Last updated 11/23/2022
Live Video
POLICY
Services delivered via telehealth will be eligible for reimbursement when all of the following conditions are met:
- The Provider at the distant site deems that the service being provided is clinically appropriate to be delivered via telehealth;
- The service delivered via telehealth meets the procedural definition and components of the CPT or HCPCS code, as defined by the American Medical Association (AMA), unless otherwise noted in Table 1 – Table 6 in this Supplement;
- The service provided via telehealth meets all state and federal laws regarding confidentiality of health care information and a patient’s right to his or her medical information;
- Services delivered via telehealth meet all applicable state laws, regulations and licensure requirements on the practice of telehealth; and
- DMAS deems the service eligible for delivery via telehealth.
In order to be reimbursed for services using telehealth that are provided to MCO-enrolled individuals, Providers must follow their respective contract with the MCO.
SOURCE: VA Dept. of Medical Assistant Svcs., Medicaid Provider Manual Supplement-Telehealth Services (Available in multiple manuals, including physician/practitioner, see overview for full list), (Oct. 2022) (Accessed Nov. 2022).
ELIGIBLE SERVICES/SPECIALTIES
The Board, subject to the approval of the Governor, is authorized to prepare, amend from time to time, and submit to the U.S. Secretary of Health and Human Services a state plan for medical assistance services. Such plan shall include:
- A provision for the payment of medical assistance for medically necessary health care services provided through telemedicine services, as defined in § 38.2-3418.16, regardless of the originating site or whether the patient is accompanied by a health care provider at the time such services are provided. No health care provider who provides health care services through telemedicine services shall be required to use proprietary technology or applications in order to be reimbursed for providing telemedicine services.
“Originating site” means any location where the patient is located, including any medical care facility or office of a health care provider, the home of the patient, the patient’s place of employment, or any public or private primary or secondary school or postsecondary institution of higher education at which the person to whom telemedicine services are provided is located.
SOURCE: VA Code Annotated Sec. 32.1-325, (Accessed Nov. 2022).
Telemedicine is available for selected services.
SOURCE: VA Dept. of Medical Assistance Svcs. General Information. All Manuals, (Accessed Nov. 2022).
Attachment A in the Telehealth Supplement lists covered services that may be reimbursed when provided via telehealth.
Certain types of services that would not be expected to be appropriately delivered via telemedicine include, but are not limited to, those 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
If, after initiating a telemedicine visit, the telemedicine modality is found to be medically and/or clinically inappropriate, or otherwise can no longer meet the requirements stipulated in the “Reimbursable Telehealth Services” section, the Provider shall provide or arrange, in a timely manner, an alternative to meet the needs of the individual (e.g., services delivered in-person; services delivered via telemedicine when conditions allow telemedicine to meet requirements stipulated in the “Reimbursable Telehealth Services” section). In this circumstance, the Provider shall be reimbursed only for services successfully delivered.
SOURCE: VA Dept. of Medical Assistant Svcs., Medicaid Provider Manual Supplement-Telehealth Services (Available in multiple manuals, including physician/practitioner, see overview for full list), (Oct. 2022) (Accessed Nov. 2022).
The following school-based services may be provided via telemedicine: PT, OT, speech and language, psychological and mental health, and medical evaluation services. DMAS does not require the presence of a paid staff person with the student at the time of the service, however, a paid staff person must be present and supervise the visit if the LEA submits a claim for the “originating site fee”.
SOURCE: VA Dept. of Medical Assistant Svcs. Medicaid Provider Manual, Local Education Agency Provider Manual, Covered Svcs. and Limitations, (Oct. 2021). (Accessed Nov. 2022).
Durable Medical Equipment (DME) and Supplies
The face-to-face encounter may occur through telehealth, which is defined as the real-time or near real-time two-way transfer of medical data and information using an interactive audio/video connection for the purposes of medical diagnosis and treatment (DMAS Medicaid Memo dated May 20, 2014). Telehealth shall not include by telephone or email.
SOURCE: VA Dept. of Medical Assistant Svcs. Medicaid Provider Manual, Durable Medical Equipment and Supplies Manual, Covered Svcs. and Limitations, (Jul. 2022). (Accessed Nov. 2022).
Opioid Treatment Services
Services can be provided face-to-face or by telemedicine according to DMAS policy regarding telemedicine.
