accessed Aug. 2022).

FQHC/RHCs are eligible to serve as an originating site for telemedicine services. An originating site is the physical location of the Medicaid recipient at the time the service is provided.

SOURCE: SD Medicaid Billing and Policy Manual:  FQHC and RHC Services, pg. 6, 14, (Oct. 2021)  (Accessed Jan. 2022).

Indian Health Services and Tribal 638 Providers

IHS and Tribal 638 facilities are eligible to serve as an originating site for telemedicine services.

SOURCE: SD Medicaid Billing and Policy Manual:  IHS and Tribal 638 Providers, p. 5, (Jun. 2022), (Accessed Aug. 2022).


GEOGRAPHIC LIMITS

Effective July 1, 2021, South Dakota Medicaid removed the same community restrictions for telemedicine services. Previously if a provider and recipient were both located in the same community, services were not covered via telemedicine unless one of the stated exceptions was met. The decision of whether it is appropriate to deliver the service via telemedicine should be determined by the provider and the recipient.

SOURCE: SD Medicaid Billing and Policy Manual: Telemedicine, p. 3 (May. 2022), & Telemedicine and Telephonic Services Updates Bulletin July 2, 2021, (Accessed Aug. 2022).


FACILITY/TRANSMISSION FEE

Certain originating sites are eligible for a facility fee and are:

  • Office of a physician or practitioner
  • Outpatient Hospital
  • Critical Access Hospital
  • Rural Health Clinic
  • Federally Qualified Health Center
  • Indian Health Services Clinic
  • Community Mental Health Center
  • Substance use disorder agency
  • Nursing Facilities
  • Schools
Originating site are not reimbursed for any additional costs associated with equipment, technicians, technology, or personnel utilized in the performance of the telemedicine service. A recipient’s home is not eligible for reimbursement of an originating site facility fee. For group services with multiple recipients in the same originating site location, only one originating site fee is billable per physical location of the recipients. For Division of Behavioral Health block grant contract providers, the originating site fee should only be billed to Medicaid if the group includes both Medicaid recipients and individuals ineligible for Medicaid. The originating site fee is not reimbursable for audio-only services and should not be billed for these services. An originating site fee also is not reimbursable if the service could be provided onsite at the originating site, but the service is being provided via telemedicine solely due to patient preference to see a provider that is not located at the originating site.

SOURCE: SD Medicaid Billing and Policy Manual: Telemedicine, p. 2-3; 9, 11. (May. 2022). (Accessed Aug. 2022).

Skilled Nursing Facility and Nursing Facility Services

The telemedicine originating site fee is reimbursed at the lesser of the provider’s usual and customary charge and the fee for HCPCS code Q3014 listed on the Physician Services Fee Schedule.  The telemedicine originating site fee must be billed using revenue code 780.

SOURCE: SD Medicaid Billing and Policy Manual: Skilled Nursing Facility and Nursing Facility Services, p. 10, (Jul. 2022), (Accessed Aug. 2022).

Teledentistry

Enrolled dental providers, such as a dental office, FQHC/RHC, or IHS facility, are eligible to receive an originating site facility fee for acting as an originating site if the service being provided from the distant site is a covered teledentistry service. Other sites not listed may also serve as an originating site but are not eligible for an originating site facility fee reimbursement. Asynchronous services are not eligible for an originating site fee. The maximum rate for originating site facility fee is listed on the physician fee schedule under procedure code Q3014. The facility fee is reimbursed on a fee for service basis for eligible encounter-based providers. There is no additional reimbursement for equipment, technicians, technology, or personnel utilized during services provided via teledentistry.  Originating site are not reimbursed for any additional costs associated with equipment, technicians, technology, or personnel utilized in the performance of the teledentistry service.

SOURCE: SD Medicaid Billing and Policy Manual, Teledentistry Services, p. 5 &6, (Oct. 2021), (Accessed Aug. 2022).

FQHC/RHC

A claim for a telemedicine originating site fee should be billed under the FQHC/RHC’s NPI. Payment is limited to the fee schedule amount.

