Last updated 05/03/2024
Live Video
POLICY
Telehealth Services
A health insurance entity shall provide coverage for healthcare services provided during a telehealth encounter in a manner that is consistent with what the health insurance policy or contract provides for in-person encounters for the same service, and shall reimburse for healthcare services provided during a telehealth encounter without distinction or consideration of the geographic location, or any federal, state, or local designation or classification of the geographic area where the patient is located.
SOURCE: TN Code Annotated, Title 56, Ch. 7, Part 1002, (Accessed May 2024).
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, Sec. 56-7-1012, (Accessed, May 2024).
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 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.
The healthcare services provider makes use of HIPAA compliant real-time, interactive audio, video telecommunications or electronic technology, or store-and-forward telemedicine services to deliver healthcare services to a patient within the scope of practice of the healthcare services provider as long as the healthcare services provider, the healthcare services provider’s practice group, or the healthcare system has established a provider-patient relationship by submitting to a health insurance entity evidence of an in-person encounter between the healthcare service provider, the healthcare services provider’s practice group, or the healthcare system and the patient within sixteen (16) months prior to the interactive visit.
The requirement of an in-person encounter between the healthcare services provider, the healthcare services provider’s practice group, or the healthcare system and the patient within sixteen (16) months prior to the interactive visit is tolled for the duration of a state of emergency declared by the governor pursuant to § 58-2-107; provided, that the healthcare services provider or the patient, or both, are located in the geographical area covered by the applicable state of emergency.
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 does not apply to a patient who is receiving an initial behavioral health evaluation or assessment.
SOURCE: TN Code Annotated, Sec. 56-7-1003, (Accessed May 2024).
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. 56-7-1012, (Accessed May 2024).
ELIGIBLE SERVICES/SPECIALTIES
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).
Section (j): 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 August 20, 2020, by the federal centers for Medicare and medicaid services.
SOURCE: TN Code Annotated, Sec. 56-7-1002 & Sec. 56-7-1012 [excludes reference to section (j)], (Accessed May 2024).
A health insurance entity:
- Shall provide coverage under a health insurance policy or contract for covered healthcare services delivered through provider-based telemedicine;
- Shall reimburse a healthcare services provider for a healthcare service covered under an insured patient’s health insurance policy or contract that is provided through 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;
- 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; and
- Shall reimburse healthcare services providers who are out-of-network for provider-based telemedicine care services under the same reimbursement policies applicable to other out-of-network healthcare services providers.
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 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.
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.
This section does not require a health insurance entity to provide coverage for healthcare services delivered by means of provider-based telemedicine if the applicable health insurance policy would not provide coverage for the same healthcare services if delivered by in-person means.
This section does not require a health insurance entity to reimburse a healthcare services provider for healthcare services delivered by means of provider-based telemedicine if the applicable health insurance policy would not reimburse that healthcare services provider if the same healthcare services had been delivered by in-person means.
Any provisions not required by this section are governed by the terms and conditions of the health insurance policy or contract.
Provider-based telemedicine is subject to utilization review under the Health Care Service Utilization Review Act, compiled in chapter 6, part 7 of this title.
SOURCE: TN Code Annotated, Sec. 56-7-1003, (Accessed May 2024).
School-Based Services
All TennCare medically necessary, covered services provided on school grounds shall be billed with the place of service code (03), defined by CMS as any facility whose primary purpose is education. School-based services rendered via telehealth shall be billed with place of service code (02), indicating telehealth was provided other than the student’s home or place of service code (10) indicating telehealth was provided in the student’s home. Additionally, the appropriate modifier should be used to indicate whether the telehealth service was delivered via a televisual visit (append using the GT modifier) or delivered via audio-only (append using the 93 modifier or FQ modifier as appropriate).
See manual for additional information.
SOURCE: TennCare Billing Manual: Tennessee School Districts (July 2023), p. 11. (Accessed May 2024).
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 Telecommunications Guidelines, p. 4 (2012) & 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 May 2024).
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 .
A health insurance entity: … Shall reimburse healthcare services providers who are out-of-network for provider-based telemedicine care services under the same reimbursement policies applicable to other out-of-network healthcare services providers.
SOURCE: TN Code Annotated, Sec. 56-7-1003, (Accessed May. 2024).
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 May 2024).
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, any facility licensed under title 33, or any other location deemed acceptable by the health insurance entity.
“Originating site” means the location where a patient is located pursuant to subdivision (a)(7)(A) and that originates a telehealth service to another qualified site.
Telehealth means the use of real-time, interactive audio, video telecommunications or electronic technology, or store-and-forward telemedicine services by a healthcare services provider to deliver healthcare services to a patient within the scope of practice of the healthcare services provider when:
- Such provider is at a qualified site other than the site where the patient is located; and
- The patient is at a qualified site, at a school clinic staffed by a healthcare services provider and equipped to engage in the telecommunications described in this section, or at a public elementary or secondary school staffed by a healthcare services provider and equipped to engage in the telecommunications described in this section.
SOURCE: TN Code Annotated, Sec. 56-7-1002 (Accessed May 2024).
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 May 2024).
“Healthcare provider” means a person who is licensed, certified, or authorized or permitted by the laws of this state to administer health care in the ordinary course of business or practice of a profession; and
“Telehealth provider group” means two (2) or more healthcare providers that share a common employer and provide healthcare services exclusively via telehealth.
This chapter does not require:
- A vendor or healthcare provider who provides healthcare services exclusively via telehealth to maintain a physical address or site in this state in order to be eligible to enroll as a vendor or provider for the medical assistance program; or
- A telehealth provider group to have a service address in this state in order to be eligible to enroll as a vendor or provider group for the medical assistance program, as long as the healthcare providers that comprise the telehealth provider group are licensed with the appropriate healthcare licensing authority in this state or are otherwise authorized by law to provide healthcare services in this state.
SOURCE: TN Code Annotated, Sec. 71-5-167, (Accessed May 2024).
School-Based Services
All TennCare medically necessary, covered services provided on school grounds shall be billed with the place of service code (03), defined by CMS as any facility whose primary purpose is education. School-based services rendered via telehealth shall be billed with place of service code (02), indicating telehealth was provided other than the student’s home or place of service code (10) indicating telehealth was provided in the student’s home. Additionally, the appropriate modifier should be used to indicate whether the telehealth service was delivered via a televisual visit (append using the GT modifier) or delivered via audio-only (append using the 93 modifier or FQ modifier as appropriate).
See manual for additional information.
SOURCE: TennCare Biling Manual: Tennessee School Districts (July 2023), p. 11. (Accessed May 2024).
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) & TN Dept. of Mental Health and Substance Abuse Services. Office of Crisis Services Telecommunications Guidelines, p. 4 & 8, (2012) (Accessed May 2024).
GEOGRAPHIC LIMITS
A health insurance entity … Shall reimburse a healthcare services provider for the diagnosis, consultation, and treatment of an insured patient for a healthcare service covered under a health insurance policy or contract that is provided through telehealth 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.
A health insurance entity shall provide coverage for healthcare services provided during a telehealth encounter in a manner that is consistent with what the health insurance policy or contract provides for in-person encounters for the same service, and shall reimburse for healthcare services provided during a telehealth encounter without distinction or consideration of the geographic location, or any federal, state, or local designation or classification of the geographic area where the patient is located.
SOURCE: TN Code Annotated, Title 56, Ch. 7, Part 1002, (Accessed May 2024).
A health insurance entity: … Shall reimburse a healthcare services provider for a healthcare service covered under an insured patient’s health insurance policy or contract that is provided through 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.
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.
SOURCE: TN Code Annotated, Part 1003, (Accessed May 2024).
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 August 20, 2020, by the federal centers for Medicare and Medicaid services.
SOURCE: TN Code Annotated, Sec. 56-7-1002, (Accessed May 2024).
Last updated 05/03/2024
Remote Patient Monitoring
POLICY
“Remote patient monitoring services” means using digital technologies to collect medical and other forms of health data from a patient and then electronically transmitting that information securely to healthcare providers in a different location for interpretation and recommendation.
A health insurance entity may consider any remote patient monitoring service a covered medical service if the same service is covered by Medicare. The appropriate parties may negotiate the rate for these services in the manner in which is deemed appropriate by the parties.
SOURCE: TN Code Annotated, Sec. 56-7-1011, (Accessed May 2024).
CONDITIONS
No later than December 31, 2024, the bureau of TennCare shall amend existing rules, or promulgate new rules, on fee-for-service and medicaid managed care plans regarding reimbursement to allow for the reimbursement of remote ultrasound procedures and remote fetal nonstress tests utilizing established CPT codes for such procedures when the patient is in a residence or other off-site location that is separate from the patient’s provider and the same standard of care is met.
SOURCE: House Bill 2461 (2024 Session) & Title 71, Ch. 5, (Accessed May 2024).