SOURCE: VA Dept. of Medical Assistance Svcs. Medicaid Provider Manual, Addiction and Recovery Treatment Services, Covered Svcs and Limitations, (Mar. 2022). (Accessed Nov. 2022).
MAT for Opioid Use Disorder
Prescribing controlled substances for the treatment of addiction delivered via telemedicine must include a qualified provider and a telepresenter located at the originating site, as well as a qualified prescribing provider located at the remote site. Psychotherapy and SUD counseling may also be provided via telemedicine by a qualified provider who is a credentialed addiction treatment professional as defined in this memorandum and DMAS ARTS Provider Manual. See manual for eligible MAT codes.
SOURCE: Medicaid Bulletin: Clarification of DMAS Requirements Related to the Use of Telemedicine in Providing MAT for OUD. Oct. 23, 2019, (Accessed Nov. 2022).
Residential Treatment Service
DMAS reimburses for telemedicine services under limited circumstances. Telemedicine is the real-time or near real-time exchange of information for diagnosing and treating medical conditions. Telemedicine utilizes audio/video connections linking medical practitioners in one locality with medical practitioners in another locality. DMAS recognizes telemedicine as a means for delivering some covered Medicaid services.
SOURCE: VA Dept. of Medical Assistance Svcs. Medicaid Provider Manual, Residential Treatment Services, Covered Services and Limitations, (Accessed Nov. 2022).
See manual for comprehensive list of authorized services.
SOURCE: VA Dept. of Medical Assistant Svcs., Medicaid Provider Manual Supplement-Telehealth Services, (Oct. 2022) (Accessed Nov. 2022).
Mobile Crisis Response Level of Care Guidelines
Covered service components of Mobile Crisis Response include:
- Assessment, including telemedicine assisted assessment
At the start of services, a LMHP, LMHP-R, LMHP-RP or LMHP-S must conduct an assessment to determine the individual’s appropriateness for the service. This assessment must be done in-person, through telemedicine or through a telemedicine assisted assessment. At a minimum, the assessment must include the following elements: risk of harm; functional status; medical, addictive and psychiatric co-morbidity; recovery environment; treatment and recovery history; and, the individual’s ability and willingness to engage.
Telehealth is permissible for prescreening activities pursuant to section §37.2-800 et. seq. and section §16.1-335 et seq. of the Code of Virginia that and are billed using modifiers HK and 32.
Community Stabilization Level of Care Guidelines
Covered Services components of Community Stabilization include:
- Assessment, including telemedicine assisted assessment
At the start of services, a LMHP, LMHP-R, LMHP-RP or LMHP-S must conduct an assessment to determine the individual’s appropriateness for the service. This assessment must be done in-person or through a telemedicine assisted assessment.
Services must be provided in-person with the exception of the telemedicine assisted assessment and care coordination activities.
SOURCE: VA Dept. of Medical Assistance Services. Medicaid Provider Manual, Mental Health Services, Ch. 11 Appendix G: Comprehensive Crisis Services, (Accessed Nov. 2022).
“Telemedicine assisted assessment” means the in-person service delivery encounter by a QMHP-A, QMHP-C, CSAC with synchronous audio and visual support from a remote LMHP, LMHP-R, LMHP-RP or LMHP-S to: obtain information from the individual or collateral contacts, as appropriate, about the individual’s mental health status; provide assessment and early intervention; and, develop an immediate plan to maintain safety in order to prevent the need for a higher level of care. The assessment includes documented recent history of the severity, intensity, and duration of symptoms and surrounding psychosocial stressors.
SOURCE: VA Dept. of Medical Assistance Services. Medicaid Provider Manual, Mental Health Services, Ch. 11 Appendix G: Comprehensive Crisis Services, (Accessed Nov. 2022).
Virtual Check-Ins
Additions to the Telehealth Supplement include defining virtual check-in services, identifying covered codes, specifying reimbursement requirements, and outlining fee-for-service (FFS) billing details. Billing codes covered by this policy, when conditions of coverage are met, and for services with dates of service on and after April 18, 2022, include the following:
- 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
- G2251: Brief communication technology-based service, e.g. virtual check-in, by a qualified health care professional who cannot report evaluation and management services, provided to an established patient, not originating from a related service provided within the previous 7 days nor leading to a service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of clinical discussion
- G2252: 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; 11-20 minutes of medical discussion
SOURCE: VA Department of Medical Assistance Services, Coverage of Virtual Check-In and Audio Only Services/Updates to Telehealth Services Supplement, April 1, 2022. (Accessed Nov. 2022).
ELIGIBLE PROVIDERS
The term “Provider” refers to the billing provider – either a qualified, licensed practitioner of the healing arts or a facility – who is enrolled with DMAS.
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 Commonwealth. If approved, these facilities may serve as the Provider or originating site and bill under the encounter rate. The encounter rate methodology for FQHCs and RHCs is described in 12VAC30-80-25; the encounter rate for IHCs (including Tribal clinics) is the All Inclusive Rate set by Indian Health Services.
SOURCE: VA Dept. of Medical Assistant Svcs., Medicaid Provider Manual Supplement-Telehealth Services (Available in multiple manuals, including physician/practitioner, see overview for full list), (Oct. 2022) (Accessed Nov. 2022).
Medication Assisted Treatment
The Member is located at an approved originating site with the Medicaid enrolled telepresenter. The originating site provider cannot bill an originating site fee unless the Member is assisted by a Medicaid enrolled telepresenter at the originating site.
SOURCE: Medicaid Bulletin: Clarification of DMAS Requirements Related to the Use of Telemedicine in Providing MAT for OUD. Oct. 23, 2019, (Accessed Nov. 2022).
Preferred OBAT Providers, previously known as “Preferred OBOTs”, deliver addiction treatment services to members with OUD as well as other primary SUD. Preferred OBAT services are required to be provided by buprenorphine-waivered practitioners working in collaboration and co-located with Credentialed Addiction Treatment Professionals providing psychosocial treatment in public and private practice settings (12VAC30-130-5020).
Credentialed Addiction Treatment Professional means:
An individual licensed or registered with the appropriate board in the following roles:
- An addiction-credentialed physician or physician with experience or training in addiction medicine;
- Physician extenders with experience or training in addiction medicine;
- A licensed psychiatrist;
- A licensed clinical psychologist;
- A licensed clinical social worker;
- A licensed professional counselor;
- A certified psychiatric clinical nurse specialist;
- A licensed psychiatric nurse practitioner;
- A licensed marriage and family therapist;
- A licensed substance abuse treatment practitioner;
- A resident who is under the supervision of a licensed professional counselor (18VAC115-20-10), licensed marriage and family therapist (18VAC115-50-10), or licensed substance abuse treatment practitioner (18VAC115-60-10) and is registered with the Virginia Board of Counseling;
- A resident in psychology who is under supervision of a licensed clinical psychologist and is registered with the Virginia Board of Psychology (18VAC125-20-10); or
- A supervisee in social work who is under the supervision of a licensed clinical social worker and is registered with the Virginia Board of Social Work (18VAC140-20-10).
Preferred OBAT services must be provided by a buprenorphine-waivered practitioner and a co-located Credentialed Addiction Treatment Professional and may be provided in a variety of practice settings including primary care clinics, outpatient health system clinics, psychiatry clinics, Federally-Qualified Health Centers (FQHCs), Community Service Boards (CSBs), local health department clinics, and physicians’/physician extenders’ offices. DMAS expects Preferred OBAT services to be primarily delivered in-person/on-site and utilize telemedicine as an option to increase access to services as needed. Preferred OBATs services must have regular access to in-person/on-site visits and services shall not be delivered solely or predominantly through telemedicine. The practitioners must be credentialed by DMAS, the DMAS fee-for-service contractor or MCOs to perform Preferred OBAT services. Preferred OBAT providers do not require a separate DBHDS license.
Thus Preferred OBAT services may be provided via telemedicine based on the individualized needs of the member and reasons why the in-person interactions are not able to meet the member’s specific needs must be documented. The primary means of services delivery shall in-person for the Preferred OBAT model with the exception of telemedicine for specific member circumstances. These circumstances may include but are not limited to: member transportation issues, member childcare needs, member employment schedule, member co-morbidities, member distance to provider, etc.). Where these situations may impede member’s access to treatment, telemedicine may be utilized as clinically appropriate and to help to remove these barriers to treatment. Providers delivering services using telemedicine shall bill according to the requirements in the DMAS Telehealth Services Supplemental Manual.
SOURCE: VA Dept. of Medical Assistance Svcs. Medicaid Provider Manual, Addiction and Recovery Treatment Services, Opioid Treatment Services/Medication Assisted Treatment, (Mar. 2022), (Accessed Nov. 2022).
23-Hour Crisis Stabilization Level of Care Guidelines
A licensed psychiatrist or nurse practitioner (who is acting within the scope of their professional license and applicable State law) must be available to the program 24/7 either in person or via telemedicine to provide assessment, treatment recommendations and consultation. A nurse practitioner or physician assistant working under the licensed psychiatrist may provide this coverage for the psychiatrist.
Psychiatric evaluation may be provided through telemedicine. Providers must follow the requirements for the provision of telemedicine described in the “Telehealth Services Supplement”, including the use of telemedicine modifiers. MCO contracted providers should consult with the contracted MCOs for their specific policies and requirements for telehealth.
Residential Crisis Stabilization Level of Care Guidelines
A licensed psychiatrist or nurse practitioner (who is acting within the scope of their professional license and applicable State law) must be available to the program 24/7 either in-person or via telemedicine to provide assessment, treatment recommendations and consultation meeting the licensing standards for residential crisis stabilization and medically monitored withdrawal services at ASAM level 3.7. A nurse practitioner or physician assistant working under the licensed psychiatrist may provide this coverage for the psychiatrist.
A psychiatric evaluation may be provided through telemedicine. Providers must follow the requirements for the provision of telemedicine described in the “Telehealth Services Supplement” including the use telemedicine modifiers. MCO contracted providers should consult with the contracted MCOs for their specific policies and requirements for telehealth.
SOURCE: VA Dept. of Medical Assistance Services. Medicaid Provider Manual, Mental Health Services, Ch. 11 Appendix G: Comprehensive Crisis Services, (Accessed Nov. 2022).
ELIGIBLE SITES
The originating site is the location of the member at the time the service is rendered, or the site where the asynchronous store-and-forward service originates (i.e., where the data are collected). Examples of originating sites include: medical care facility; Provider’s outpatient office; the member’s residence or school; or other community location (e.g., place of employment).
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 Commonwealth. If approved, these facilities may serve as the Provider or originating site and bill under the encounter rate. The encounter rate methodology for FQHCs and RHCs is described in 12VAC30-80-25; the encounter rate for IHCs (including Tribal clinics) is the All Inclusive Rate set by Indian Health Services.
SOURCE: VA Dept. of Medical Assistant Svcs., Medicaid Provider Manual Supplement-Telehealth Services (Available in multiple manuals, including physician/practitioner, see overview for full list), (Oct. 2022) (Accessed Nov. 2022).
The Board, subject to the approval of the Governor, is authorized to prepare, amend from time to time, and submit to the U.S. Secretary of Health and Human Services a state plan for medical assistance services. Such plan shall include:
- A provision for the payment of medical assistance for medically necessary health care services provided through telemedicine services, as defined in § 38.2-3418.16, regardless of the originating site or whether the patient is accompanied by a health care provider at the time such services are provided. No health care provider who provides health care services through telemedicine services shall be required to use proprietary technology or applications in order to be reimbursed for providing telemedicine services.
“Originating site” means any location where the patient is located, including any medical care facility or office of a health care provider, the home of the patient, the patient’s place of employment, or any public or private primary or secondary school or postsecondary institution of higher education at which the person to whom telemedicine services are provided is located.
SOURCE: VA Code Annotated Sec. 32.1-325, (Accessed Nov. 2022).
Mobile OBAT
Preferred OBAT Providers of an opportunity to provide OBAT services through a new mode of delivery called “Mobile Preferred OBATs.” Note this is separate from the Drug Enforcement Administration (DEA) recent approval in July 2021, of adding a “mobile component” to OTPs certified by SAMSHA. DMAS is working with DBHDS and will follow with updated policies when this is implemented in Virginia.
The Mobile Preferred OBAT model shall allow Preferred OBAT providers to provide the same services in a Mobile Unit as in a traditional Preferred OBAT setting. As indicated by the Centers for Medicare and Medicaid Services (CMS), and accepted by the Medicaid MCOs and the DMAS fee-for-service contractor, a “Mobile Unit” is designated as place of service (POS) 15 and is defined as a facility or unit that moves from place to place equipped to provide preventive, screening, diagnostic, and/or treatment services: https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set.
A Mobile Unit shall also be permitted to operate as an extension of an established Preferred OBAT’s primary location. This shall allow providers at a Preferred OBAT to also provide services in the community using the POS “015” for a Mobile Unit. Providers working in the Mobile OBAT setting shall provide services in-person as well as be permitted to utilize technology to provide telemedicine sessions with providers located at the Preferred OBAT’s primary location. Providers delivering services using telemedicine shall follow the requirements set forth in the DMAS Telehealth Services Supplemental Manual. Current Preferred OBAT Providers shall notify the MCOs and the DMAS fee-for-services contractor prior to providing services in a Mobile Unit.
SOURCE: VA Dept. of Medical Assistant Svcs., Medicaid Provider Manual, Addiction and Recovery Treatment Services Manual, Ch. 8 Preferred Office-Based Addiction Treatment Programs, (Accessed Nov. 2022).
GEOGRAPHIC LIMITS
No reference found.
FACILITY/TRANSMISSION FEE
In the event it is medically necessary for a Provider to be present at the originating site at the time a synchronous telehealth service is delivered, said Provider may bill an originating site fee (via procedure code Q3014) when the following conditions are met:
- The Medicaid member is located at a provider office or other location where services are delivered on an in-person basis (this does not include the member’s residence);
- The member and distant site Provider are not located in the same location; and
- The Provider (or the Provider’s designee), is affiliated with the provider office or other location where the Medicaid member is located and attends the encounter with the member. The Provider or designee may be present to assist with initiation of the visit but the presence of the Provider or designee in the actual visit shall be determined by a balance of clinical need and member preference or desire for confidentiality.
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 Commonwealth. If approved, these facilities may serve as the Provider or originating site and bill under the encounter rate. The encounter rate methodology for FQHCs and RHCs is described in 12VAC30-80-25; the encounter rate for IHCs (including Tribal clinics) is the All Inclusive Rate set by Indian Health Services.
SOURCE: VA Dept. of Medical Assistant Svcs., Medicaid Provider Manual Supplement-Telehealth Services (Available in multiple manuals, including physician/practitioner, see overview for full list), (Oct. 2022) (Accessed Nov. 2022).
The following school-based services may be provided via telemedicine: PT, OT, speech and language, psychological and mental health, and medical evaluation services. DMAS does not require the presence of a paid staff person with the student at the time of the service, however, a paid staff person must be present and supervise the visit if the LEA submits a claim for the “originating site fee”.
Reference the “DMAS Telehealth Manual Supplement” for additional details on DMAS’s requirements for telemedicine.
Service providers must include the modifier GT on claims for services delivered via telemedicine.
Place of Service (POS), the two-digit code placed on claims used to indicate the setting where the service occurred, must reflect the location in which a telehealth service would have normally been provided, had interactions occurred in person. The school setting code is 03. (Providers should not use POS 02 on telehealth claims, even though this POS is referred to as “telehealth” for other payers.
The services of a school employee supervising the student at the originating school site (the site where the student is located during the telehealth service), must be billed using procedure code, Q3014.
SOURCE: VA Dept. of Medical Assistant Svcs. Medicaid Provider Manual, Local Education Agency Provider Manual, Covered Svcs. and Limitations, (Oct 2021) & Billing Instructions, (Oct. 2021), (Accessed Nov. 2022).
Medication Assisted Treatment
The originating site provider cannot bill an originating site fee unless the Member is assisted by a Medicaid enrolled telepresenter at the originating site.
SOURCE: Medicaid Bulletin: Clarification of DMAS Requirements Related to the Use of Telemedicine in Providing MAT for OUD. Oct. 23, 2019. (Accessed Nov. 2022).
Medication Assisted Treatment (MAT) – Outpatient Settings – non OTP/OBAT Settings
The telehealth originating site facility fee is not authorized.
SOURCE: VA Dept. of Medical Assistant Svcs., Medicaid Provider Manual, Addiction and Recovery Treatment Services Manual, Ch. 8 Preferred Office-Based Addiction Treatment Programs, (Accessed Nov. 2022).
Emergency Ambulance Transport Providers
DMAS will reimburse an originating site fee to emergency ambulance transport providers for facilitating a telemedicine consultation between a Medicaid member and a Medicaid- enrolled provider for the purposes of identifying whether the Medicaid member is in need of emergency ambulance transportation. Specifically, emergency ambulance transportationproviders may submit a claim for providing a telemedicine “originating site fee” service (CPT Q3014) under the following conditions:
- The Emergency Ambulance Transport provider is licensed as a Virginia Emergency Medical Services (EMS) ambulance provider.
- The Emergency Ambulance Transport provider must be enrolled as such with DMAS.
- The Medicaid member is in a physical location where telemedicine services can be received per requirements set forth in the Telehealth Supplement.
- The member and provider of telemedicine services are not in the same physical location during the consultation.
- The Emergency Ambulance Transport provider assists with initiation of the visit but the presence of the Emergency Ambulance Transportation provider in the actual visit shall be determined by a balance of clinical need and member preference or desire for confidentiality.
Emergency Ambulance Transport providers should submit a claim for providing an originating site fee service in one of two ways:
- If the Member receives emergency ambulance transportation subsequent to and based on the facilitated telemedicine consultation, submit two claims: one claim for Q3014 on a CMS-1500 and a separate claim for emergency transportation services.
- If the Member does not receive emergency ambulance transportation subsequent to and based on the facilitated telemedicine consultation, submit one claim for Q3014 on a CMS-1500.
Emergency Ambulance Transport providers should maintain the Pre-hospital Patient Care Report (PPCR) documentation that includes identifying information of the Provider of telemedicine services (e.g., NPI), evidence that emergency transportation was or was not recommended by the telemedicine provider, and whether the member did or did not receive emergency ambulance transportation services subsequent to and based on the facilitated telemedicine consultation.
SOURCE: VA Dept. of Medical Assistant Svcs., Medicaid Provider Manual, Transportation Manual, Billing Instructions, (Oct. 2022). (Accessed Nov. 2022).
Last updated 11/23/2022
Remote Patient Monitoring
POLICY
Face-to-face encounters may occur through telemedicine, which is defined as the two-way, real time interactive electronic communication between the member and the Provider located at a site distant from the member. This electronic communication must include, at a minimum, the use of audio and video equipment. Telemedicine shall not include by telephone or email.
SOURCE: VA Dept. of Medical Assistance Svcs., Medicaid Provider Manual, Home Health Manual, Covered Services and Limitations. (Oct 2022). (Accessed Nov. 2022).
VA Medicaid reimburses for Continuous Glucose Monitoring.
SOURCE: VA Department of Medical Assistance Services. Medicaid Memo. Clarification of Existing Medicaid Coverage of Continuous Glucose Monitoring for Members in Medicaid/FAMIS/FAMIS MOMS Fee-for-Service Programs. (Nov. 2016) (Accessed Nov. 2022).
The Board, subject to the approval of the Governor, is authorized to prepare, amend from time to time, and submit to the U.S. Secretary of Health and Human Services a state plan for medical assistance services. Such plan shall include a provision for payment of medical assistance for remote patient monitoring services provided via telemedicine for specific conditions (see section below).
“Remote patient monitoring services” means the use of digital technologies to collect medical and other forms of health data from patients in one location and electronically transmit that information securely to health care providers in a different location for analysis, interpretation, and recommendations, and management of the patient. “Remote patient monitoring services” includes monitoring of clinical patient data such as weight, blood pressure, pulse, pulse oximetry, blood glucose, and other patient physiological data, treatment adherence monitoring, and interactive videoconferencing with or without digital image upload.
SOURCE: VA Code Annotated Sec. 32.1-325 (Accessed Nov. 2022).
Remote Patient Monitoring (RPM) involves the collection and transmission of personal health information from a beneficiary in one location to a provider in a different location for the purposes of monitoring and management. This includes monitoring of both patient physiologic and therapeutic data.
SOURCE: VA Dept. of Medical Assistant Svcs., Medicaid Provider Manual Supplement-Telehealth Services (Physician/Practitioner), (Oct. 2022) (Accessed Nov. 2022).
DMAS and all managed care organizations (MCOs) will cover remote patient monitoring (RPM) services for full benefit Medicaid and FAMIS populations in accordance with the 2021 Special Session I Budget, Item 313.VVVVV. DMAS also has clarified guidance on select Behavioral Health codes eligible for telemedicine delivery included in the Telehealth Supplement.
See bulletin for additional information
SOURCE: VA Department of Medical Assistant Services. Bulletin Coverage of Remote Patient Monitoring/Update to Telehealth Services Supplement, (Mar. 2022). (Accessed Nov. 2022).
CONDITIONS
The Board, subject to the approval of the Governor, is authorized to prepare, amend from time to time, and submit to the U.S. Secretary of Health and Human Services a state plan for medical assistance services. Such plan shall include:
- A provision for payment of medical assistance for remote patient monitoring services provided via telemedicine for:
- High-risk pregnant persons;
- Medically complex infants and children; Transplant patients;
- Patients who have undergone surgery, for up to three months following the date of such surgery; and
- Patients with a chronic health condition who have had two or more hospitalizations or emergency department visits related to such chronic health condition in the previous 12 months.
“Remote patient monitoring services” means the use of digital technologies to collect medical and other forms of health data from patients in one location and electronically transmit that information securely to health care providers in a different location for analysis, interpretation, and recommendations, and management of the patient. “Remote patient monitoring services” includes monitoring of clinical patient data such as weight, blood pressure, pulse, pulse oximetry, blood glucose, and other patient physiological data, treatment adherence monitoring, and interactive videoconferencing with or without digital image upload.
SOURCE: VA Code Annotated Sec. 32.1-325 (Accessed Nov. 2022).
Coverage Continuous Glucose Monitoring is limited to members with:
- Type 1 diabetes
- Type 2 diabetes (when over 16 years old)
- Pregnant women who are injecting insulin with either Type 1 or 2.
Service authorization is required. Additional requirements apply.
SOURCE: VA Department of Medical Assistance Services. Medicaid Memo. Clarification of Existing Medicaid Coverage of Continuous Glucose Monitoring for Members in Medicaid/FAMIS/FAMIS MOMS Fee-for-Service Programs. (Nov. 2016) (Accessed Nov. 2022).
Effective for services with dates of service on and after May 1, 2022, RPM will be covered by FFS and MCOs for the following populations:
- Medically complex patients under 21 years of age
- Transplant patients
- Post-surgical patients
- Patients with a chronic health condition who have had two or more hospitalizations or emergency department visits related to such chronic health condition in the previous 12 months
- High-risk pregnant persons
See manual for covered billing codes.
Prior authorization will be required for coverage of these services. Please reference the updated Telehealth Supplement, and its associated references, for FFS policies, service authorization criteria, quantity limits and billing processes. MCOs will adopt equivalent service authorization criteria and quantity limits as FFS.
SOURCE: VA Department of Medical Assistant Services. Bulletin Coverage of Remote Patient Monitoring/Update to Telehealth Services Supplement. (Mar. 2022). (Accessed Nov. 2022).
PROVIDER LIMITATIONS
The Provider must have an established relationship with the member receiving the RPM service, including at least one visit in the last 12 months (which can include the date RPM services are initiated).
The member receiving the RPM service must fall into one of the following five populations, with duration of initial service authorization in parentheses as per below:
-
-
- Medically complex patient under 21 years of age (6 months);
- Transplant patient (6 months);
- Post-surgical patient (up to 3 months following the date of surgery);
- Patient with a chronic health condition who has had two or more hospitalizations or emergency department visits related to such chronic health condition in the previous 12 months (6 months); and/or a
- High-risk pregnant person (6 months).
All service authorization criteria outlined in the DMAS Form “DMAS-P268” are met prior to billing the following CPT/HCPCS codes:
- Physiologic Monitoring: 99453, 99454, 99457, 99458, and 99091
- Therapeutic Monitoring: 98975, 98976, 98977, 98980, and 98981
- Self-Measured Blood Pressure: 99473, 99474
Providers must meet the criteria outlined in the DMAS Form “DMAS-P268” and submit their requests to the DMAS service authorization contractor by direct data entry (DDE) via their provider portal. See Appendix D of the Physician/Practitioner manual for details on the current service authorization contractor and accessing the provider portal.
Service authorization requests must be submitted at least 30 days prior to the scheduled date of initiation of services.
Reauthorizations will be permitted for select services, as appropriate and as per criteria in the DMAS Form “DMAS-P268”.
OTHER RESTRICTIONS
Equipment utilized for Remote Patient Monitoring must meet the Food and Drug Administration (FDA) definition of a medical device as described in section 201(h) of the Federal, Food, Drug and Cosmetic Act.
SOURCE: VA Dept. of Medical Assistant Svcs., Medicaid Provider Manual Supplement-Telehealth Services (Physician/Practitioner), (Oct. 2022) (Accessed Nov. 2022).