SOURCE: SD Medicaid Billing and Policy Manual: FQHC and RHC Services, p. 10 (Jun. 2022). (Accessed Aug. 2022).

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Tennessee

Last updated 09/05/2022

POLICY

Telehealth Services

A health insurance entity (includes Medicaid) shall …

POLICY

Telehealth Services

A health insurance entity (includes Medicaid) shall provide coverage for healthcare services provided during a telehealth encounter in a manner that is consistent with what the health insurance policy or contract provides for in-person encounters for the same service, and shall reimburse for healthcare services provided during a telehealth encounter without distinction or consideration of the geographic location, or any federal, state, or local designation or classification of the geographic area where the patient is located. Any provisions not stipulated in the telehealth services section of the insurance code shall be governed by the terms and conditions of the health insurance contract.

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

SOURCE: TN Code Annotated, Title 56, Ch. 7, Part 1002 & Sec. 56-7-1012, (Accessed Sept. 2022).

Provider-based Telemedicine

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

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

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

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

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

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


ELIGIBLE SERVICES/SPECIALTIES

Telehealth Services

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

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

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

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

SOURCE: TN Code Annotated, Sec. 56-7-1002 & Sec. 56-7-1012, (Accessed Sept. 2022).

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

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

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

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

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

Mental Health & Substance Abuse Services

TennCare will reimburse for live video for crisis-related services or an assessment for emergency admission by an in-patient psychiatric facility.

Please see Telecommunications Guidelines for policy guidance.

SOURCE: TN Dept. of Mental Health and Substance Abuse Services. Office of Crisis Services and Suicide Prevention. Minimal Standards of Care.  p. 46 & 56, (2017) (Accessed Sept 2022).

SOURCE: TN Dept. of Mental Health and Substance Abuse Services. Office of Crisis Services Telecommunications Guidelines, p. 4 (2012) (Accessed Sept. 2022).


ELIGIBLE PROVIDERS

Provider based telemedicine

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

“Healthcare services provider” means an individual acting within the scope of a valid license issued pursuant to title 63 or title 68, chapter 24, part 6, or any state-contracted crisis service provider employed by a facility licensed under title 33 .

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

Telehealth Services

“Healthcare services provider” means an individual acting within the scope of a valid license issued pursuant to title 63 or any state-contracted crisis service provider employed by a facility licensed under title 33.

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


ELIGIBLE SITES

Telehealth Services

“Qualified site” means the office of a healthcare services provider, a hospital licensed under title 68, a facility recognized as a rural health clinic under federal Medicare regulations, a federally qualified health center, a facility licensed under title 33, or another location deemed acceptable by the health insurance entity; and

Includes, for the provision of behavioral health services provided via telehealth, the patient’s home or a remote location chosen by the patient.

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

Provider-Based Telemedicine

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

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

Mental Health & Substance Abuse Services

Crisis service providers may connect from:

  • Emergency departments;
  • Jails;
  • Detention centers; and
  • Other similar locations

All telehealth sites shall ensure that telehealth equipment is located in a space conducive to a clinical environment.

SOURCE: TN Dept. of Mental Health and Substance Abuse Services. Office of Crisis Services and Suicide Prevention. Minimal Standards of Care.  p. 46 & 50, (2017) (Accessed Nov. 2021) & TN Dept. of Mental Health and Substance Abuse Services. Office of Crisis Services Telecommunications Guidelines, p. 4 & 8, (2012) (Accessed Sept. 2022).


GEOGRAPHIC LIMITS

Reimbursement and coverage must be provided for telehealth services and provider based telemedicine without any distinction or consideration of the geographic location or any federal, state, or local designation, or classification of the geographic area where the patient is located.

SOURCE: TN Code Annotated, Title 56, Ch. 7, Part 1002, & Part 1003, (Accessed Sept. 2022).


FACILITY/TRANSMISSION FEE

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

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

 

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Texas

Last updated 09/07/2022

POLICY

Synchronous audiovisual technology between the distant site provider and …

POLICY

Synchronous audiovisual technology between the distant site provider and the client in another location is reimbursable under Texas Medicaid fee-for-service.

