Last updated 06/21/2022
Definitions
Telehealth services means the transmission of health-related services or information through the use of electronic communication or information technology.
SOURCE: Utah Medicaid Provider Manual: Section I: General Information, p. 48 (Apr. 2022), & UT Admin. Code R414-42-2. (Accessed Jun. 2022).
Telemedicine is the delivery of medical services and any diagnosis, consultation, treatment, transfer of medical data or education related to health care services using interactive audio or interactive video communication instead of in person contact.
Teledentistry is the use of information technology and telecommunications for dental care, consultation, and education.
Telepsychiatric Consultation is a consultation between a physician and a board-certified psychiatrist that utilizes:
- the health records of the patient, provided from the patient or the referring physician
- a written, evidence-based patient questionnaire
SOURCE: Utah Medicaid Provider Manual: Section I: General Information, p. 48 (Apr. 2022). (Accessed Jun. 2022).
Last updated 06/21/2022
Live Video
POLICY
The department shall adopt administrative rules which establish:
- the particular telemedicine services that are considered face-to-face encounters for reimbursement purposes under the state’s medical assistance program; and
- the reimbursement methodology for the telemedicine services
The reimbursement rate for telemedicine services shall be subject to reimbursement policies set by the state plan; and may be based on:
- a monthly reimbursement rate;
- a daily reimbursement rate; or
- an encounter rate.
SOURCE: UT Code Annotated Sec. 26-18-13. (Accessed Jun. 2022).
Utah Medicaid covers medically necessary, non-experimental and cost-effective services provided via telehealth.
Limitations: Telehealth encounters must comply with HIPAA privacy and security measures and the Health Information Technology for Economic and Clinical Health Act, Pub. L. No.111-5, 123 Stat. 226, 467, as amended to ensure that all member communications and records, including recordings of telehealth encounters, are secure and remain confidential. The provider is responsible for ensuring the encounter is HIPAA compliant. Security measures for transmission may include password protection, encryption, and other reliable authentication techniques. Compliance with the Utah Health Information Network (UHIN) Standards for Telehealth must be maintained. These standards provide a uniform standard of billing for claims and encounters delivered via telehealth.
CMS 1500 Professional Claims- Provider must indicate that the service(s) was provided via telehealth by indicating Place of Service (POS) 02 – Telehealth Provided Other than in Patient’s Home, or POS 10 – Telehealth Provided in Patient’s Home on the CMS 1500 claim form with the service’s usual billing codes.
UB-04 Institutional Claims- Providers must indicate that the service(s) were provided via telehealth by appending the GT modifier to the UB-04 institutional claim form with the service’s usual billing codes.
- GT – Via interactive audio and video telecommunication systems
Services provided via telehealth have the same service thresholds, authorization requirements and reimbursement rates as services delivered face-to-face.
SOURCE: Utah Medicaid Provider Manual: Section I: General Information, p. 48 & 50 (Apr. 2022). (Accessed Jun. 2022).
A licensed provider may deliver services via synchronous telehealth, as clinically appropriate. Services include consultation services, evaluation and management services, teledentistry services, mental health services, substance use disorder services, and telepsychiatric consultations.
Must comply with privacy and security measures set forth by HIPAA and HITECH. The provider is responsible to ensure the encounter is HIPAA compliant. Security measures for transmission may include password protection, encryption, and other reliable authentication techniques.
A provider must comply with the Utah Health Information Network (UHIN) standards for telehealth. These standards provide a uniform standard of billing for claims and encounters delivered via telehealth.
The Department pays the lesser of the amount billed or the rate on the fee schedule. A provider shall not charge the Department a fee that exceeds the provider’s usual and customary charges for the provider’s private pay patients.
SOURCE: UT Admin. Code R414-42-3, R414-42 (Accessed Jun. 2022).
ELIGIBLE SPECIALTIES/SERVICES
Examples of covered telehealth services include but are not limited to:
- Consultation services
- Evaluation and management services
- Mental health services
- Substance use disorder services
- Teledentistry
- Telepsychiatric consultations
It is acceptable to use telehealth to facilitate contact directly between a member and a provider.
Telepsychiatric consultations, as described in Utah Code 26-18-13.5, between a physician and a board-certified psychiatrist are covered a service. Psychiatrists are limited to certain time-based CPT codes.
Teledentistry services are covered for eligible members statewide. See manual for eligible codes.
SOURCE: Utah Medicaid Provider Manual: Section I: General Information, p. 48-49 (Apr. 2022) (Accessed Jun. 2022).
The Medicaid program is required to reimburse for telemedicine services at the same rate the Medicaid program reimburses for other health care services (includes managed care plans). The Medicaid program is required to reimburse for telepsychiatric consultations at a rate set by the Medicaid program.
SOURCE: UT Code 26-18-13.5 (Accessed Jun. 2022).
Rehabilitative Mental Health and Substance Use Disorder
Services may be provided via telemedicine when clinically appropriate.
The scope of rehabilitative behavioral health services includes the following:
- Psychiatric Diagnostic Evaluation
- Mental Health Assessment by a Non-Mental Health Therapist
- Psychological Testing
- Psychotherapy with Patient and/or Family Member
- Family psychotherapy with Patient Present and Family Psychotherapy without Patient Present
- Group Psychotherapy and Multiple Family Group Psychotherapy
- Psychotherapy for Crisis
- Psychotherapy with Evaluation and Management (E/M) Services
- Evaluation and Management (E/M) Services (Pharmacologic Management)
- Therapeutic Behavioral Services
- Psychosocial Rehabilitative Services
- Peer Support Services
- SUD Services in Licensed SUD Residential Treatment Programs
- Assertive Community Treatment (ACT)
- Mobile Crisis Outreach Teams (MCOT)
- Clinically Managed Residential Withdrawal Management
- Mental Health Services in Licensed Mental Health Residential Treatment Programs
- Behavioral Health Receiving Centers
SOURCE: Utah Medicaid Provider Manual: Rehabilitative Mental Health and Substance Use Disorder Services. P. 9-10 (Mar. 2022) (Accessed Jun. 2022).
ELIGIBLE PROVIDERS
The distant site provider may participate in the telehealth interaction from any appropriate location.
Providers may submit claims for procedure codes that they are already eligible to report.
Psychiatrists and dentists are limited to reporting certain CPT codes.
SOURCE: Utah Medicaid Provider Manual: Section I: General Information, p. 49-50 (Apr. 2022). (Accessed Jun. 2022).
ELIGIBLE SITES
CMS 1500 Professional Claims- Provider must indicate that the service(s) was provided via telehealth by indicating Place of Service (POS) 02 – Telehealth Provided Other than in Patient’s Home, or POS 10 – Telehealth Provided in Patient’s Home on the CMS 1500 claim form with the service’s usual billing codes.
It is acceptable to use telehealth to facilitate contact directly between a member and a provider. For example, services are provided between a member and a distant site provider when they are in their home or another location. Additionally, the distant site provider may participate in the telehealth interaction from any appropriate location.
SOURCE: Utah Medicaid Provider Manual: Section I: General Information, p. 49-50 (Apr. 2022), (Accessed Jun. 2022).
GEOGRAPHIC LIMITS
There are no geographic restrictions for telehealth services.
SOURCE: Utah Medicaid Provider Manual: Section I: General Information, p. 48 (Apr. 2022), (Accessed Jun. 2022).
Home and Community Based Services Autism Waiver
For those clients living outside of the Wasatch Front, the BCBA may use tele-health for the supervision time. In-person visits should be used for those clients living inside the Wasatch Front.
SOURCE: Utah Medicaid Provider Manual: Home and Community Based Waiver Services Autism Waiver, p. 10, (Jan. 2016). (Accessed Jun. 2022).
FACILITY/TRANSMISSION FEE
The provider at the originating site receives no additional reimbursement for the use of telemedicine.
SOURCE: Utah Medicaid Provider Manual: Section I: General Information, p. 50 (Apr. 2022) & R414-42-4.(3). (Accessed Jun. 2022).
Last updated 06/21/2022
Miscellaneous
Telepsychiatric consultations are a covered service. Psychiatrist service will be covered by all Managed Care Entities (MCE). If a member receiving the service is part of an MCE, then the provider must be enrolled with the member’s MCE in order to receive reimbursement.
Teledentistry services are covered for eligible members statewide. Providers must bill the appropriate teledentistry code, D9995. See manual for additional teledentistry codes.
SOURCE: Utah Medicaid Provider Manual: Section I: General Information, p. 49 (Apr. 2022), (Accessed Jun. 2022).
Documentation must include: …setting in which the service was rendered (when via telehealth, the provider setting and notation that the service was provided via telehealth).
SOURCE: Utah Medicaid Provider Manual: All Inclusive Master Manual, p. 20, 609 (May 2022), (Accessed Jun. 2022).
If the required face-to-face encounter for certain durable medical equipment occurred via telehealth it must be documented.
SOURCE: Utah Medicaid Provider Manual: Durable Medical Equipment, p. 6, (Jan. 2022). (Accessed Jun. 2022).
Home and Community Based New Choices Waiver Services
A non face-to-face medication reminder system using telecommunication device is covered.
SOURCE: Utah Medicaid Provider Manual: Home and Community Based Waiver Services, New Choices Waiver, p. 63-64, (Jul. 2021). (Accessed Jun. 2022).
Home and Community Based Services Autism Waiver
For those clients living outside of the Wasatch Front, the BCBA may use tele-health for the supervision time. In-person visits should be used for those clients living inside the Wasatch Front.
SOURCE: Utah Medicaid Provider Manual: Home and Community Based Waiver Services Autism Waiver, p. 10, (Jan. 2016). (Accessed Jun. 2022).
Last updated 06/21/2022
Remote Patient Monitoring
POLICY
Home telemetry for outpatient long-term cardiac monitoring is allowed with prior authorization. Criteria include:
- A cardiologist must order outpatient, long-term cardiac (Holter) monitoring
- Member must have had a stroke or TIA with no identifiable cause
- Member should have already had 24-hour monitoring done previously
- Member should not be currently taking anti-coagulated or Warfarin for any other reason
- Member should not have a known contraindication for Warfarin
- Outpatient long-term cardiac monitoring may only be authorized for the 30-day test
- Data from the test must be reviewed and interpreted by a cardiologist
SOURCE: Utah Medicaid Provider Manual: Physician Manual, p. 23 (Apr. 2022). (Accessed Jun. 2022).
CONDITIONS
Only for patients with a long-term cardiac health issue.
SOURCE: Utah Medicaid Provider Manual: Physician Manual, p. 23 (Apr. 2022). (Accessed Jun. 2022).
PROVIDER LIMITATIONS
Test must be ordered by a cardiologist and reviewed and interpreted by a cardiologist.
SOURCE: Utah Medicaid Provider Manual: Physician Manual, p. 23 (Apr. 2022). (Accessed Jun. 2022).
OTHER RESTRICTIONS
No Reference Found