PROVIDER LIMITATIONS
No Reference Found
OTHER RESTRICTIONS
Reimbursement of expenses for covered remote patient monitoring services must be established through negotiations conducted by the health insurance entity with the healthcare services provider, healthcare system, or practice group in the same manner as the health insurance entity establishes reimbursement of expenses for covered healthcare services that are delivered by in-person means.
Remote patient monitoring services are subject to utilization review under the Health Care Service Utilization Review Act, compiled in chapter 6, part 7 of this title.
This section does not apply to a health incentive program operated by a health insurance entity that utilized an electronic device for physiological monitoring.
SOURCE: TN Code Annotated, Sec. 56-7-1011, (Accessed May 2024).
When amending or promulgating rules pursuant to subsection (b), the bureau shall ensure that: A remote ultrasound procedure or remote fetal nonstress test is only reimbursable when the provider uses digital technology:
- To collect medical and other forms of health data from a patient and electronically transmit that information securely to a healthcare provider who is in a separate location for the purpose of interpretation and making recommendations;
- That is compliant with the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) (42 U.S.C. § 1320d et seq.); and
- That is approved by the federal food and drug administration; and
A fetal nonstress test is only reimbursable with a place of service modifier for at-home monitoring with remote monitoring solutions that are cleared by the federal food and drug administration for on-label use for monitoring fetal heart rate, maternal heart rate, and uterine activity.
SOURCE: House Bill 2461 (2024 Session) & Title 71, Ch. 5, (Accessed May 2024).
Last updated 05/03/2024
Store and Forward
POLICY
“Store-and-forward telemedicine services”: (A) Means the use of asynchronous computer-based communications between a patient and healthcare services provider at a distant site for the purpose of diagnostic and therapeutic assistance in the care of patients; and (B) Includes the transferring of medical data from one (1) site to another through the use of a camera or similar device that records or stores an image that is sent or forwarded via telecommunication to another site for consultation.
SOURCE: TN Code Annotated, Sec. 56-7-1002 & 1003, (Accessed May 2024).
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 for healthcare services delivered by means of telehealth if the applicable health insurance policy would not provide coverage for the same healthcare services if delivered by in-person means.
This section does not require a health insurance entity to reimburse a healthcare services provider for healthcare services delivered by means of telehealth if the applicable health insurance policy would not reimburse that healthcare services provider if the same healthcare services had been delivered by in-person means.
SOURCE: TN Code Annotated, Sec. 56-7-1002, (Accessed May 2024).
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 for healthcare services delivered by means of provider-based telemedicine if the applicable health insurance policy would not provide coverage for the same healthcare services if delivered by in-person means.
This section does not require a health insurance entity to reimburse a healthcare services provider for healthcare services delivered by means of provider-based telemedicine if the applicable health insurance policy would not reimburse that healthcare services provider if the same healthcare services had been delivered by in-person means.
SOURCE: TN Code Annotated, Sec. 56-7-1003, (Accessed May 2024).
Mental Health & Substance Abuse Services
TennCare will not reimburse for store-and-forward based upon definition of “telehealth systems” which describes it as “live interactive audio-video”.
SOURCE: TN Dept. of Mental Health and Substance Abuse Services. Office of Crisis Services and Suicide Prevention. Minimal Standards of Care. p. 46, (2017) (Accessed Sept. 2022) & TN Dept. of Mental Health and Substance Abuse Services. Office of Crisis Services Telecommunications Guidelines, p. 4, (2012) (Accessed May 2024).
ELIGIBLE SERVICES/SPECIALTIES
No Reference Found
GEOGRPAHIC LIMITS
A health insurance entity … Shall reimburse a healthcare services provider for the diagnosis, consultation, and treatment of an insured patient for a healthcare service covered under a health insurance policy or contract that is provided through telehealth 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.
A health insurance entity shall provide coverage for healthcare services provided during a telehealth encounter in a manner that is consistent with what the health insurance policy or contract provides for in-person encounters for the same service, and shall reimburse for healthcare services provided during a telehealth encounter without distinction or consideration of the geographic location, or any federal, state, or local designation or classification of the geographic area where the patient is located.
SOURCE: TN Code Annotated, Title 56, Ch. 7, Part 1002, (Accessed May 2024).
A health insurance entity: … Shall reimburse a healthcare services provider for a healthcare service covered under an insured patient’s health insurance policy or contract that is provided through 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.
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.
SOURCE: TN Code Annotated, Part 1003, (Accessed May 2024).
TRANSMISSION FEE
No Reference Found