SOURCE: TX Medicaid Telecommunication Services Handbook, p. 13 (Sept. 2022) (Accessed Sept. 2022).

The executive commissioner by rule shall develop and implement a system to reimburse providers of services under Medicaid for services performed using telemedicine medical services, teledentistry dental services, or telehealth services.

SOURCE: TX Govt. Code Sec. 531.0216. (Accessed Sept. 2022).

Provider reimbursement for telemedicine services must be at the same rate as Medicaid reimburses for the same in-person medical service.  A request for reimbursement may not be denied solely because an in-person medical service between a physician and a patient did not occur.  The commission may not limit a physician’s choice of platform for providing a telemedicine medical service or telehealth service by requiring that the physician use a particular platform to receive reimbursement for the service.

SOURCE: TX Govt. Code Sec. 531.0217(d). (Accessed Sept. 2022).

Texas Medicaid managed care organiziations (MCOs) are prohibited from denying reimbursement for covered services solely because they are delivered remotely. MCOs must consider reimbursement for all medically necessary Medicaid-covered services that are provided using telemedicine or telehealth.

Texas Medicaid MCOs must determine whether to reimburse for a telemedicine or telehealth service based on clinical and cost effectiveness, among other factors.

Texas Medicaid MCOs cannot deny, limit, or reduce reimbursement for a covered health-care service or procedure based on the provider’s choice of telecommunications platform to provide the service or procedure using telemedicine or telehealth. Providers should refer to individual MCO policies for additional coverage information.

Clinical and cost effectiveness determinations that result in prohibiting a service from being delivered using a synchronous audio-only technology, or store and forward technology in conjunction with synchronous audio-only technology are not considered denying, limiting, or reducing reimbursement for a covered health care service.

Telemedicine and telehealth services are reimbursed in accordance with 1 TAC §355.

In the event of a Declaration of State of Disaster, HHSC will issue direction to providers regarding the use of telemedicine or telehealth services to include the use of a synchronous telephone (audio-only) platform to provide covered services outside of the allowances described herein to the extent permitted by Texas law.

Declaration of State of Disaster is when to an executive order or proclamation is issued by the governor declaring a state of disaster in accordance with Texas Government Code §418.014.

A valid practitioner-patient relationship must exist between the distant site provider and the patient receiving telemedicine services. A valid practitioner-patient relationship exists between the distant site provider and the patient if:

  • The distant site provider meets the same standard of care required for and in-person service.
  • The relationship can be established through:
    • A prior in-person service.
    • A prior telemedicine service that meets the delivery method requirements specified in Texas Occupations Code §111.005(a)(3).
    • The current telemedicine service that meets the delivery method requirements specified in Texas Occupations Code §111.005(a)(3).

The valid practitioner-patient relationship can be established through a call coverage agreement established in accordance with Texas Medical Board (TMB) administrative rules in 22 TAC §177.20.

SOURCE: TX Medicaid Telecommunication Services Handbook, Sept. 2022, p. 5, 7 & 8 (Accessed Sept. 2022).

The following delivery methods may be used to provide telemedicine within fee-for-service (FFS) Medicaid:

  • Synchronous audiovisual technology between the distant site provider and the client in another location
  • Synchronous audio-only technology between the distant site provider and the client in another location
  • Store and forward technology in conjunction with synchronous audio-only technology between the distant site provider and the client in another location. The distant site provider must use one of the following:
    • Clinically relevant photographic or video images, including diagnostic images
    • The client’s relevant medical records, such as medical history, laboratory and pathology results, and prescriptive histories

SOURCE: TX Medicaid Telecommunication Services Handbook, pg. 7, 9, & 13, (Sept. 2022). (Accessed Sept. 2022).

Eligible distant site providers are reimbursed in the same manner as their other professional services.  See administrative code for each provider type and the reference for the code under which TX Medicaid pays in the same manner of.

SOURCE: TX Admin. Code, Title 1 Sec. 355.7001, (Accessed Sept. 2022).

Telemedicine:  Texas health and human services agencies that administer a part of Medicaid are required to provide Medicaid reimbursement for a telemedicine service initiated or provided by a physician. Reimbursement is provided only for a telemedicine medical service initiated or provided by a physician.

A request for reimbursement may not be denied solely because an in-person medical service between a physician and a patient did not occur. Medicaid cannot limit a physician’s choice of platform for providing a telemedicine or telehealth service by requiring the use of a particular platform to receive reimbursement.

Medicaid reimbursement is provided to a physician for a telemedicine medical service provided by the physician, even if the physician is not the patient’s primary care physician or provider, if:

  • The physician is an authorized health care provider under Medicaid;
  • The patient is a child who receives the services in a primary or secondary school-based setting; and
  • The parent or legal guardian of the patient provides consent before the services is provided.

SOURCE: TX Govt. Code Sec. 531.0217, (Accessed Sept. 2022)

Telehealth:  Before receiving a telehealth service, the patient must receive an initial evaluation for the same diagnosis or condition by a physician or other qualified healthcare professional licensed in Texas which can be performed in-person or as a telemedicine visit that conforms to 22 TAC Ch. 174.  A patient receiving telehealth services must be evaluated annually by a physician or other healthcare professional (in-person or via a telemedicine visit) to determine if the patient has a continued need for the service.  If the patient is receiving the telehealth services to treat a mental health diagnosis or condition, the patient is not required to receive an initial evaluation.

SOURCE: TX Admin. Code, Title 1, Sec. 354.1432(2) (Accessed Sept. 2022).


ELIGIBLE SERVICES/SPECIALTIES

Telemedicine & Telehealth

Not all Medicaid-covered services are authorized by HHSC for telemedicine or telehealth delivery in fee-for-service. Providers must always ensure the covered service is allowable by HHSC for telemedicine or telehealth services delivery.

Note: For example, if a service is authorized for telemedicine or telehealth delivery only when using synchronous audiovisual technology, that service may not be delivered using store and forward technology, store and forward technology in conjunction with synchronous audio-only technology, synchronous audio-only technology, or asynchronous audio-only technology.

Telemedicine or telehealth may be provided if clinically appropriate and safe, as determined by the provider, and agreed to by the person receiving services. Whenever possible, HHSC encourages face-to-face interaction, such as an in-person visit.

SOURCE: TX Medicaid Telecommunication Services Handbook, pg. 6, (Accessed Sept. 2022).

Texas Medicaid reimburses for telemedicine and telehealth codes specified in the TX Medicaid Provider Procedures Manual. See individual manuals for reimbursable services provided through telehealth.

Telemedicine medical services, also known as telemedicine, are allowable for Texas Medicaid. Telemedicine has the meaning assigned by Texas Occupations Code §111.001. Telemedicine services are defined as health-care services delivered by a physician licensed in Texas or a health professional who acts under the delegation and supervision of a health professional licensed in Texas and within the scope of the health professional’s license to a client at a different physical location using telecommunications or information technology. Telemedicine excludes teledentistry services.

Telehealth services, also known as telehealth, are allowable for Texas Medicaid. Telehealth has the meaning assigned by Texas Occupations Code §111.001. Telehealth services are defined as health- care services, other than telemedicine medical services or a teledentistry service, delivered by a health professional licensed, certified or otherwise entitled to practice in Texas and acting within the scope of the health professional’s license, certification or entitlement to a patient at a different physical location other than the health professional using telecommunications or information technology.

Telehealth services are reimbursed in accordance with 1 TAC §355.

Telemedicine and telehealth services must be provided in compliance with standards established by the respective licensing or certifying board of the professional providing the services.

The use of telemedicine and telehealth services within intermediate care facilities for individuals with intellectual disabilities (ICD-IID) and State Supported Living Centers is subject to the policies established by the Health and Human Services Commission (HHSC).

More than one medically necessary telemedicine service or telehealth service may be reimbursed for the same date and same place of service if the services are billed by providers of different specialties.

Procedure codes that are reimbursed to distant site providers when billed with the 95 modifier (synchronous audiovisual technology) are included in the individual TMPPM handbooks. Procedure codes that indicate remote (telemedicine) delivery in the description do not need to be billed with the 95 modifier.

SOURCE: