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 07/17/2024

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 (as defined in section 1861(r)) or a practitioner (described in section 1842(b)(18)(C)) to an eligible telehealth individual enrolled under this part notwithstanding that the individual physician or practitioner providing the telehealth service is not at the same location as the beneficiary.

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

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

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

Billing and Payment

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

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

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

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

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

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

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

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

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

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

These requirements do not apply to services:

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

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

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

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

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

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

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

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

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

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

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

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

Background

Section 223 of the Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) – Revision of Medicare Reimbursement for Telehealth Services amended §1834 of the Act to provide for an expansion of Medicare payment for telehealth services.

Effective October 1, 2001, coverage and payment for Medicare telehealth includes consultation, office visits, individual psychotherapy, and pharmacologic management delivered via a telecommunications system. Eligible geographic areas include rural health professional shortage areas (HPSA) and counties not classified as a metropolitan statistical area (MSA). Additionally, Federal telemedicine demonstration projects as of December 31, 2000, may serve as the originating site regardless of geographic location.

An interactive telecommunications system is required as a condition of payment; however, BIPA does allow the use of asynchronous “store and forward” technology in
delivering these services when the originating site is a Federal telemedicine demonstration program in Alaska or Hawaii. BIPA does not require that a practitioner present the patient for interactive telehealth services.

With regard to payment amount, BIPA specified that payment for the professional service performed by the distant site practitioner (i.e., where the expert physician or practitioner is physically located at time of telemedicine encounter) is equal to what would have been paid without the use of telemedicine. Distant site practitioners include only a physician as described in §1861(r) (go to the link and select the applicable title) of the Act and a medical practitioner as described in §1842(b)(18)(C) (go to the link and select the applicable title) of the Act. BIPA also expanded payment under Medicare to include a $20 originating site facility fee (location of beneficiary).

Previously, the Balanced Budget Act of 1997 (BBA) limited the scope of Medicare telehealth coverage to consultation services and the implementing regulation prohibited the use of an asynchronous, ‘store and forward’ telecommunications system. BBA 1997 also required the professional fee to be shared between the referring and consulting practitioners, and prohibited Medicare payment for facility fees and line charges associated with the telemedicine encounter.

BIPA required that Medicare Part B (Supplementary Medical Insurance) pay for this expansion of telehealth services beginning with services furnished on October 1, 2001.

Section 149 of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) amended §1834 of the Act to add certain entities as originating sites for payment of telehealth services. Effective for services furnished on or after January 1, 2009, eligible originating sites include a hospital-based or critical access hospital-based renal dialysis center (including satellites); a skilled nursing facility (as defined in §1819(a) of the Act); and a community mental health center (as defined in §1861(ff)(3)(B) of the Act). MIPPA also amended§1888(e)(2)(A)(ii) of the Act to exclude telehealth services furnished under §1834(m)(4)(C)(ii)(VII) from the consolidated billing provisions of the skilled nursing facility prospective payment system (SNF PPS).

NOTE: MIPPA did not add independent renal dialysis facilities as originating sites for payment of telehealth services.

The telehealth provisions authorized by §1834(m) of the Act are implemented in 42 CFR 410.78 and 414.65.

Conditions of Payment

For Medicare payment to occur, interactive audio and video telecommunications must be used, permitting real-time communication between the distant site physician or practitioner and the Medicare beneficiary. As a condition of payment, the patient must be present and participating in the telehealth visit.

SOURCE: Centers for Medicare and Medicaid Services, Medicare Claims Processing Manual, Ch. 12 – Physicians/Nonphysician Practitioners, Revised 6/6/24, pg. 141-142, 151, (Accessed Jul. 2024).

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

ELIGIBLE SERVICES/SPECIALTIES

Temporary Policy Ending Dec. 31, 2024

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

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

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

See factsheet for Medicare telehealth service list.

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

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

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

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

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

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

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

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

Temporarily removing frequency limitations in 2024 for:

Subsequent inpatient visits
Subsequent nursing facility visits
Critical care consultation

SOURCE: CMS Medicare Learning Network (MLN) Telehealth Services, MLN 901705 (April 2024). (Accessed Jul. 2024).

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

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

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

Permanent Policy

Subject to paragraph (8), the term “telehealth service” means professional consultations, office visits, and office psychiatry services (identified as of July 1, 2000, by HCPCS codes 99241–99275, 99201–99215, 90804–90809, and 90862 (and as subsequently modified by the Secretary)), and any additional service specified by the Secretary.

The Secretary shall establish a process that provides, on an annual basis, for the addition or deletion of services (and HCPCS codes), as appropriate, to those specified in clause (i) for authorized payment under paragraph (1).

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

The use of a telecommunications system may substitute for an in-person encounter for professional consultations, office visits, office psychiatry services, and a limited number of other physician fee schedule (PFS) services. The various services and corresponding current procedure terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes are listed on the CMS website at www.cms.gov/Medicare/MedicareGeneral-Information/Telehealth/

NOTE: Beginning January 1, 2010, CMS eliminated the use of all consultation codes, except for inpatient telehealth consultation G-codes. CMS no longer recognizes office/outpatient or inpatient consultation CPT codes for payment of office/outpatient or inpatient visits. Instead, physicians and practitioners are instructed to bill a new or established patient office/outpatient visit CPT code or appropriate hospital or nursing facility care code, as appropriate to the particular patient, for all office/outpatient or inpatient visits.

Telehealth Consultation Services, Emergency Department or Initial Inpatient versus Inpatient Evaluation and Management (E/M) Visits

A consultation service is an evaluation and management (E/M) service furnished to evaluate and possibly treat a patient’s problem(s). It can involve an opinion, advice, recommendation, suggestion, direction, or counsel from a physician or qualified nonphysician practitioner (NPP) at the request of another physician or appropriate source. Section 1834(m) of the Social Security Act includes “professional consultations” in the definition of telehealth services. Inpatient or emergency department consultations furnished via telehealth can facilitate the provision of certain services and/or medical expertise that might not otherwise be available to a patient located at an originating site. The use of a telecommunications system may substitute for an in-person encounter for emergency department or initial and follow-up inpatient consultations.

Medicare A/B MACs (B) pay for reasonable and medically necessary inpatient or emergency department telehealth consultation services furnished to beneficiaries in hospitals or SNFs when all of the following criteria for the use of a consultation code are met:

An inpatient or emergency department consultation service is distinguished from other inpatient or emergency department evaluation and management (E/M) visits because it is provided by a physician or qualified nonphysician practitioner (NPP) whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source. The qualified NPP may perform consultation services within the scope of practice and licensure requirements for NPPs in the State in which he/she practices;
A request for an inpatient or emergency department telehealth consultation from an appropriate source and the need for an inpatient or emergency department telehealth consultation (i.e., the reason for a consultation service) shall be documented by the consultant in the patient’s medical record and included in the requesting physician or qualified NPP’s plan of care in the patient’s medical record; and
After the inpatient or emergency department telehealth consultation is provided, the consultant shall prepare a written report of his/her findings and recommendations, which shall be provided to the referring physician.

The intent of an inpatient or emergency department telehealth consultation service is that a physician or qualified NPP or other appropriate source is asking another physician or qualified NPP for advice, opinion, a recommendation, suggestion, direction, or counsel, etc. in evaluating or treating a patient because that individual has expertise in a specific medical area beyond the requesting professional’s knowledge.

Unlike inpatient or emergency department telehealth consultations, the majority of subsequent inpatient hospital, emergency department and nursing facility care services require in-person visits to facilitate the comprehensive, coordinated, and personal care that medically volatile, acutely ill patients require on an ongoing basis.

Subsequent hospital care services are limited to one telehealth visit every 3 days. Subsequent nursing facility care services are limited to one telehealth visit every 30 days. Beginning with dates of service on and after January 1, 2021, the limit for nursing facility care services is one telehealth visit every 14 days.

Telehealth Consultation Services, Emergency Department or Initial Inpatient Defined

Emergency department or initial inpatient telehealth consultations are furnished to beneficiaries in hospitals or SNFs via telehealth at the request of the physician of record, the attending physician, or another appropriate source. The physician or practitioner who furnishes the emergency department or initial inpatient consultation via telehealth cannot be the physician of record or the attending physician, and the emergency department or initial inpatient telehealth consultation would be distinct from the care provided by the physician of record or the attending physician. Counseling and coordination of care with other providers or agencies is included as well, consistent with the nature of the problem(s) and the patient’s needs. Emergency department or initial inpatient telehealth consultations are subject to the criteria for emergency department or initial inpatient telehealth consultation services, as described in section 190.3.1 of this chapter.

Payment for emergency department or initial inpatient telehealth consultations includes all consultation related services furnished before, during, and after communicating with the patient via telehealth. Pre-service activities would include, but would not be limited to, reviewing patient data (for example, diagnostic and imaging studies, interim labwork) and communicating with other professionals or family members. Intra-service activities must include the three key elements described below for each procedure code. Post-service activities would include, but would not be limited to, completing medical records or other documentation and communicating results of the consultation and further care plans to other health care professionals. No additional E/M service could be billed for work related to an emergency department or initial inpatient telehealth consultation.

Emergency department or initial inpatient telehealth consultations could be provided at various levels of complexity. (see manual for details).

Although emergency department or initial inpatient telehealth consultations are specific to telehealth, these services must be billed with POS 02 to identify the telehealth technology used to provide the service.

Follow-Up Inpatient Telehealth Consultations Defined

Follow-up inpatient telehealth consultations are furnished to beneficiaries in hospitals or SNFs via telehealth to follow up on an initial consultation, or subsequent consultative visits requested by the attending physician. The initial inpatient consultation may have been provided in-person or via telehealth.

Follow-up inpatient telehealth consultations include monitoring progress, recommending management modifications, or advising on a new plan of care in response to changes in the patient’s status or no changes on the consulted health issue. Counseling and coordination of care with other providers or agencies is included as well, consistent with the nature of the problem(s) and the patient’s needs.

The physician or practitioner who furnishes the inpatient follow-up consultation via telehealth cannot be the physician of record or the attending physician, and the follow-up inpatient consultation would be distinct from the follow-up care provided by the physician of record or the attending physician. If a physician consultant has initiated treatment at an initial consultation and participates thereafter in the patient’s ongoing care management, such care would not be included in the definition of a follow-up inpatient consultation. Follow-up inpatient telehealth consultations are subject to the criteria for inpatient telehealth consultation services, as described in section 190.3.1 of this chapter.

Payment for follow-up inpatient telehealth consultations includes all consultation related services furnished before, during, and after communicating with the patient via telehealth. Pre-service activities would include, but would not be limited to, reviewing patient data (for example, diagnostic and imaging studies, interim labwork) and communicating with other professionals or family members. Intra-service activities must include at least two of the three key elements described below for each procedure code. Post-service activities would include, but would not be limited to, completing medical records or other documentation and communicating results of the consultation and further care plans to other health care professionals. No additional evaluation and management service could be billed for work related to a follow-up inpatient telehealth consultation.

Follow-up inpatient telehealth consultations could be provided at various levels of complexity (see manual for details).

Although follow-up inpatient telehealth consultations are specific to telehealth, these services must be billed with POS 02 to identify the telehealth technology used to provide the service.

ESRD-Related Services as a Telehealth Service

The ESRD-related services included in the monthly capitation payment (MCP) with 2 or 3 visits per month and ESRD-related services with 4 or more visits per month may be paid as Medicare telehealth services. However, at least 1 visit must be furnished face-to-face “hands on” to examine the vascular access site by a physician, clinical nurse specialist, nurse practitioner, or physician assistant. An interactive audio and video telecommunications system may be used for providing additional visits required under the 2-to-3 visit MCP and the 4-or-more visit MCP. The medical record must indicate that at least one of the visits was furnished face-to-face “hands on” by a physician, clinical nurse specialist, nurse practitioner, or physician assistant.

Clinical Criteria: The visit, including a clinical examination of the vascular access site, must be conducted face-to-face “hands on” by a physician, clinical nurse specialist, nurse practitioner or physician’s assistant. For additional visits, the physician or practitioner at the distant site is required, at a minimum, to use an interactive audio and video telecommunications system that allows the physician or practitioner to provide medical management services for a maintenance dialysis beneficiary. For example, an ESRD-related visit conducted via telecommunications system must permit the physician or practitioner at the distant site to perform an assessment of whether the dialysis is working effectively and whether the patient is tolerating the procedure well (physiologically and psychologically). During this assessment, the physician or practitioner at the distant site must be able to determine whether alteration in any aspect of the beneficiary’s prescription is indicated, due to such changes as the estimate of the patient’s dry weight.

Subsequent Hospital Care Services and Subsequent Nursing Facility Care Services as Telehealth Services

Subsequent hospital care services are limited to one telehealth visit every 3 days. The frequency limit of the benefit is not intended to apply to consulting physicians or practitioners, who should continue to report initial or follow-up inpatient telehealth consultations using the applicable HCPCS G-codes.

Similarly, subsequent nursing facility care services are limited to one telehealth visit every 30 days. Beginning with dates of service on and after January 1, 2021, the limit for nursing facility care services is one telehealth visit every 14 days. Furthermore, subsequent nursing facility care services reported for a Federally-mandated periodic visit under 42 CFR 483.40(c) may not be furnished through telehealth. The frequency limit of the benefit is not intended to apply to consulting physicians or practitioners, who should continue to report initial or follow-up inpatient telehealth consultations using the applicable HCPCS G-codes.

Inpatient telehealth consultations are furnished to beneficiaries in hospitals or skilled nursing facilities via telehealth at the request of the physician of record, the attending physician, or another appropriate source. The physician or practitioner who furnishes the initial inpatient consultation via telehealth cannot be the physician or practitioner of record or the attending physician or practitioner, and the initial inpatient telehealth consultation would be distinct from the care provided by the physician or practitioner of record or the attending physician or practitioner. Counseling and coordination of care with other providers or agencies is included as well, consistent with the nature of the problem(s) and the patient’s needs. Initial and follow-up inpatient telehealth consultations are subject to the criteria for inpatient telehealth consultation services, as described in section 190.3 of this chapter.

Diabetes Self-Management Training as a Telehealth Service

Individual and group DSMT services may be paid as a Medicare telehealth service. Before 03-11-2016, this manual provision required that 1 hour of the 10 hour DSMT benefit’s initial training must be furnished in-person to allow for effective injection training. Because injection training is not always clinically indicated, we are revising this provision to permit all 10 hours of the initial training and the two (2) hours of annual follow-up training to be furnished via telehealth in those cases when injection training is not applicable. The in-person injection training, when provided, may be furnished through either individual or group DSMT services. By reporting place of service (POS) 02 or the – GT or –GQ modifier with HCPCS code G0108 (Diabetes outpatient self-management training services, individual, per 30 minutes) or G0109 (Diabetes outpatient self-management training services, group session (2 or more), per 30 minutes), the distant site practitioner attests that the beneficiary has received or will receive 1 hour of in-person DSMT services for purposes of injection training when it is indicated during the year following the initial DSMT service or any calendar year’s 2 hours of follow-up training.

Payment for Telehealth for Individuals with Acute Stroke

Section 50325 of the Bipartisan Budget Act of 2018 amended section 1834(m) of the Act by adding a new paragraph (6) that provides special rules for telehealth services furnished on or after January 1, 2019, for purposes of diagnosis, evaluation, or treatment of symptoms of an acute stroke (acute stroke telehealth services), as determined by the Secretary. Specifically, section 1834(m)(6)(A) of the Act removes the restrictions on the geographic locations and the types of originating sites where acute stroke telehealth services can be furnished. Section 1834(m)(6)(B) of the Act specifies that acute stroke telehealth services can be furnished in any hospital, critical access hospital, mobile stroke units (as defined by the Secretary), or any other site determined appropriate by the Secretary, in addition to the current eligible telehealth originating sites. Section 1834(m)(6)(C) of the Act limits payment of an originating site facility fee to acute stroke telehealth services furnished in sites that meet the usual telehealth restrictions under section 1834(m)(4)(C) of the Act. These are identified in Section 190.1 of this chapter.

Effective for claims with dates of service on and after January 1, 2019, contractors shall accept new informational HCPCS modifier G0 (G zero), to be used to identify Telehealth services furnished for purposes of diagnosis, evaluation, or treatment of symptoms of an acute stroke. Modifier G0 is valid for all:

Telehealth distant site codes billed with Place of Service (POS) code 02 or Critical Access Hospitals, CAH method II (revenue codes 096X, 097X, or 098X); or
Telehealth originating site facility fee, billed with HCPCS code Q3014

Editing of Telehealth Claims

Medicare telehealth services (as listed in section 190.3) are billed with POS 02 and 10. The contractor shall approve covered telehealth services if the physician or practitioner is licensed under State law to provide the service. Contractors must familiarize themselves with licensure provisions of States for which they process claims and disallow telehealth services furnished by physicians or practitioners who are not authorized to furnish the applicable telehealth service under State law. For example, if a nurse practitioner is not licensed to provide individual psychotherapy under State law, he or she would not be permitted to receive payment for individual psychotherapy under Medicare. The contractor shall install edits to ensure that only properly licensed physicians and practitioners are paid for covered telehealth services.

Contractors shall deny telehealth services if the physician or practitioner is not eligible to bill for them.

SOURCE: Centers for Medicare and Medicaid Services, Medicare Claims Processing Manual, Ch. 12 – Physicians/Nonphysician Practitioners, Revised 6/6/24, pg. 145, (Accessed Jul. 2024).

ESRD Treatment – Temporary Policy

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

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

Since telehealth dialysis services are limited to renal dialysis services for home dialysis patients telehealth related to renal dialysis services is not available for beneficiaries with AKI.

SOURCE: Centers for Medicare and Medicaid Services, Medicare Benefit Policy Manual, Ch. 11: End Stage Renal Disease (ESRD), 3/1/19, pg. 60, (Accessed Jul. 2024).

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

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

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

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

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

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

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

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

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

Through December 31, 2024:

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

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

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

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

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

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

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

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

See fact sheet for additional details.

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

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

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

Temporarily delaying the requirement for an in-person visit with the physician or practitioner within 6 months before initiating mental health telehealth services, and, again, at subsequent intervals as the Secretary determines appropriate, as well as similar requirements for RHCs, FQHCs, and hospital outpatient departments (HOPDs)
Temporarily removing frequency limitations in 2024 for:
- Subsequent inpatient visits
- Subsequent nursing facility visits
- Critical care consultation

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

Communication Technology-Based Services (CTBS)

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

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

CTBS services are not regarded by CMS as telehealth.

ELIGIBLE PROVIDERS

Temporary Policy – Ends Dec. 31, 2024

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

…

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

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

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

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

[Also listed in Teaching Hospital COVID Factsheet]

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

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

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

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

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

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

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

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

Beginning on or after January 1, 2023, HHAs may voluntarily report the use of telecommunications technology in the provision of home health services on claims. This information is required on home health claims beginning on July 1, 2023. HHAs shall submit the use of telecommunications technology when furnishing home health services, on the home health claim via three G-codes.

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

HHAs shall submit services furnished via telecommunications technology in line item detail and each service must be reported as a separately dated line under the appropriate revenue code for each discipline furnishing the service. Two occurrences of G0320 or G0321 on the same day for the same revenue code shall be reported as separate line items.

Claims with no billable visits are not submitted to Medicare, including claims for billing periods where only telehealth services are provided.

Telehealth services with HCPCS codes G0320 or G0321 are reported with units of 1.

SOURCE: Centers for Medicare and Medicaid Services, Medicare Claims Processing Manual, Ch. 10: Home Health Agency Billing, 10/19/23, pg. 61, (Accessed Jul. 2024).

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

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

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

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

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

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

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

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

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

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

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

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

For SNFs and inpatient rehabilitation facilities (IRFs), under Part A, CMS pays through a bundled payment for all covered Part A services. To the extent that therapy services furnished via telehealth or telecommunications technology are covered Part A services, then these services would be considered part of the bundled prospective payment system payment under Part A and such services would not be separately billable for those patients in a Part A covered SNF or IRF stay.

Again, Part B outpatient therapy, DSMT, and MNT services furnished remotely by institutional providers of therapy, should continue to be furnished and billed the same way they have been during the PHE, which can include the use of telecommunications technology.

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

Inpatient Rehabilitation Facility (IRF) Flexibilities Issued on March 30, 2020

On March 30, 2020, CMS issued the interim final rule “Medicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency” (CMS-1744-IFC). …

This interim final rule also revises the physician supervision requirement in 42 CFR § 412.622(a)(3)(iv) and § 412.29(e) to permit physician visits in the IRF required under these provisions to be conducted via telehealth to safeguard the health and safety of Medicare beneficiaries and the rehabilitation physicians treating them during the PHE. Contractors shall allow rehabilitation physicians to use telehealth services as defined in section 1834(m)(4)(F) of the Act to conduct the required 3 physician visits per week during the PHE for the COVID-19 pandemic.

SOURCE: Centers for Medicare and Medicaid Services, Medicare Benefit Policy Manual, Ch. 1: Inpatient Hospital Services Covered Under Part A, 8/6/21, pg. 40, (Accessed Jul. 2024).

Permanent Policy

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

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

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

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

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

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

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

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

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

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

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

Temporarily removing frequency limitations in 2024 for:
- Subsequent inpatient visits
- Subsequent nursing facility visits
- Critical care consultation

Institutional Billing

Use modifier 95 when the clinician is in the hospital and the patient is in the home, as well as for outpatient therapy services provided via telehealth by qualified PTs, OTs, or SLPs employed by hospitals through December 31, 2024

See the Policy Overview section at the top for Professional Billing requirements.

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

ESRD Services: The MCP physician, for example, the physician or practitioner who is responsible for the complete monthly assessment of the patient and establishes the patient’s plan of care, may use other physicians and practitioners to furnish ESRD-related visits through an interactive audio and video telecommunications system. The non-MCP physician or practitioner must have a relationship with the billing physician or practitioner such as a partner, employees of the same group practice or an employee of the MCP physician, for example, the non MCP physician or practitioner is either a W-2 employee or 1099 independent contractor. However, the physician or practitioner who is responsible for the complete monthly assessment and establishes the ESRD beneficiary’s plan of care should bill for the MCP in any given month.

A medical professional is not required to present the beneficiary to physician or practitioner at the distant site unless medically necessary. The decision of medical necessity will be made by the physician or practitioner located at the distant site.

The term “distant site” means the site where the physician or practitioner, providing the professional service, is located at the time the service is provided via a telecommunications system.

The payment amount for the professional service provided via a telecommunications system by the physician or practitioner at the distant site is equal to the current fee schedule amount for the service provided. Payment for an office visit, consultation, individual psychotherapy or pharmacologic management via a telecommunications system should be made at the same amount as when these services are furnished without the use of a telecommunications system. For Medicare payment to occur, the service must be within a practitioner’s scope of practice under State law. The beneficiary is responsible for any unmet deductible amount and applicable coinsurance.

As a condition of Medicare Part B payment for telehealth services, the physician or practitioner at the distant site must be licensed to provide the service under state law. When the physician or practitioner at the distant site is licensed under state law to provide a covered telehealth service (i.e., professional consultation, office and other outpatient visits, individual psychotherapy, and pharmacologic management) then he or she may bill for and receive payment for this service when delivered via a telecommunications system.

If the physician or practitioner at the distant site is located in a CAH that has elected Method II, and the physician or practitioner has reassigned his/her benefits to the CAH, the CAH bills its regular A/B/MAC (A) for the professional services provided at the distant site via a telecommunications system, in any of the revenue codes 096x, 097x or 098x. All requirements for billing distant site telehealth services apply.

Medicare Practitioners Who May Bill for Covered Telehealth Services are Listed Below (subject to State law)

Physician
Nurse practitioner
Physician assistant
Nurse-midwife
Clinical nurse specialist
Clinical psychologist*
Clinical social worker*
Registered dietitian or nutrition professional
Certified registered nurse anesthetist

*Clinical psychologists and clinical social workers cannot bill for psychotherapy services that include medical evaluation and management services under Medicare. These practitioners may not bill or receive payment for the following CPT codes: 90805, 90807, and 90809.

As specified in 42 CFR 410.141(e) and stated in Pub. 100-02, Medicare Benefit Policy Manual, chapter 15, section 300.2, individual and group DSMT services may be furnished by a physician, other individual, or entity that furnishes other items or services for which direct Medicare payment may be made and that submits necessary documentation to, and is accredited by a national accreditation organization approved by CMS. However, consistent with the statutory requirements of section 1834(m)(1) of the Act, as provided in 42 CFR 410.78(b)(1) and (b)(2) and stated in section 190.6 of this chapter, Medicare telehealth services, including individual and group DSMT services furnished as a telehealth service, could only be furnished by a physician, PA, NP, CNS, CNM , clinical psychologist, clinical social worker, or registered dietitian or nutrition professional, as applicable.

See manual for additional billing guidance.

SOURCE: Centers for Medicare and Medicaid Services, Medicare Claims Processing Manual, Ch. 12 – Physicians/Nonphysician Practitioners, Revised 6/6/24, pg. 145, 152 (Accessed Jul. 2024).

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

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

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

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

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

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

Communication Technology-Based Services

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

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

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

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

Medicare waives the RHC and FQHC face-to-face requirements when an RHC or FQHC furnishes these services 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.

RHCs and FQHCs may only bill for these services when the medical discussion or remote evaluation is for a condition not related to an RHC or FQHC service provided within the previous 7 days, and does not lead to an RHC or FQHC service within the next 24 hours or at the soonest available appointment, since in those situations, Medicare already pays for the services as part of the RHC or FQHC per-visit payment.

RHCs and FQHCs can bill G0511, G0512, and G0071 alone or with other payable services on an RHC or FQHC claim.

SOURCE: Medicare Learning Network Matters Factsheet, MM10843, Aug. 10, 2018, (Accessed Jul. 2024).

What are “virtual communication services” for RHCs and FQHCs?

In the 2019 Physician Fee Schedule (PFS) Final Rule, CMS finalized a policy that, effective January 1, 2019, RHCs and FQHCs can receive payment for virtual communication services when at least 5 minutes of communication technology-based or remote evaluation services are furnished by an RHC or FQHC practitioner to a patient who has had an RHC or FQHC billable visit within the previous year, and both of the following requirements are met:

The medical discussion or remote evaluation is for a condition not related to an RHC or FQHC service provided within the previous 7 days, and
The medical discussion or remote evaluation does not lead to an RHC or FQHC visit within the next 24 hours or at the soonest available appointment.

See FAQ for more details.

SOURCE: Virtual Communication Services RHCs and FQHCs FAQs, December 2018, (Accessed Jul. 2024).

Mental Health for FQHCs and RHCs

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

A mental health service should be reported using a valid HCPCS code for the service furnished, a mental health revenue code, and for FQHCs, an appropriate FQHC mental health payment code. For detailed information on reporting mental health services and claims processing, see Pub. 100-04, Medicare Claims Processing Manual, chapter 9, http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/downloads/clm104c09.pdf

SOURCE: CMS, Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) Medicare Benefit Policy Manual Chapter 13 Update, Jan. 26, 2023, pg. 38 (Accessed Jul. 2024).

RHCs and FQHCs may bill the Telehealth originating site facility fee on a RHC or FQHC claim under revenue code 0780 and HCPCS code Q3014. Telehealth services are the only services billed on FQHC claims that are subject to the Part B deductible. Additionally, a FQHC payment code and qualifying visit HCPCS code are not required when the only service reported on the claim is for Telehealth services. RHCs and FQHCs are not authorized to serve as distant practitioners for Telehealth services.

For more information on Telehealth services please see Pub 100-04, chapter 12, section 190: http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Downloads/clm104c12.pdf

SOURCE: CMS, Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) Medicare Claims Processing Manual Ch. 9, Update, Jun 7, 2023, pg. 36 (Accessed Jul. 2024).

A face-to-face encounter means an in-person or telehealth encounter between the treating practitioner and the beneficiary.

SOURCE: Centers for Medicare and Medicaid Services, Medicare Claims Processing Manual, Ch. 5: Durable Medical Equipment, Prosthetics, Orthotics, Supplies (DMEPOS) Items and Services Having Special DME Review Considerations, 2/15/24, pg. 7, (Accessed Jul. 2024).

FQHCs/RHCs

RHCs and FQHCs are not authorized to serve as a distant site for telehealth consultations, which is the location of the practitioner at the time the telehealth service is furnished, and may not bill or include the cost of a visit on the cost report. This includes telehealth services that are furnished by an RHC or FQHC practitioner who is employed by or under contract with the RHC or FQHC, or a non-RHC or FQHC practitioner furnishing services through a direct or indirect contract. For more information on Medicare telehealth services, see Pub. 100-02, Medicare Benefit Policy Manual, chapter 15, and Pub. 100-04, Medicare Claims Processing Manual, chapter 12.

SOURCE: CMS, Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) Medicare Benefit Policy Manual Chapter 13 Update, Jan. 26, 2023, pg. 41, (Accessed Jul. 2024).

Home Health (HH) Agencies

Starting on or after January 1, 2023, you may voluntarily report the use of telecommunications technology in providing HH services on HH payment claims. We’ll require this information on HH claims starting on July 1, 2023. You’ll submit the use of telecommunications technology on the HH claim using the following 3 G-codes:

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

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

Can MFTs and MHCs perform telehealth services?

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

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

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

Opioid Treatment Programs

During the Public Health Emergency (PHE) for the COVID-19 pandemic, as well as after the conclusion of the PHE, therapy and counseling may be furnished using audio-only telephone calls rather than via two-way interactive audio-video communication technology if two-way audio/video communications technology is not available to the beneficiary, provided all other applicable requirements are met, including circumstances in which the beneficiary is not capable of or does not consent to the use of devices that permit a two-way audio/video interaction

OTPs are allowed to furnish the substance use counseling, individual therapy, and group therapy included in the bundle via two-way interactive audio-video communication technology, as clinically appropriate, in order to increase access to care for beneficiaries. In addition, initiation of treatment with buprenorphine (but not methadone) via the OTP intake add-on code may be furnished via two-way audio-video communications technology to the extent that the use of audio-video telecommunications technology to initiate treatment with buprenorphine is authorized by DEA and SAMHSA at the time the service is furnished. For additional information please refer to Section 20 – Definitions relating to OTPs, C. Opioid use disorder treatment service. During the Public Health Emergency (PHE) for the COVID-19 pandemic, as well as after the conclusion of the PHE, therapy and counseling may be furnished using audio-only telephone calls rather than via two-way interactive audio-video communication technology if two-way audio/video communications technology is not available to the beneficiary, provided all other applicable requirements are met, including circumstances in which the beneficiary is not capable of or does not consent to the use of devices that permit a two-way audio/video interaction.

Beginning January 1, 2021, OTPs are allowed to use two-way interactive audio-video communication technology, as clinically appropriate, to furnish the periodic assessment add-on code. Additionally, during the PHE which expired on May 11, 2023, in cases where a beneficiary did not have access to two-way audio-video communications technology, periodic assessments could be furnished using audio-only telephone calls if all other applicable requirements were met. Through the end of CY 2024, in cases where a beneficiary does not have access to two-way audio-video communications technology, periodic assessments can be furnished using audio-only telephone calls if all other applicable requirements are met.

Beginning January 1, 2023, OTPs are allowed to furnish the OTP intake add-on code via two-way audio- video communication technology when billed for the initiation of treatment with buprenorphine, to the extent that the use of audio-video telecommunications technology to initiate treatment with buprenorphine is authorized by DEA and SAMHSA at the time the service is furnished. OTPs are also allowed to use audio- only communication technology to initiate treatment with buprenorphine in cases where audio-video technology is not available to the beneficiary, including circumstances in which the beneficiary is not capable of or has not consented to the use of devices that permit a two-way, audio/video interaction.

OTPs providing intensive outpatient services to Medicare beneficiaries with an OUD shall not receive payment under Medicare part B if the intensive outpatient services are furnished via audio-video or audio-only communications technology.

Telemedicine services should not, under any circumstances, expand the scope of practice of a healthcare professional or permit practice in a jurisdiction (the location of the patient) where the provider is not licensed.

Counseling or therapy furnished via communication technology as part of OUD treatment services furnished by an OTP must not be separately billed by the practitioner furnishing the counseling or therapy because these services would already be paid through the bundled payment made to the OTP.

SOURCE: Centers for Medicare and Medicaid Services, Medicare Benefit Policy Manual, Ch. 17: Opioid Treatment Programs (OTPs), 12/21/23, (Accessed Jul. 2024).

ELIGIBLE SITES

Temporary Policy – Ends Dec. 31, 2024

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

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

Permanent Policy

Eligible Sites:

The office of a physician or practitioner.
A critical access hospital
A rural health clinic
A Federally qualified health center
A hospital
A hospital-based or critical access hospital- based renal dialysis center (including satellites).
A skilled nursing facility
Rural emergency hospital
A community mental health center
A renal dialysis facility for purposes of individuals with end-stage renal disease getting home dialysis.
The home of an individual, but only for purposes of individuals with end-stage renal disease getting home dialysis or telehealth services to treat substance use disorder or individuals with co-occurring mental health disorders, or mental health disorders under certain circumstances.
Mobile Stroke Unit
The home of an individual (only for 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 a beneficiary for the purposes of diagnosis, evaluation, and/or treatment of a mental health disorder for services that are furnished during the period beginning on the first day after the end of the emergency period as defined in our regulation at § 400.200 and ending on December 31, 2024 except as otherwise provided in this paragraph. Payment will not be made for a telehealth service furnished under this paragraph unless the following conditions are met:
- The physician or practitioner has furnished an item or service in-person, without the use of telehealth, for which Medicare payment was made (or would have been made if the patient were entitled to, or enrolled for, Medicare benefits at the time the item or service is furnished) within 6 months prior to the initial telehealth service;
- The physician or practitioner has furnished an item or service in-person, without the use of telehealth, at least once within 12 months of each subsequent telehealth service described in this paragraph, unless, for a particular 12-month period, the physician or practitioner and patient agree that the risks and burdens associated with an in-person service outweigh the benefits associated with furnishing the in-person item or service, and the practitioner documents the reason(s) for this decision in the patient’s medical record.
- The requirements of paragraphs (b)(3)(xiv)(A) and (B) may be met by another physician or practitioner of the same specialty and subspecialty in the same group as the physician or practitioner who furnishes the telehealth service, if the physician or practitioner who furnishes the telehealth service described under this paragraph is not available.

Note:

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

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

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

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 Jul. 2024).

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

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

After December 31, 2024:

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

Institutional Billing

Professional billing

Starting January 1, 2024, use:

POS 02: Telehealth Provided Other than in Patient’s Home
- Descriptor: The location where health services and health related services are provided or received, through telecommunication technology. Patient is not located in their home when receiving health services or health related services through telecommunication technology.
POS 10: Telehealth Provided in Patient’s Home
- Descriptor: The location where health services and health related services are provided or received through telecommunication technology. 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.
- Starting January 1, 2024, we pay for telehealth services you provide to patients in their homes at the non-facility PFS rate. See MLN Matters Article MM13452.

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

Effective for claims with dates of service on and after January 1, 2024, claims for covered Telehealth services furnished at the distant site can be billed with POS code 10 when the patient is located in their home. Claims for covered Telehealth services using POS 10, if payable by Medicare, shall be paid at the Medicare Physician Fee Schedule non-facility rate.

The POS code 10 for Telehealth would not apply to originating site facilities billing a facility fee.

SOURCE: Centers for Medicare and Medicaid Services, Pub. 100-04, Medicare Claims Processing, Transmittal 12671, June 6, 2024, (Accessed Jul. 2024).

Medicare beneficiaries are eligible for telehealth services only if they are presented from an originating site located in either a rural health professional shortage area (HPSA) as defined by §332(a)(1) (A) of the Public Health Services Act or in a county outside of an MSA as defined by §1886(d)(2)(D) (go to the link and select the applicable title) of the Act.

Effective January 1, 2014, rural HPSAs include HPSAs located outside of a county outside of an MSA as well as those located in rural census tracts as determined by the Office of Rural Health Policy. Also effective January 1, 2014, geographic eligibility for an originating site is established for each calendar year based upon the status of the area as of December 31st of the prior calendar year.

Exception to rural HPSA and non MSA geographic requirements Entities participating in a Federal telemedicine demonstration project that were approved by or were receiving funding from the Secretary of Health and Human Services as of December 31, 2000, qualify as originating sites regardless of geographic location. Such entities are not required to be in a rural HPSA or nonMSA.

The term originating site means the location of an eligible Medicare beneficiary at the time the service being furnished via a telecommunications system occurs. Originating sites authorized by law are listed below:

The office of a physician or practitioner;
A hospital (inpatient or outpatient);
A critical access hospital (CAH);
A rural health clinic (RHC);
A federally qualified health center (FQHC);
A hospital-based or critical access hospital-based renal dialysis center (including satellites) (effective January 1, 2009);
A skilled nursing facility (SNF) (effective January 1, 2009); and
A community mental health center (CMHC) (effective January 1, 2009).

NOTE: Independent renal dialysis facilities are not eligible originating sites.

Payment for Telehealth for Individuals with Acute Stroke

Telehealth distant site codes billed with Place of Service (POS) code 02 or Critical Access Hospitals, CAH method II (revenue codes 096X, 097X, or 098X); or

Telehealth originating site facility fee, billed with HCPCS code Q3014

The term originating site means the location of an eligible Medicare beneficiary at the time the service being furnished via a telecommunications system occurs.

SOURCE: Centers for Medicare and Medicaid Services, Medicare Claims Processing Manual, Ch. 12 – Physicians/Nonphysician Practitioners, Revised 6/6/24, (Accessed Jul. 2024).

The list of settings where a physician’s services are paid at the facility rate include: …

Telehealth Provided Other than in Patient’s Home (POS code 02); …

Physicians’ services are paid at nonfacility rates for procedures furnished in the following settings:

Telehealth Provided in Patient’s Home (POS code 10);

SOURCE: Centers for Medicare and Medicaid Services, Medicare Claims Processing Manual, Ch. 12 – Physicians/Nonphysician Practitioners, Revised 6/6/24, pg. 12-13, (Accessed Jul. 2024).

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

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

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

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

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

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

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

Treatment of stroke telehealth services

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

With respect to telehealth services described in subparagraph (A), the term “originating site” shall include any hospital (as defined in section 1861(e)) or critical access hospital (as defined in section 1861(mm)(1)), any mobile stroke unit (as defined by the Secretary), 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 Jul. 2024).

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

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

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

In the case of telehealth services described in paragraph (1) 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 under section 1834(m)(2)(B).
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 Jul. 2024).

Hospital Expansion Site

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

Hospital Without Walls

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

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

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

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

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

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

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

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

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

02 Telehealth Provided Other than in Patient’s Home (January 1, 2017): 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.
10 Telehealth Provided in Patient’s Home (January 1, 2022): 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.

Beginning in CY 2024, practitioners may receive either the facility or the non-facility payment rate for an otherwise eligible Medicare telehealth service, depending on whether the billing practitioner selects POS code 02 or POS code 10. The only two valid POS codes for Medicare telehealth billing in CY 2024 are POS 02 and POS 10. As appropriate, POS 02 or POS 10 may be used and must be paired with the appropriate telehealth modifier (modifier 93 for audio-only and modifier 95 for audio/video). The payment rate for POS 02 is the facility payment rate (F); the payment rate for POS 10 is the non-facility rate (NF). Use of audio-only (93) or audio-video (95) does not change rate of payment, only the POS code determines the non-facility or facility payment rate.

Mobile Unit Setting

A physician or practitioner’s office, even if mobile, qualifies to serve as a telehealth originating site. Assuming such an office also fulfills the requirement that it be located in either a rural health professional shortage area as defined under section 332(a)(1)(A) of the Public Health Service Act (42 U.S.C. 254e(a)(1)(A)) or in a county that is not included in a Metropolitan Statistical Area as defined in section 1886(d)(2)(D) of the Act, the originating physician’s office should use POS code 11 (Office) in order to ensure appropriate payment for services on the list of Medicare Telehealth Services.

SOURCE: Centers for Medicare and Medicaid Services, Medicare Claims Processing Manual, Ch. 26: Completing and Processing Form CMS-1500 Data Set, 6/6/24, pg. 23-32, (Accessed Jul. 2024).

Home Health Services

The face-to-face encounter can be performed via a telehealth service, in an approved originating site. An originating site is considered to be the location of an eligible Medicare beneficiary at the time the service being furnished via a telecommunications system occurs. Medicare beneficiaries are eligible for telehealth services only if they are presented from an originating site located in a rural health professional shortage area or in a county outside of a Metropolitan Statistical Area.

Entities that participate in a Federal telemedicine demonstration project approved by (or receiving funding from) the Secretary of the Department of Health and Human Services as of December 31, 2000, qualify as originating sites regardless of geographic location.

The originating sites authorized by law are:

The office of a physician or practitioner;
Hospitals;
Critical Access Hospitals (CAH);
Rural Health Clinics (RHC);
Federally Qualified Health Centers (FQHC);
Hospital-based or CAH-based Renal Dialysis Centers (including satellites);
Skilled Nursing Facilities (SNF); and
Community Mental Health Centers (CMHC).

Section 1895(e) governs the home health prospective payment system (PPS) and provides that telehealth services are outside the scope of the Medicare home health benefit and home health PPS.

SOURCE: Centers for Medicare and Medicaid Services, Medicare Benefit Policy Manual, Ch. 7: Home Health Services, 12/21/23, (Accessed Jul. 2024).

FQHCs/RHCs

RHCs and FQHCs may serve as an originating site for telehealth services, which is the location of an eligible Medicare beneficiary at the time the service being furnished via a telecommunications system occurs. RHCs and FQHCs that serve as an originating site for telehealth services are paid an originating site facility fee.

Although FQHC services are not subject to the Medicare deductible, the deductible must be applied when an FQHC bills for the telehealth originating site facility fee, since this is not considered an FQHC service.

SOURCE: CMS, Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) Medicare Benefit Policy Manual Chapter 13 Update, Jan. 26, 2023, pg. 41, (Accessed Jul. 2024).

GEOGRAPHIC LIMITS

Temporary Policy – Ends Dec. 31, 2024

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

Permanent Policy

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

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

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

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

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

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

NOTE: Independent renal dialysis facilities are not eligible originating sites.

SOURCE: Center for Medicare and Medicaid Services, Medicare Claims Processing Manual, Chapter 12 – Physicians/Nonphysicians Practitioners (Jun. 6, 2024), p. 145. (Accessed July. 2024).

Treatment of stroke telehealth services

The geographic requirements described in paragraph (4)(C)(i) shall not apply with respect to telehealth services furnished on or after January 1, 2019, for purposes of section 1881(b)(3)(B), at an originating site described in subclause (VI), (IX), or (X) of paragraph (4)(C)(ii).

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

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

After December 31, 2024:

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

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

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

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

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

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

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

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

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

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

Payment for Telehealth for Individuals with Acute Stroke

Effective for claims with dates of service on and after January 1, 2019, contractors shall accept new informat HCPCS modifier G0 (G zero), to be used to identify Telehealth services furnished for purposes of diagnosis, evaluation, or treatment of symptoms of an acute stroke. Modifier G0 is valid for all:

Telehealth distant site codes billed with Place of Service (POS) code 02 or Critical Access Hospitals, CAH method II (revenue codes 096X, 097X, or 098X); or
Telehealth originating site facility fee, billed with HCPCS code Q3014

SOURCE: Centers for Medicare and Medicaid Services, Medicare Claims Processing Manual, Ch. 12 – Physicians/Nonphysician Practitioners, Revised 6/6/24, (Accessed Jul. 2024).

Home Health Services

The originating sites authorized by law are:

The office of a physician or practitioner;
Hospitals;
Critical Access Hospitals (CAH);
Rural Health Clinics (RHC);
Federally Qualified Health Centers (FQHC);
Hospital-based or CAH-based Renal Dialysis Centers (including satellites);
Skilled Nursing Facilities (SNF); and
Community Mental Health Centers (CMHC).

Section 1895(e) governs the home health prospective payment system (PPS) and provides that telehealth services are outside the scope of the Medicare home health benefit and home health PPS.

SOURCE: Centers for Medicare and Medicaid Services, Medicare Benefit Policy Manual, Ch. 7: Home Health Services, 12/21/23, (Accessed Jul. 2024).

FACILITY/TRANSMISSION FEE

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

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

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

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

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

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

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

The originating site facility fee is a separately billable Part B payment. The contractor pays it outside of other payment methodologies. This fee is subject to post payment verification.

For telehealth services furnished from October 1, 2001, through December 31, 2002, the originating site facility fee was the lesser of $20 or the actual charge. For services furnished on or after January 1 of each subsequent year, the originating site facility fee is updated by the Medicare Economic Index. The updated fee is included in the Medicare Physician Fee Schedule (MPFS) Final Rule, which is published by November 1 prior to the start of the calendar year for which it is effective. The updated fee for each calendar year is also issued annually in a Recurring Update Notification instruction for January of each year. See manual for more information about the payment amount and billing procedures for different types of entities.

SOURCE: Centers for Medicare and Medicaid Services, Medicare Claims Processing Manual, Ch. 12 – Physicians/Nonphysician Practitioners, Revised 6/6/24, pg. 145, (Accessed Jul. 2024).

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

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

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

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

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

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

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

Indian Health Services

All charges, except therapies, telehealth originating site facility fee, PPV, influenza virus and hepatitis B vaccines are combined and reported under revenue code 024X (all-inclusive ancillary) on TOB 12X (hospital inpatient Part B). Medicare Part B deductible and coinsurance amounts are applied to inpatient Medicare Part B ancillary services, but are waived by the IHS. The MSN is suppressed.

All charges, except for therapies, telehealth originating site facility fee, PPV, influenza virus vaccine, hepatitis B vaccine and hospital-based ambulance services are combined and reported under revenue code 0510 (clinic visit) on TOB 13X (hospital outpatient).

Effective January 1, 2009, IHS providers, including CAHs are paid separately from the AIR for the Telehealth Originating Site Facility Fee. HCPCS code Q3014 (“telehealth originating site facility fee”) is a Part B benefit. The fee is updated each calendar year by the Medicare Economic Index announced in the annual Physician Fee Schedule Final Regulation.

IHS providers are paid for HCPCS code Q3014 at the fee schedule payment, not the provider’s usual all-inclusive payment methodology (e.g., inpatient DRG or AIR or CAH per diem). For CAHs, the payment amount is 80 percent of the fee, not 101 percent of cost.

The Medicare Part B deductible and coinsurance apply to the Telehealth Originating Site Facility Fee, but are waived by the IHS.

The Telehealth Originating Site Facility Fee is reported on TOB 12X, 13X or 85X along with the revenue code 0780 and HCPCS code Q3014 as described in Chapter 12, Section 190 of Pub. 100-04, Medicare Claims Processing Manual.

No clinic visit shall be billed if this is the only service received. There is no requirement that a practitioner present the patient for interactive telehealth services.

SOURCE: Centers for Medicare and Medicaid Services, Medicare Claims Processing Manual, Ch. 19: Indian Health Services, 5/20/22, pg. 36, 51-52, (Accessed Jul. 2024).

Federally Qualified Health Centers/Rural Health Clinics

SOURCE: Center for Medicare and Medicaid Services, Medicare Claims Processing Manual, Chapter 9 – Rural Health Clinics/Federally Qualified Health Centers (Jun. 7, 2023), p. 36. (Accessed Jul. 2024).

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Alabama

Last updated 11/20/2024

POLICY

This general information is related to the telehealth medical …

POLICY

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

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

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

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

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

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

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

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

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

Therapy Services

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

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

SOURCE: AL Medicaid Management Information System Provider Manual, Therapy Services, Oct. 2024, pg. 17, (Accessed Nov. 2024).

Several manual chapters refer to telemedicine chapter for information.

ELIGIBLE SERVICES/SPECIALTIES

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

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

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

A covered telemedicine service will count towards each recipient’s benefit limit of 14 annual physician office visits.

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

Services NOT Eligible for Reimbursement for Telemedicine Services

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

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

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

BMI Requirements

The BMI will be required for office visits including the telemedicine visits. The BMI is required at least once per calendar year on all claims with procedure codes 99202-99205, 99211- 99215, and 99242-99245 and EPSDT procedure codes 99382-99385 and 99392-99395. Providers should use subjective data to calculate the BMI which can include providers asking the recipient for his or her height and weight during the telemedicine visit. The BMI should be calculated, based on the information provided by the recipient, and appended to the claim for reimbursement. The BMI should also be documented in the recipient’s medical record.

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

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

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

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

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

ABA Therapy Services

SOURCE: AL Medicaid Management Information System Provider Manual, Therapy Services, Oct. 2024, pg. 17, (Accessed Nov. 2024).

Nurse-Family Partnership

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

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

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

Prescriptions for Certain Home Health Services

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

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

Behavioral Health

Refer to Chapter 112, Telemedicine Services, for general information and limitations.

SOURCE: AL Medicaid Management Information System Provider Manual, Behavioral Health, Ch. 34, Oct. 2024, (Accessed Nov. 2024).

A Well Child Check Up

Refer to Chapter 112, Telemedicine Services, for general benefit information and limitations.

SOURCE: AL Medicaid Management Information System Provider Manual, A Well Child Check-Up (EPSDT), A-5, Oct. 2024, (Accessed Nov. 2024).

Targeted Case Management

Refer to Chapter 112, Telemedicine Services, for general information and limitations.

SOURCE: AL Medicaid Management Information System Provider Manual, Targeted Case Management, Ch. 106-27, Oct. 2024, (Accessed Nov. 2024).

OTPs shall provide adequate: … Initial medical examination.

The screening and full examination may be completed via telehealth for those recipients being admitted for treatment at the OTP with either buprenorphine or methadone, if a practitioner or primary care provider determines that an adequate evaluation of the recipient can be accomplished via telehealth and according to state and federal law.

SOURCE: AL. Admin Code 580-9-44-.29, (Accessed Oct. 2024).

ELIGIBLE PROVIDERS

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

Provider Types Eligible for Reimbursement for Telemedicine Services

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

Provider Types NOT Eligible for Telemedicine Reimbursement

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

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

Telemedicine Provider Requirements

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

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

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

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

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

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

Providers must indicate an in-state or qualifying bordering state site of practice address from which telemedicine services will be provided.

Note: This policy does not expand or grant any authority outside that authority granted to the provider by their respective licensure board or by federal or state law.

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

The BMI will be required for all visits including the telemedicine visits. (Refer to Chapter 112, Telemedicine Services, for general benefit information and limitations.)

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. 14). Oct. 2024, (Accessed Nov. 2024).

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

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

SOURCE: AL Medicaid Management Information System Provider Manual, Rehabilitative Services – DMH, DHR, DYS, DCA, Sec. 105, Oct. 2024. (Accessed Nov. 2024).

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

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

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

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

Therapy Services

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

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

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

SOURCE: AL Medicaid Management Information System Provider Manual, Therapy Services, Oct. 2024, pg. 17, (Accessed Nov. 2024).

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

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

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

Provider-Based RHCs and RHCs Independent

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

SOURCE: AL Medicaid Management Information System Provider Manual, Provider-Based RHCs, Oct. 2024, Ch. 32, pg. 2, & AL Medicaid Management Information System Provider Manual, RHCs Independent, Oct. 2024, Ch. 36, pg. 3, (Accessed Nov. 2024).

Certified Registered Nurse Practitioner and Physician Assistant

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

Telemedicine Service (931)

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

Eye Care Services

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

Telemedicine (931) Ophthalmologist and Optometrist

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

ELIGIBLE SITES

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

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

The following sites are recognized by Medicaid as origination sites:

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

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

Note: If a Medicaid-enrolled provider performs another medically necessary service(s), the provider may bill for the covered service(s) in addition to providing his/her facility as an origination site and be eligible for reimbursement for the origination site facility fee and the other medically necessary service(s).

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

Certified Registered Nurse Practitioner and Physician Assistant

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

02 – Telemedicine Services

SOURCE: AL Medicaid Management Information System Provider Manual, Certified Registered Nurse Practitioner and Physician Assistant, Ch. 21 Oct. 2024, pg. 8, (Accessed Nov. 2024).

GEOGRAPHIC LIMITS

No reference found.

FACILITY/TRANSMISSION FEE

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

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

A recipient’s home should not be considered an origination site entitled to receive an origination site fee.

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

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Alaska

Last updated 11/22/2024

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 same manner as if the services had been 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. Regulations calculating the rate of payment for a rural health clinic or federally qualified health center must treat services provided through telehealth in the same manner as if the services had been provided in person, including calculations based on the rural health clinic’s or federally qualified health center’s reasonable costs or on the number of visits for recipients provided services, and must define “visit” to include a visit provided by telehealth. The department may not decrease the rate of payment for a telehealth service based on the location of the person providing the service, the location of the eligible recipient of the service, the communication method used, or whether the service was provided asynchronously or synchronously. 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

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

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

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

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

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

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

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

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

Note: Manual is under review.

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

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

What are the covered modalities for telehealth services?

Synchronous through a real-time, interactive:

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

Asynchronous:

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

Patient-Initiated Online Digital Services:

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

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

ELIGIBLE SERVICES/SPECIALTIES

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

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

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

The department shall pay for all services covered by the medical assistance program provided through telehealth in the same manner as if the services had been provided in person, including

behavioral health services;
services covered under home and community-based waivers;
services covered under state plan options under 42 U.S.C. 1396-1396p (Title XIX, Social Security Act);
services provided by a community health aide or a community health practitioner certified by the Community Health Aide Program Certification Board;
services provided by a behavioral health aide or behavioral health practitioner certified by the Community Health Aide Program Certification Board;
services provided by a dental health aide therapist certified by the Community Health Aide Program Certification Board;
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;
services provided by a rural health clinic or a federally qualified health center;
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;
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;
assessment, evaluation, consultation, planning, diagnosis, treatment, case management, and the prescription, dispensing, and administration of medications, including controlled substances; and
services covered under federal waivers or demonstrations other than home and community-based waivers.

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

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

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

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

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

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

SOURCE: Medicaid Provider Assistance Information, Division of Behavioral health, Fee Schedules [fee schedules listed at bottom of page], (Accessed Nov. 2024).

Eligible services:

An initial visit
One follow-up visit;
A consultation to confirm a diagnosis;
Diagnostic, therapeutic or interpretive service;
A psychiatric or substance abuse assessments;
Psychotherapy
Pharmacological management services on an individual recipient basis.

Note: Manual is under review.

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

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

Note: Manual is under review.

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

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

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

The department will not pay

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

long term services and supports targeted case management services, except for case management services provided under 7 AAC 128.010(b)(2).

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

Alaska Medicaid will not pay for

The use of telemedicine equipment and systems
Services delivered by telephone when not part of a dedicated audio conference system
Services delivered by facsimile
The following services provided by telemedicine application:
- Direct entry midwife
- Durable medical equipment (DME)
- End-stage renal disease
- Home and community-based waiver
- Personal care assistant
- Pharmacy
- Private duty nursing
- Transportation and accommodation
- Vision (includes visual care, dispensing, or optician services)

Note: Manual under review.

SOURCE: State of AK Dept. of Health and Social Svcs., Alaska Medical Assistance Provider Billing Manuals for Physician, ARNP and PA Services (5/13), pg. 31-32 (Nov. 2024).

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

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

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

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

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

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

Non-Emergency Medical Transportation and Escort Coverage

Clarifies types of services feasible for telehealth throughout the document.

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

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

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

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

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

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

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

Are initial hospital services reimbursable if performed via telehealth?

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

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

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

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

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

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

DME Oxygen Guidelines and Concerns

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

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

ELIGIBLE PROVIDERS

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

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

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

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

Procedure Code Modifier:

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

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

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

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

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

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

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

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

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

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

Can direct entry midwives provide telehealth services?

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

Can optometrists provide telehealth services?

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

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

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

Providers subject to Telemedicine Business Registry requirements:

Alaska-licensed audiologist or speech-language pathologist; behavior analyst; chiropractor; professional counselor; dentist or dental hygienist; dietitian or nutritionist; naturopath; marital and family therapist; physician, podiatrist, osteopath, or physician assistant; direct-entry midwife; nurse or advanced practice registered nurse (APRN); dispensing optician; optometrist; pharmacist; physical therapist or occupational therapist; psychologist or psychological associate; social worker; or a physician licensed in another state.
* This information is based off of May 22nd, 2023, DCCED publication. See DCCED’s Telehealth Information Webpage for updates.

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

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

…

services provided by a community health aide or a community health practitioner certified by the Community Health Aide Program Certification Board;
services provided by a behavioral health aide or behavioral health practitioner certified by the Community Health Aide Program Certification Board;
services provided by a dental health aide therapist certified by the Community Health Aide Program Certification Board;
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;
services provided by a rural health clinic or a federally qualified health center;
services provided by an individual or entity that is required by statute or regulation to be licensed or certified by the department or that is eligible to receive payments, in whole or in part, from the department;

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

The role of the provider falls into three categories:

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.
Presenting Provider: Introduces a patient to the consulting provider during an interactive telemedicine session (may assist in the telemedicine consultation).
Consulting Provider: Evaluates the patient and/or medical data/images using telemedicine mode of delivery upon recommendation of the referring provider.

NOTE: Manual is under review.

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

Mental Health

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

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

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

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

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

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

Uniform Alcoholism and Intoxication Treatment

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

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

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

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

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

Various services are allowed via telehealth for Alaska Behavioral Health and Substance Use Disorder (SUD) Providers. See manuals.

SOURCE: State of Alaska Department of Health and Social Services Division of Behavioral Health Services, Alaska Behavioral Health Providers Services Standards & Administrative Procedures for Behavioral Health Provider Services & SUD Services [see both documents], (Accessed Nov. 2024).

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

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

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

Tribal FQHC

Will my facility be able to continue to provide telemedicine (video-audio synchronous) and telephonic (audio-only) behavioral health services as a Tribal FQHC?

Refer to the most current guidance document on telehealth: https://extranetsp.dhss.alaska.gov/hcs/medicaidalaska/Provider/Updates/20230919_Telehealth_FAQs.pdf.

Telehealth Services. Will my facility be able to provide telemedicine (video-audio synchronous), telephonic (audio-only), and store and forward telehealth services and be reimbursed for those services as a Tribal FQHC?

Yes, telehealth services regulations were effective 9/1/2023. Refer to the most current guidance on telehealth services: https://extranetsp.dhss.alaska.gov/hcs/medicaidalaska/Provider/Sites/Telehealth.html

Can a Tribal FQHC provide services off-site after February 11, 2025?

Yes, please refer to telehealth regulations that were effective 9/1/2023 https://aws.state.ak.us/OnlinePublicNotices/Notices/Attachment.aspx?id=142671

SOURCE: Alaska Medicaid, FAQs on Tribal FQHCs, (Accessed Nov. 2024).

This manual includes information about Alaska Medical Assistance for the following types of providers and services:

Telemedicine

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

SOURCE: State of Alaska Department of Health and Social Services Division, Alaska Medical Assistance Provider Billing Manual, Tribal Facility Services, Policies and Procedures, Feb. 18, 2021, (Accessed Nov. 2024).

ELIGIBLE SITES

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

Place of Service Code:

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

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

GEOGRAPHIC LIMITS

No reference found.

FACILITY TRANSMISSION FEE

The department will not pay

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

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

READ LESS

Arizona

Last updated 05/29/2024

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, (5/2/2024), pg. 48, & IHS/Tribal Provider Billing Manual, (5/2/2024), pg. 52 (Accessed Oct. 2024).

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

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

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

ELIGIBLE SERVICES/SPECIALTIES

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

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

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

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

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

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

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

SOURCE: AZ Health Care Cost Containment System, AHCCCS Fee-For-Service Provider Billing Manual, Ch. 10: Individual Practitioner Services, (5/2/2024), pg 50 -51; IHS/Tribal Provider Billing Manual, Ch. 8 Individual Practitioner Services, (5/2/24), pg. 52-54 (Accessed Oct. 2024).

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

SOURCE: AZ Health Care Cost Containment System, AHCCCS Fee-For-Service Provider Manual, Ch. 10: Individual Practitioner Services, (5/2/2024), pg. 51, (Accessed Oct. 2024).

AHCCCS Policy Manual

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

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

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

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

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

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

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

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

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

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

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

In addition to services provided pursuant to section 36-2907, subsection A, paragraph 7, the 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 Oct. 2024).

Remote Monitoring:

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

SOURCE: AZ Administrative Code Title 20, Ch. 5, pg. 402. (Accessed Oct. 2024).

Home Health Services

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

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

SOURCE: AZ Medical Policy for AHCCCS Covered Services. Home Health Services, Ch 211, (pg. 1 & 5), Approved 4/11/24. & FFS Manual, Home Health, Ch. 20, Revised 10/1/18, pg. 2, & IHS/Tribal Billing Manual, Ch. 13 Home Health, (Revised 10/1/18) pg. 2, (Accessed Oct. 2024).

Medical Equipment, Medical Appliances and Medical Supplies

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

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

Transportation

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

SOURCE: AZ Medical Policy for AHCCCS Covered Services. Transportation, Ch 310-BB, (pg. 4), Approved 8/6/24. (Accessed Oct. 2024).

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

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

Therapeutic Foster Care for Children (TFC)

A BHP shall participate in a meeting with the TFC Agency worker and the TFC Family Provider at least once per month, in-person or via telemedicine (i.e., interactive audio/video communications). The BHP shall also be available by request or as needed to provide any necessary support to the TFC Family Provider.

During the initial six weeks of a child receiving services in a TFC, the TFC agency shall conduct one home visit per week with the child and TFC Family Provider. In addition to licensure required home visits outlined in AAC Title 21, Chapter 6 the TFC agency will support the TFC Family Provider with therapeutic interventions used to meet TFC Treatment Plan goals; these visits may occur in-person or via telemedicine (i.e., interactive audio/video communications)

SOURCE: AZ Medical Policy for AHCCCS Covered Services. Therapeutic Foster Care for Children, Ch 320-W, (pg. 4-5), Approved 5/14/24. (Accessed Oct. 2024).

Out-Of-State Placements for Behavioral Health Treatment

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

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

Behavioral Health Crisis Services and Care Coordination

Crisis services are provided in a variety of settings, such as face-to-face at an individual’s home, in the community or via telehealth (inclusive of services provided via text, chat, and phone).

SOURCE: AZ Medical Policy for AHCCCS Covered Services. Behavioral Health Crisis Services and Care Coordination, Ch 590, (pg. 3), Approved 7/10/24. (Accessed Oct. 2024).

ELIGIBLE PROVIDERS

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

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

SOURCE: AZ Health Care Cost Containment System, AHCCCS Fee-For- Service Provider Billing Manual, Ch. 10: Individual Practitioner Services, (5/2/24), pg. 51, & IHS/Tribal Provider Billing Manual (5/2/24), pg. 55. (Accessed Oct. 2024).

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

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

SOURCE: AZ Health Care Cost Containment System, AHCCCS IHS/Tribal Provider Billing Manual (5/2/24), pg. 55. (Accessed Oct. 2024).

Telehealth and telemedicine may qualify as an FQHC/RHC visit if it meets the requirements specified in AMPM 320-I, Telehealth and Telemedicine. To qualify as a reimbursable telehealth visit, claims with procedure code T1015 must additionally include another eligible code from the AHCCCS Telehealth Code Set.

SOURCE: AZ Health Care Cost Containment System, AHCCCS. Provider Qualifications and Provider Requirements. Ch. 600, Oct. 2015, pg. 3 & AZ Health Care Cost Containment System, AHCCCS Fee-For- Service Provider Billing Manual, Ch. 10: Addendum FQHC/RHC, (8/25/2022), pg. 3, (Accessed Oct. 2024).

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

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

School Based Claiming Program

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

SOURCE: AZ Medical Policy for AHCCCS Covered Services. School Based Claiming Program Ch 700, (710 pg. 3), Approved 8/3/21. (Accessed Oct. 2024).

ELIGIBLE SITES

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

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

Fee-for-Service Provider Manual definitions:

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

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

SOURCE: AZ Health Care Cost Containment System, AHCCCS Fee-For- Service Provider Billing Manual, Ch. 10: Individual Practitioner Services, (5/2/24), pg. 50 & IHS/Tribal Provider Billing Manual, (5/2/24). pg. 54 (Accessed Oct. 2024).

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

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

GEOGRAPHIC LIMITS

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

SOURCE: AZ Medical Policy for AHCCCS Covered Services. Telehealth and Telemedicine Ch 300, (320-I pg. 1), Approved 8/29/23 ; AZ Health Care Cost Containment System, AHCCCS Fee-For-Service Provider Billing Manual, Ch. 10: Individual Practitioner Services, (5/2/24), pg. 48, & IHS/Tribal Provider Billing Manual, (5/2/24), pg. 52. (Accessed Oct. 2024).

FACILITY/TRANSMISSION FEE

No Reference Found

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Arkansas

Last updated 10/21/2024

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. I-13 Updated Jan. 1, 2022 (Accessed Oct. 2024).

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

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

Rural Health Centers

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

SOURCE: AR Medicaid Provider Manual. Section II Rural Health. Rule 211.300. p. II-6 Updated 10/13/03. (Accessed May 2024).

Occupational Therapy, Physical Therapy and Speech-Language Pathology Services

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

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 Oct. 2024).

ELIGIBLE SERVICES/SPECIALTIES

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

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

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

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

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

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

Occupational Therapy, Physical Therapy and Speech-Language Pathology Services

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

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

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

Rural Health Centers

Arkansas Medicaid covers RHC encounters and two ancillary services (fetal echography and echocardiography) as “telemedicine” services.

Arkansas Medicaid defines telemedicine services as medical services performed as electronic transactions in real time. 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. 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 2/1/24. (Accessed Oct. 2024).

Patient-Led Arkansas Shared Savings Entity (PASSE) Program

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

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

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

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

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

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

Home Health

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

SOURCE: AR Medicaid Provider Manual. Section II Nurse Practitioner. Rule 203.020, II-7. Updated 1/1/24 (Section updated 7-1-17) & AR Medicaid Provider Manual. Section II Home Health. Rule 206.000, II-5. Section updated July 1, 2017, & AR Medicaid Provider Manual. Section II Certified Nurse-Midwife. Rule 204.101, II-6. Section updated July 1, 2017. (Accessed Oct. 2024).

Behavioral Health Conditions and Services

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

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

Ambulance Services

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

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

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

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

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

See statute for additional restrictions.

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

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

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

Ground ambulance triage, treat, and transport to alternative location/destination services (T3AL) may be covered only when provided by an ambulance company that is licensed and is an enrolled provider in the Arkansas Medicaid Program. An ambulance service may triage and transport a beneficiary to an alternative destination or treat in place if the ambulance service is coordinating the care of the beneficiary through telemedicine with a physician for a medical-based complaint or with a behavioral health specialist for a behavioral-based complaint. Telemedicine rules are described in Section 105.190 and must be followed unless instructions are given within Section II of the prevailing Medicaid manual. The use of audio-only electronic technology is not allowed for T3AL services.

For the purposes of T3AL, a behavioral health specialist is a board-certified psychiatrist or an Independently Licensed Practitioner who can provide counseling services to Medicaid beneficiaries in the Outpatient Behavioral Health program.

SOURCE: AR Medicaid Provider Manual. Section II Transportation. Rule 214.100, II-7 to 8. Updated 2/1/24, (Accessed Oct. 2024).

Group Therapy – General Professional Requirement (Not Medicaid exclusive)

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

Telemedicine 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 Oct. 2024).

Life360 HOMES

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

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

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

AR Independent Assessment (ARIA)

Behavioral Health Services:

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

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

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

Life Choices Lifeline and Continuum of Care Program

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

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

SOURCE: AR Rules for Life Choices Lifeline and Continuum of Care Program, Sec. 102, (Lexis Nexis: 016 Dep of Human Services, 29 Div. of Medical Services, 009 Developmental Screens for Children), (Accessed Oct. 2024).

Covered EIDT services are clinic-based services and cannot be delivered through telemedicine or at any location other than the licensed EIDT facility.

SOURCE: AR Rules and Regulations, Sec. 016.05.24-002, & AR Medicaid Provider Manual. Section II EIDT. Rule 221.000. Updated 4-1-24 (Accessed Oct. 2024).

ELIGIBLE PROVIDERS

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

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

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

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

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

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

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

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

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

See Miscellaneous section for additional restrictions.

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

Medication Assisted Treatment (MAT) for Opioid Use Disorder

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

SOURCE: AR Medicaid Provider Manual Physician Section II-129, 2/1/24, (Accessed Oct. 2024)

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

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

Patient-Led Arkansas Shared Savings Entity (PASSE) Program

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

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

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

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

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

Ambulance Service

An ambulance service may:

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

An encounter between an ambulance service and a beneficiary that results in no transport of the enrollee is allowable if the beneficiary declines to be transported against medical advice and the ambulance service is coordinating the care of the beneficiary through telemedicine with a physician for a medical-based complaint.

An encounter between an ambulance service and a beneficiary is billable as follows:

The ambulance service may bill either a basic life support (BLS) or advanced life support (ALS) service according to the level of the service provided to the beneficiary, plus mileage. Mileage may be billed for treating in the alternative location (one-way mileage to the location of the beneficiary. Mileage rules set forth in Section 204.000, 205.000, 214.000, and 216.000 will otherwise be followed.

SOURCE: AR Medicaid Provider Manual. Section II Transportation. Rule 214.110, II-8. Updated 2/1/24, (Accessed Oct. 2024).

ELIGIBLE SITES

Patient-Led Arkansas Shared Savings Entity (PASSE) Program

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

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

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

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

School Based

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

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

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

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

Early Intervention Day Treatment (EIDT)

Since EIDT services are clinic-based services, three services cannot be delivered through telemedicine or at any location other than through the licensed EIDT clinic. EIDT providers are considered all-inclusive, meaning a beneficiary attending an EIDT should have all of their habilitative occupational therapy, physical therapy, and speech-language pathology service needs performed by the EIDT program at the EIDT clinic.

SOURCE: AR Rules and Regulations, Sec. 016.05.24-002, (Accessed Oct. 2024).

GEOGRAPHIC LIMITS

No Reference Found

FACILITY/TRANSMISSION FEE

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

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

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

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

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

Federally Qualified Health Centers

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

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

SOURCE: AR Medicaid Provider Manual. Section II FQHC. Rule 262.120. Updated 2/1/24. pg. II-34, (Accessed Oct. 2024).

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

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

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California

Last updated 06/29/2024

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 Jun. 2024).

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

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

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

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

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

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

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

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

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

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

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

SOURCE: Welfare and Institutions Code 14132.725. (Accessed Jun. 2024).

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

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

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

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

Patient Choice of Telehealth Modality

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

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

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

Exception to Telehealth Modalities Provider Requirement

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

Right to In-person Services

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

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

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

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth (Mar. 2024). Pg. 6-7; Medi-Cal: Family PACT – Benefits: Clinical Services Overview (May 2024), p. 10. (Accessed Jun. 2024).

Brief Virtual Communications and Check-ins

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

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

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

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

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

See manual for billing examples.

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

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

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

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

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

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

SOURCE: Welfare and Institutions Code 14132.100. (Accessed Jun. 2024).

Family PACT

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

SOURCE: CA Department of Health Care Services. Family Planning, Access, Care and Treatment Program. Benefits Manual. May. 2024, Pg. 7. (Accessed Jun. 2024).

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

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

Managed Care

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

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

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

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

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

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

See manual for billing examples.

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

Local Educational Agency (LEA)

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

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

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

Effective retroactively for dates of service on or after July 1, 2023, CPT^® codes 99402, 99403 and 99404 (preventive medicine counseling and/or risk factor reduction intervention) have been added for Provider Type 55 to allow for additional minutes of service for Health Education and Anticipatory Guidance Individualized Education Plan (IEP)/Individualized Family Services Plan (IFSP) under the Local Educational Agency (LEA) Medi-Cal Billing Option Program (BOP). The chart notes that the codes are eligible via telehealth when billed with the addition of modifier 95.

SOURCE: CA Department of Health Care Services. (DHCS). Addition of CPT Codes for LEA BOP. Apr. 2024. (Accessed Jun. 2024).

Dental Services

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

A patient who receives teledentistry services under these provisions shall also have the ability to receive in-person services from the dentist or dental practice or assistance in arranging a referral for in-person services.

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

Drug Medi-Cal Treatment Program

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

SOURCE: Welfare and Institutions Code 14132.731. (Accessed Jun. 2024).

ELIGIBLE SERVICES/SPECIALTIES

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

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

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

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

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

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

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

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

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 27. Dec 2022. (Accessed Jun. 2024).

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.

See Telehealth Modifier Reference Sheet- Organized by Delivery System and 2024 Medi-Cal Provider Training: RHC/FQHC Services, p. 16 for more information on modifiers.

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 (Mar. 2024). Pg. 10. (Accessed Jun. 2024).

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

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

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

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

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

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.

Tribal FQHCs may bill for a telehealth visit if it is medically necessary for a billable provider to be present with a patient during the telehealth visit.
IHS-MOA clinics/tribal FQHCs must submit claims for telehealth services using the appropriate per visit IHS-MOA billing codes/tribal FQHC all-inclusive billing code sets, modifiers and related claims submission requirements. Providers may refer to the Indian Health Services (IHS), Memorandum of Agreement (MOA) 638, Clinics: Billing Codes section in the appropriate Part 2 manual. Tribal FQHC providers may refer to the Tribal Federally Qualified Health Centers (Tribal FQHCs): Billing Codes section in the appropriate Part 2 manual.

SOURCE: CA Department of Health Care Services (DHCS). Indian Health Services, Memorandum of Agreement (MOA) 638, Clinics Manual. Jun. 2024, Pg. 7-8; Tribal FQHC May 2023, p. 13. (Accessed Jun. 2024).

Dental Services

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

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

Home Health & Durable Medical Equipment

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

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

CA Children’s Services (CCS)

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

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

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

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

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

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

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

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

Opioid Use Disorder Treatment Services

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

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

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

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. (Accessed Jun. 2024).

Multipurpose Senior Services Program

Providers are required to report revenue code 0780 with each MSSP procedure code that is rendered via telehealth.

SOURCE: DHCS Provider Bulletin, Multipurpose Senior Services Program Transitions to HIPAA-Compliant Code Sets. Dec. 2023. & Multipurpose Senior Services Program (MSSP) Billing Codes, p. 15. Dec. 2023. (Accessed Jun. 2024).

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

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

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

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

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

Doula Services

IHS-MOA and Tribal FQHC providers may bill for doula services provided via telehealth using either modifier 93 for synchronous audio-only or modifier 95 for synchronous video.

SOURCE: CA Dept. of Health Care Services (DHCS) Provider Bulletin, Doula Services Now a Benefit for IHS-MOA and Tribal FQHC Providers. Jul. 2023. (Accessed Jun. 2024).

Doulas may bill for services provided by telehealth using either modifier 93 for synchronous audio-only or modifier 95 for synchronous video. Doulas should refer to the Medicine: Telehealth section in Part 2 of the Provider Manual for guidance regarding providing services via telehealth for prenatal or postpartum visits, labor and delivery support, and for abortion and miscarriage support.

SOURCE: CA Dept. of Health Care Services (DHCS) Doula Services Manual, p. 5-6. (Dec. 2022). (Accessed Jun. 2024).

Family PACT

Family PACT covered benefits or services, identified by CPT or HCPCS codes and subject to all existing Family PACT coverage and reimbursement policies, including any Treatment Authorization Request (TAR) requirements, may be provided via a telehealth modality, as outlined in this section, only if all of the following are satisfied:

The provider at the distant site believes that the benefits or services being provided are clinically appropriate based upon evidence-based medicine and/or best practices to be delivered via telehealth.
The benefits or services delivered via telehealth meet the procedural definition and components of the CPT or HCPCS code(s), as defined by the American Medical Association (AMA), associated with the Family PACT covered service or benefit, as well as any extended guidelines as described in this section and the Medicine: Telehealth section in the appropriate Part 2 Medi-Cal manual.
The benefits or services provided via telehealth meet all laws regarding confidentiality of health care information and a client’s right to his or her medical information.

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

SOURCE: CA Department of Health Care Services. Family Planning, Access, Care and Treatment Program. Benefits Manual. May. 2024, Pg. 11. (Accessed Jun. 2024).

Medication Abortion

The COVID-19 PHE ended May 11, 2023, but DHCS will continue to allow flexibilities granted during the PHE for services billed under HCPCS code S0199. The following policies are effective July 1, 2023:

Medication abortion policy allows for 77 days gestational age and continues the COVID-19 PHE policies regarding in-person visits and ultrasounds without payment reduction.
When determined clinically appropriate based on a provider’s clinical judgement, services may be provided through telehealth. Confirmation of pregnancy must be documented.
Ultrasound to confirm gestational age and/or intrauterine pregnancy, and ultrasound to confirm completion of abortion, must be provided when clinically indicated, but is not required in all cases.
Providers may bill S0199 without providing a pre-abortion ultrasound when a pre-abortion ultrasound is not clinically indicated.
Providers may bill S0199 without providing a post-abortion ultrasound when a post-abortion ultrasound is not clinically indicated.
Providers may bill S0199 when a post-abortion assessment is provided via telehealth, if clinically appropriate and if patient prefers assessment via telehealth. An in-person visit must be offered but is not required to bill S0199.
For recipients who do not show up for follow-up visits, HCPCS code S0199 must be billed using the “from-through” method with the “no show” date as the “through” date and modifier 52 is not required.

In addition, as specified in DHCS telehealth guidance, services may be provided via telehealth when:

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

As specified in the above telehealth guidance, delivery of benefits or services that require the in-person presence of the patient for any reason are not appropriate for delivery via a telehealth modality.

SOURCE: DHCS Provider Bulletin, Post-PHE Policy Clarification for Medication Abortion. (Sept. 2023). (Accessed Jun. 2024).

Managed Care

Existing Covered Services, identified by Current Procedural Terminology – 4th Revision (CPT-4) or Healthcare Common Procedure Coding System (HCPCS) codes and subject to any existing treatment authorization requirements, may be provided via a Telehealth modality only if all of the following criteria are satisfied:

The treating Provider at the distant site believes the Covered Services being provided are clinically appropriate to be delivered via Telehealth based upon evidence-based medicine and/or best clinical judgment.
The Member has provided verbal or written consent.
The Medical Record documentation substantiates that the Covered Services delivered via Telehealth meet the procedural definition and components of the CPT-4 or HCPCS code(s) associated with the Covered Service. Providers are not required to:
- Document a barrier to an in-person visit for Covered Services provided via Telehealth (WIC section 14132.72(d)); or
- Document the cost effectiveness of Telehealth to be reimbursed for Covered Services provided via a Telehealth modality.
The Covered Services provided via Telehealth meet all state and federal laws regarding confidentiality of health care information and a Member’s right to their own medical information.

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

Behavioral Health Services

Medi-Cal covered services delivered via telehealth (synchronous audio-only and synchronous video interactions) are reimbursable in Medi-Cal Specialty Mental Health Services (SMHS), the Drug Medi-Cal Organized Delivery System (DMC-ODS), and the Drug Medi-Cal (DMC) programs (including initial assessments, only as set forth in this BHIN). Patient choice must be preserved; therefore, patients have the right to request and receive in-person services. See Behavioral Health Information Notice No.: 23-018 for program specific telehealth reimbursement requirements. Behavioral Health Information Notice No.: 21-075 has additional program specific information related to telehealth services.

The use of telehealth modifiers on SMHS, DMC, and DMC-ODS claims is mandatory and necessary for accurate tracking of telehealth usage in behavioral health. Billing codes must be consistent with the level of care provided. The following codes shall be used in SMHS, DMC, and DMC-ODS:

Synchronous video interaction service: GT
Synchronous audio-only interaction service: SC
Asynchronous store and forward (e-consult in DMC-ODS only): GQ

Effective July 1, 2023, additional modifiers will be required for Current Procedural Terminology (CPT) codes after DHCS implements a successor payment methodology and transitions from Healthcare Common Procedure Coding System (HCPCS) codes to a combination of HCPCS and CPT codes. See BHIN 22-046 for more information and the MEDCCC Library for the version of the billing manuals that will take effect in 2023. If a telehealth modifier is used for outpatient services on or after July 1, 2023, the place of service must be “02” or “10” unless the service is Mobile Crisis Services.

SOURCE: CA Department of Health Care Service (DHCS). Behavioral Health Information Notice No.: 23-018. Apr. 25, 2023. Pg. 2, 8. (Accessed Jun. 2024).

Managed Care & Behavioral Health

Effective no sooner than January 1, 2024, to preserve a beneficiary’s right to access covered services in person, a provider furnishing services through telehealth must do one of the following:

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

SOURCE: CA Department of Health Care Services (DHCS). All Plan Letter 23-007: Telehealth Services Policy. Apr. 10, 2023, p. 3.; CA Department of Health Care Service (DHCS). Behavioral Health Information Notice No.: 23-018. Apr. 25, 2023. Pg. 3-5, 8 (Accessed Jun. 2024).

Diabetes Prevention Program (DPP)

The Medi-Cal DPP can be offered through telehealth where trained peer coaches deliver sessions via remote classroom or telehealth where the peer coach is present in one location and participants are calling or video-conferencing in from another location. DPP providers that offer online, virtual, or distance learning programs may bill one of the fourteen HCPCS codes in conjunction with an appropriate telehealth modifier when all requirements for billing the HCPCS code have been met.

SOURCE: CA Dept. of Health Care Services. Medi-Cal’s Diabetes Prevention Program (DPP) Policy Preview. Pg. 3, 8. (Accessed Jun. 2024).

Medication Therapy Management

MTM pharmacist services can be rendered via telecommunication systems provided the pharmacy is meeting the contractual requirements for telehealth. When MTM services are provided or received, through a telecommunication system, the provider must indicate on the claim by entering the most applicable Place of Service code in the Place of Service Code field (Box 24b).

SOURCE: CA Dept. of Health Care Services, Medi-Cal Manual: Medication Therapy Management, May 2024, p. 7. (Accessed Jun. 2024).

Non-Specialty Mental Health Services: Psychiatric and Psychological Services

NSMHS may be delivered via telehealth when Medi-Cal requirements are met. For more information, refer to the Medicine: Telehealth section of this manual.

SOURCE: CA Dept. of Health Services, Medi-Cal Non-Specialty Mental Health Services: Psychiatric and Psychological Services, Dec. 2021, p. 5. (Accessed Jun. 2024).

ELIGIBLE PROVIDERS

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

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

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

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

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

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

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

Telehealth services must meet all billing requirements that would have applied if the applicable services were delivered via a face-to-face encounter with a billable provider and meet the applicable standard of care. An FQHC patient who receives telehealth services shall otherwise be eligible to receive in-person services from that FQHC pursuant to Health Resources Services Administration requirements.

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

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

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

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

Dental Professionals

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

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

Psychiatrists

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

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

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

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

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

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

Non-Physician Medical Practitioners

Licensed Midwife Code – T1014 Telehealth.

SOURCE: CA Dept. of Health Care Services, Medi-Cal, Non-Physician Medical Practitioners, Mar. 2024, p. 27. (Accessed Jun. 2024).

ELIGIBLE SITES

“Originating site” means a site where a patient is located at the time health care services are provided via a telecommunications system or where the asynchronous store and forward service originates. 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.

“Distant site” means a site where a health care provider who provides health care services is located while providing these services via a telecommunications system. The distant site for purposes of telehealth 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. (Accessed Jun. 2024).

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

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

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

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

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

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

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

Family PACT

“Distant site” means a site where a health care provider who provides health care services is located while providing these services via a telecommunications system. The distant site can be different from the enrolled Family PACT service site for telehealth purposes only.

“Originating site” means a site where a patient is located at the time health care services are provided via a telecommunications system or where the asynchronous store and forward service originates. For purposes of reimbursement for Family PACT covered services provided through telehealth, the type of setting where services are provided for the client or by the health care provider is not limited. The type of setting may include, but is not limited to, an enrolled Family PACT site such as a FQHC, medical office, community clinic, or the client’s home.

SOURCE: CA Department of Health Care Services. Family Planning, Access, Care and Treatment Program. Benefits Manual. May. 2024, Pg. 8. (Accessed Jun. 2024).

GEOGRAPHIC LIMITS

No Reference Found.

FACILITY/TRANSMISSION FEE

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

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

FQHC & RHC/IHS-MOA

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

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

Local Education Agency

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

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

Every Woman Counts Program

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

SOURCE: Department of Health Care Services. Every Woman Counts Program Manual. Pgs. 42-43. Apr. 2024. (Accessed Jun. 2024).

Rates: Maximum Reimbursement for Optometry Services

T1014 – Telehealth transmission, per minute, profesional services bill separately.

SOURCE: Dept of Health Care Services, Medi-Cal, Rates: Maximum Reimbursement for Optometry Services, Oct. 2021, p. 6. (Accessed Jun. 2024).

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Colorado

Last updated 08/13/2024

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,” 5/24. (Accessed Aug. 2024).

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

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

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. The state department may consider setting the reimbursement rate on a monthly basis as well as on a daily or per-visit basis.

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

Interim Therapeutic Restorations

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

SOURCE: CO Revised Statutes 25.5-5-321.5 as proposed to be amended by SB 24-176 (2024 Session). (Accessed Aug. 2024).

ELIGIBLE SERVICES/SPECIALTIES

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

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

SOURCE: CO Revised Statutes 25.5-5-320 as proposed to be amended by HB 24-1045 (2024 Session). (Accessed Aug. 2024).

Services may be rendered via telemedicine when the service is:

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

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

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

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

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

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

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

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

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

SOURCE: CO Department of Health Care Policy and Financing. “Telemedicine – Provider Information”, CO Department of Health Care Policy and Financing, CO Department of Health Care Policy and Financing. “Telemedicine Billing Manual”, 5/24. (Accessed Aug. 2024).

Physician services may be provided as telemedicine in accordance with Section 8.095.

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

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

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

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

SOURCE: CO Department of Health Care Policy and Financing. “Telemedicine Billing Manual” 5/24. (Accessed Aug. 2024).

All Colorado Medicaid clients are eligible for medical and behavioral services delivered by telemedicine.

Covered Telemedicine services must:

Meet the same standard of care as in-person care;
Be compliant with state and federal regulations regarding care coordination;
Be services the Department has approved for delivery through Telemedicine;
Be within the provider’s scope of practice and for procedure codes the provider is already eligible to bill;
Be provided only where contact with the provider was initiated by the member for the services rendered; and
Be provided only after the member’s consent, either verbal or written, to receive telemedicine services is documented.

The reimbursement rate for a Telemedicine service shall, as a minimum, be set at the same rate as the Colorado Medicaid rate for a comparable in-person service.

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

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

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

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

SOURCE: CO Department of Health Care Policy and Financing. “Telemedicine Billing Manual” 5/24. (Accessed Aug. 2024).

Durable Medical Equipment Encounters

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

Telehealth visits are allowed for reauthorization of continuous glucose monitoring in some cases.

SOURCE: CO Department of Health Care Policy and Financing. “Durable Medical Equipment, Prosthetics, Orthotics, and Supplies”, 7/24. (Accessed Aug. 2024).

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

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

Pediatric Behavioral Therapy

Pediatric Behavioral Therapists are covered under the telemedicine policy.

SOURCE: CO Department of Health Care Policy and Financing. “Pediatric Behavioral Therapies Billing Manual”, 8/24 (Accessed Aug. 2024).

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

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

Screening Brief Intervention Treatment

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

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

Education-Only Services

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

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

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” 5/24. (Accessed Aug. 2024).

Abortion Services

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

HCPCS S0199 covers:

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

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

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

FQHC/RHC

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

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

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

SOURCE: CO Department of Health Care Policy and Financing. “Telemedicine Billing Manual” 5/24. (Accessed Aug. 2024).

For Health First Colorado a billable encounter at an FQHC and RHC 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 in the Telemedicine Billing Manual. Services provided via telemedicine must use modifier GT on the claim. All other claim submission information is the same.

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

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

SOURCE: CO FQHC & RHC Billing Manual 5/24. (Accessed Aug. 2024).

The visit definition for a FQHC includes interactive audio (including but not limited to telephone and relay calls), interactive video (including but not limited to interactive audiovisual modalities), or interactive data communication (including but not limited to live chat and excluding text messaging, electronic mail, and facsimile transmission) encounters in accordance with Section 8.095. 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 in accordance with Section 8.095.

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

Visit for a RHC means a face-to-face encounter, or an interactive audio (including but not limited to telephone and relay calls), interactive video (including but not limited to interactive audiovisual modalities), or interactive data communication (including but not limited to live chat and excluding text messaging, electronic mail, and facsimile transmission) encounter in accordance with Section 8.095 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 Aug. 2024).

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

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

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

Home and Community-Based Services for Persons with Intellectual and/or Developmental Disabilities Waiver Programs & Targeted Case Management for Home and Community-Based Services Waiver Programs

Targeted case management via telephone and video is listed as allowed. See manual.

SOURCE: CO Dep. of Health Care Policy and Financing, Home and Community-Based Services for Persons with Intellectual and/or Developmental Disabilities Waiver Programs & Targeted Case Management for Home and Community-Based Services Waiver Programs, Last revised 6/23/24, (Accessed Aug. 2024).

Home and Community-Based Services

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

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

Members eligible to use HCBS Telehealth are those enrolled in the waivers and services as defined in this rule at Section 8.7100. Additional requirements include:

The Case Management Agency shall ensure the use of HCBS Telehealth is the choice of the Member through the Person-Centered Support Planning process by indicating the Member’s choice to receive HCBS Telehealth in the Department prescribed IT system.
Through the Person-Centered Support Planning process, the Case Management Agency shall identify and address the benefits and possible detriments to Members choosing to use HCBS Telehealth for service delivery.
HCBS Telehealth delivery must be prior authorized and documented in the Member’s Person-Centered Support Plan.
Telehealth as a service delivery method for authorized HCBS Waiver Services, shall not interfere with any individual rights or be used as any part of a Rights Modification plan.
Provider Agencies that provide HCBS Telehealth services shall establish and maintain documented policies on the use of Telehealth services that comply with Section 8.7559.

HCBS Telehealth may be used to deliver support through authorized HCBS Waiver Services listed at Section 8.7559A. See Sec. 8.7559 for additional information on services authorized for consultation through telehealth, HCBS telehealth exclusions and limitations, as well as HCBS telehealth provider agency requirements, which include that providers that choose to use HCBS Telehealth shall develop and make available a written HCBS Telehealth Policy which includes that providers shall ensure the use of HCBS Telehealth is the choice of the Member. HCBS Waiver providers must be able to use a technology solution that allows real-time interaction with the Member which may include audio, visual and/or tactile technologies. Providers shall not use HCBS Telehealth to address a Member’s emergency needs.

HCBS Telehealth does not include reimbursement for the purchase or installation of Telehealth equipment or technologies. HCBS Waiver service providers utilizing Telehealth shall follow all billing policies and procedures as outlined in the Department’s current waiver billing manuals and rates/fees schedules. This includes the prohibition on collecting copayments or charging Members for missing set times for services.

SOURCE: 10 CCR 2505-10, Sec. 8.7202H, 8.7408, 8.7559. (Accessed Aug. 2024).

Adult Day Services (ADS)

Adult Day Services (ADS) may be provided out of an Adult Day Services Center or through Non-Center-Based means including Telehealth.

Telehealth Adult Day Services are provided through virtual means in a group or on an individual basis. Telehealth ADS are ways for participants to engage in activities, with their community, and connect to staff and other ADS participants virtually or over the phone, only if a participant does not have access or the ability to use video chat technology. Services provided through Telehealth are not required to provide nutrition services. See rules for staffing, documentation, billing and written policy requirements specific to use of telehealth ADS.

SOURCE: 10 CCR 2505-10 8.491; 8.7504B. (Accessed Aug. 2024).

Telehealth Day Habilitation services

Telehealth Specialized Habilitation services includes provider-hosted virtual meetings, groups, and activities where Members virtually engage and interact with provider staff, volunteers, and other Members.

Telehealth Supported Community Connections services includes virtual meetings, groups and activities, that are hosted by non-provider entities where Members virtually engage and interact with persons without disabilities other than those individuals who are providing services to the Member.

SOURCE: 10 CCR 2505-10 Sec. 8.7516. (Accessed Aug. 2024).

Program of All-Inclusive Care for the Elderly (PACE)

Telehealth is allowed for the provision of services delivered under PACE. The PACE organization must visit each participant in-person or via telehealth across all care settings as often as the participant’s condition requires, but no less than once each calendar month. If the PACE organization provides these visits via telehealth, the PACE organization must ensure the telehealth delivery option meets the following requirements:

Participants must have an informed choice between in-person and telehealth services;
The use of the telehealth delivery option will not prohibit or discourage the use of in-person services;
Telehealth will not be used for the provider’s convenience; and
Telehealth must be provided using technology compliant with Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy, Security and Breach Notification Rules.

The telehealth permissions in this section do not apply to the in-person assessment and reassessment requirements as described in 8.497.8.G. In addition to the medical record content requirements set forth in 42 CFR Â§ 460.210(b), the PACE organization must document whether a service or visit was provided in person or via telehealth.

SOURCE: 10 CCR 2505-10, Section 8.497 . (Accessed Aug. 2024).

Mobile Crisis Response (MCR) Services

MCR services may be provided via Telemedicine in accordance with Section 8.095 by any one (1) member of the MCR provider’s team, where appropriate. The initial Telemedicine face-to-face crisis response must include at least (1) in-person responder from the MCR team.

SOURCE: 10 CCR 2505-10 8.020. (Accessed Aug. 2024).

Behavioral Health

“Session” means a face-to-face, telehealth, or audio-only interaction of the individual and personnel. Session may include but is not limited to individual therapy, group therapy, medication-assisted treatment education and/or monitoring, family therapy, peer professional services, educational/occupational groups, recreational therapy, intake, discharge, service planning, and other therapies.

The BHE may use telehealth methods for the provision of services under these regulations except for services that specifically require in-person contact. If a service is allowable via telehealth according to state and federal regulations, appropriate methods will be noted within the applicable endorsement Chapter. If an individual prefers to receive services in-person and the BHE does not offer the appropriate service in-person, the BHE shall refer the individual to another entity that offers the service in-person.

If the BHE uses telehealth methods, it must develop and implement policies and procedures regarding telehealth services, including:

Collection of required signatures;
Training for personnel specific to the modality or manner for determining competence with the modality;
Procedure for personnel response if an individual experiences an emergency while receiving services via telehealth, including collection of information about the individual’s remote location for each session;
Confidentiality protocols designed to protect the individual’s privacy in accordance with state and federal law; and
Specification as to whether policies apply to the BHE as a whole, a physical location, or a specific endorsement, as appropriate.

Services provided via telehealth methods must be documented in the individual’s record, consistent with documentation requirements for in-person services.

Screenings should be conducted in-person unless contraindicated. If contraindicated, screenings may be conducted via audio-visual or audio only telehealth. Clinical rationale must be documented in the case of a telehealth screening.

A peer support professional may provide services in a variety of settings, if permitted access, that may include but are not limited to audio-visual or audio-only telehealth.

Early intervention services may be delivered via telehealth in accordance with the standards set in part 2.9 of these rules.

Various outpatient services may be delivered via in-person, audio-visual telehealth, or audio-only telehealth format in accordance with part 2.9 of these rules.

Walk-In crisis services follow-up communication may be conducted face-to-face, via telehealth, or via telephone only, based on an individual’s clinical need and preferences. Telehealth may be used to secure expertise for individuals served by the mobile crisis response team with a physical or I/DD.

If telehealth services do not best meet the needs of the individual and the BHE endorsed to provide DUI/DWAI programming cannot accommodate in-person services, the BHE must refer the individual to a provider that can meet the individual’s needs. Level II Four Plus must be completed as in-person services. 1. Telehealth may only be utilized if clinically indicated for the individual, or if the individual is unable to attend in-person. Documentation must be present in the individual record stating why telehealth was utilized.

BHE policies and procedures should include how telehealth services are deployed, how individual preference for in-person services are addressed, and when based on diagnosis or other need, telehealth services are not appropriate.

Essential behavioral health safety net providers offering outpatient behavioral health services must have in-person service offerings in addition to any telehealth services the agency may elect to provide.

SOURCE: 2 CO Code of Regulation 502-1, 1.2, p. 18, 2.9, p. 40, 2.12, p. 49, 3.2, p. 91, 4.2, p. 94, 4.3, p. 96, 4.6, p. 104, 4.7, p. 106, 6.3, p. 149, 151, 156, 10.5, p. 184, 10.9, p. 193, 12.3, p. 284, 12.4, p. 293, 21.6, p. 475. (Accessed Aug. 2024).

School-Linked Health Care Services

School-linked health care services, meaning primary health-care services, behavioral health-care services, oral health-care services, or preventative health-care services, may be delivered through telehealth, mobile services, or referrals for health-care services at a clinic located near school grounds.

SOURCE: CO Statute Sec. 25-20.5-502 as proposed to be amended by SB 24-034 (2024 Session). (Accessed Aug. 2024).

School Health Services

Telehealth codes listed as eligible with GT modifier throughout manual.

SOURCE: CO Dep. of Health Care Policy and Financing, School Health Services, Last revised 7/1/24, (Accessed Aug. 2024).

Doula Services

Doula services are billed using two Healthcare Common Procedure Coding System (HCPCS) procedure codes, two International Classification of Diseases (ICD)-10 diagnosis codes, and a combination of modifier codes if services are delivered via telemedicine. The modifier codes shown below should only be used in circumstances involving telemedicine.

See billing manual for codes that are allowed via telehealth.

Doulas can provide prenatal and postpartum care in variety of settings, including the member’s home, clinics and provider offices, community-based settings or via telehealth. A full list of allowable places of service for doula services are indicated below.

Labor and delivery services (T1033) cannot be provided via telemedicine with Place of Service codes 02 or 10. While doulas must provide in-person labor and delivery support, location can vary.

SOURCE: CO Dep. of Health Care Policy and Financing, Doula Billing Manual, Last revised 8/9/24, (Accessed Aug. 2024).

Pharmacy Services

Some codes are allowed for telemedicine delivery. Refer to the Telemedicine Services web page for more detail.

SOURCE: CO Dep. of Health Care Policy and Financing, Pharmacy Services, Last revised 2/29/24, (Accessed Aug. 2024).

ELIGIBLE PROVIDERS

Any licensed provider enrolled with Colorado Medicaid is eligible to provide telemedicine services within the scope of the provider’s practice.

SOURCE: Colorado Adopted Rule 8.095.3. CO Department of Health Care Policy and Financing. “Telemedicine Billing Manual” 5/24. (Accessed Aug. 2024).

All distant providers should bill the appropriate procedure code and Place of Service 02 or 10 and FQ or FR modifiers if appropriate on the CMS 1500 paper claim form or as an 837P transaction.

The following distant provider types may bill using modifier GT:

Physician
Clinic
Osteopath
FQHC
Doctorate Psychologist
MA Psychologist
Physician Assistant
Nurse Practitioner
RHC

A primary care provider (PCP) is eligible to be reimbursed as the ‘originating provider’ when present with the patient. In order for a PCP to be reimbursed as a distant provider, the PCP must be able to facilitate an in-person visit in the state of CO if necessary for treatment of the member’s condition.

A specialist is eligible to be an originating provider (if present with the patient) or distant provider.

The distant provider may participate in the telemedicine interaction from any appropriate location.

When the patient is located in a hospital, please use the appropriate place of service code for where the patient is located.

SOURCE: CO Department of Health Care Policy and Financing. “Telemedicine Billing Manual” 5/24. (Accessed Aug. 2024).

Health First Colorado has expanded the list of providers eligible to deliver telemedicine services to include FQHCs, RHCs, IHS, physical therapists, occupational therapists, home health providers, hospice and pediatric behavioral health providers. Outpatient physical, occupational and speech therapy services must have an interactive audio/visual connection with the member to be provided via telemedicine.

SOURCE: CO Dept. of Health Care Policy and Financing, Provider Bulletin, June 2023. (Accessed Aug. 2024).

Physical Therapists, Occupational Therapists, Hospice, Home Health Providers and Pediatric Behavioral Health Providers

Physical therapists, occupational therapists, hospice, home health providers and pediatric behavioral health providers are eligible to deliver telemedicine services.

Home Health Agency services and therapies, Hospice, and Pediatric Behavioral Treatment may be provided via telephone-only.
Outpatient Physical, Occupational, and Speech Therapy services must have an interactive audio/visual connection with the member to be provided via telemedicine.

Telemedicine is covered for behavioral health providers under the capitated behavioral health benefit administered by the Regional Accountable Entities (RAEs). Behavioral health providers should contact their RAE for guidance. Visit the Accountable Care Collaborative Phase II web page for more information.

SOURCE: CO Department of Health Care Policy and Financing. “Telemedicine Billing Manual” 5/24. (Accessed Aug. 2024).

RHC/IHS/FQHC

A telemedicine service meets the definition of a face-to-face encounter for a rural health clinic, Indian health service, or federally qualified health center. The reimbursement rate for a telemedicine service provided by a rural health clinic or federal Indian health service or federally qualified health center must be set at a rate that is no less than the medical assistance program rate for a comparable face-to-face encounter or visit.

SOURCE: CO Statute, Sec. 25.5-5-320. (Accessed Aug. 2024).

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 Dep. of Health Care Policy and Financing, FQHC/RHC Services, Last revised 5/15/24, (Accessed Aug. 2024).

eHealth Entities

Providers that meet the definition of an eHealth Entity shall enroll as the eHealth specialty. Electronic Health Entity (eHealth Entity) means a group practice that delivers services exclusively through telemedicine and is enrolled in a provider type that has an eHealth specialty. eHealth entities:

1. Cannot be Primary Care Medical Providers
  1. Primary Care Medical Provider (PCMP) means an individual physician, advanced practice nurse or physician assistant, who contracts with a Regional Accountable Entity (RAE) in the Accountable Care Collaborative (ACC), with a focus on primary care, general practice, internal medicine, pediatrics, geriatrics, or obstetrics and gynecology.
2. Can be either in-state or out-of-state.

eHealth Entities shall only provide Covered Telemedicine services, including Facilitated Visits. A Facilitated Visit means a Telemedicine visit where the rendering provider is at a distant site and the member is physically present with a support staff team member who can assist the provider with in-person activities. eHealth Entities must maintain a Release of Information in compliance with current HIPAA standards to facilitate communication with the member’s PCMP.

SOURCE: Colorado Adopted Rule 8.095.1, 8.095.3, 8.095.4, 8.095.6. (Accessed Aug. 2024).

As of October 30th, 2022, there is a provider specialty type for Clinic and Non-Physician Practitioner groups that meet the following definition:

An eHealth entity is defined as a group practice that delivers services exclusively through telemedicine and is enrolled in a provider type that has an eHealth specialty. Providers who meet this definition must update their enrollment to this provider specialty type.

SOURCE: CO Department of Health Care Policy and Financing. “Telemedicine Billing Manual” 5/24. (Accessed Aug. 2024).

The telemedicine rule 10 CCR 2505-10 8.095 regarding eHealth entities is effective as of October 30, 2022. An eHealth entity is defined as a group practice that delivers services exclusively through telemedicine and is enrolled in a provider type that has an eHealth specialty.

Telemedicine-only providers are to use Specialty Code 878.
Telemedicine and in-person providers will continue to use the appropriate specialty code for their chosen provider type.

SOURCE: CO Department of Health Care Policy and Financing, Health First CO Provider Bulletin B2200485, (Nov. 2022), (Accessed Aug. 2024).

Ambulatory Surgery Centers & Immunizations Manual

For distant provider use procedure code + modifier GT.

SOURCE: CO Dep. of Health Care Policy and Financing, Ambulatory Surgery Centers (ASC) Billing Manual, Last revised 5/18/23, & Immunizations Billing Manual, Last revised 7/5/24, (Accessed Aug. 2024).

ELIGIBLE SITES

If no originating provider is present during a Telemedicine Services appointment, then the location of the originating site is at the member’s discretion and can include the member’s home. However, members can be required to choose a location suitable to delivery of telemedicine services that may include adequate lighting and environmental noise levels suitable for easy conversation with a provider.

Services can be provided via telemedicine between a member and a distant provider when a member is located in their home or other location of their choice.

A specialist is eligible to be an originating provider (if present with the patient) or distant provider.

If practitioners at both the originating site and the distant site provide the same service to the member, both providers submit claims using the same procedure code with modifier 77 (Repeat procedure by another physician).

SOURCE: CO Department of Health Care Policy and Financing. “Telemedicine Billing Manual” 5/24. (Accessed Aug. 2024).

Telemedicine can work:

From a provider office: You can connect through video with a provider in another office. Both offices must have telemedicine equipment.
From your home or other location like a library: You may be able to use your mobile phone, tablet or desktop computer to connect to a provider. Health First Colorado will not pay for the equipment.

SOURCE: CO Department of Health Care Policy and Financing. “Telemedicine”. (Accessed Aug. 2024).

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

SOURCE: Colorado Adopted Rule 8.200.3.B.3.D.2.c.7. (Accessed Apr. 2024).

Speech Therapy

Telemedicine POS 02 and Telehealth POS 10 are allowed place of service codes.

SOURCE: CO Department of Health Care Policy and Financing. “Speech Therapy”, 7/24. (Accessed Aug. 2024).

Therapy Providers

POS Code 02 or 10 should be used to report services delivered via telecommunication depending on the location of the member when receiving telehealth services. POS 02 is used when the member is receiving telehealth service in a place that is not their home. POS 10 is used when a member is receiving telehealth services when the member is located in their home.

Outpatient physical, occupational, and speech therapy services must have an interactive audio/visual connection with the member to be provided via telemedicine.

SOURCE: CO Department of Health Care Policy and Financing. Provider Bulletin B2200480. July 2022. (Accessed Aug. 2024).

Physical Therapy and Occupational Therapy

Place of Service Codes

02 – Telemedicine – Not provided in patient’s home (only applicable to certain procedure codes). Refer to the Telemedicine Billing Manual.
10 – Telehealth – Provided in patient’s home. Refer to the Telemedicine Billing Manual.

Telemedicine place of service (POS) code 02 is available for specific procedure codes. Visit the Telemedicine – Provider Information web page for a list of allowed procedure codes.

SOURCE: CO Dep. of Health Care Policy and Financing, Physical Therapy and Occupational Therapy Billing Manual, Last revised 7/24/24, (Accessed Aug. 2024).

Home Health Services

Services shall be provided in the client’s place of residence or one of the following places of service: Services may be provided using interactive audio (including but not limited to telephone and relay calls), interactive video (including but not limited to interactive audiovisual modalities), or interactive data communication (including but not limited to live chat and excluding text messaging, electronic mail, and facsimile transmission) instead of in-person contact. Any health benefits provided through interactive audio, interactive video, or interactive data communication must meet the same standard of care as in-person care.

SOURCE: Colorado Adopted Rule 8.520.4.B.g. (Accessed Aug. 2024).

Telehealth monitoring is available for members who are eligible through the Home Health benefit and should not be billed as telemedicine. Providers rendering telehealth monitoring should consult the Home Health Billing Manual on the Billing Manuals web page under the CMS 1500 drop-down.

SOURCE: CO Department of Health Care Policy and Financing. “Telemedicine Billing Manual” 5/24. (Accessed Aug. 2024).

Family Planning Services

Eligible places of service include telemedicine provided in accordance with Section 8.095.

SOURCE: Colorado Adopted Rule 8.730.3.B. (Accessed Aug. 2024).

FQHC/RHC

FQHCs, RHCs, and IHS providers can serve as an originating site allowing a member to connect with a distant provider that is not affiliated with the originating site. The service must be submitted on a professional service claim form (the 1500). Refer to the Telemedicine Billing Manual for the coverage of the originating site procedure code.

SOURCE: CO Dep. of Health Care Policy and Financing, FQHC/RHC Services, Last revised 5/15/24, (Accessed Aug. 2024).

Doula Services

Labor and delivery services (T1033) cannot be provided via telemedicine with Place of Service codes 02 or 10. While doulas must provide in-person labor and delivery support, location can vary.

Allowed Place of Service Codes

02 – Telehealth Provided Other than in Patient’s Home
10 – Telehealth Provided in Patient’s Home

SOURCE: CO Dep. of Health Care Policy and Financing, Doula Billing Manual, Last revised 8/9/24, (Accessed Aug. 2024).

Pediatric Behavioral Therapies

Place of Service:

02 – Telemedicine (Refer to the Telemedicine Billing Manual)

Telemedicine place of service (POS) code 02 is available for specific procedure codes. Visit the Telemedicine – Provider Information web page for a list of allowed procedure codes.

SOURCE: CO Dep. of Health Care Policy and Financing, Pediatric Behavioral Therapies Billing Manual, Last revised 8/12/24, (Accessed Aug. 2024).

Pharmacy Services

Allowed Place of Service Codes

02 – Telemedicine, other than in patient’s home (only applicable to certain procedure codes, see details below)
10 – Telemedicine, in patient’s home (only applicable to certain procedure codes, see details below)

Telemedicine place of service (POS) codes 02 and 10 are available for specific procedure codes. Refer to the Telemedicine Billing Manual for further details.

SOURCE: CO Dep. of Health Care Policy and Financing, Pharmacy Services Billing Manual, Last revised 2/29/24, (Accessed Aug. 2024).

GEOGRAPHIC LIMITS

No Reference Found.

FACILITY/TRANSMISSION FEE

In some cases, the originating provider site will not be providing clinical services, but only providing a site and telecommunications equipment. In this situation, the telemedicine originating site facility fee is billed using procedure code Q3014.

Originating providers bill as follows:

If the originating provider is making a room and telecommunications equipment available but is not providing clinical services, the originating provider bills Q3014 (the procedure code for the telemedicine originating site facility fee).
If the originating provider also provides clinical services to the member, the provider bills the rendering provider’s appropriate procedure code and bills Q3014.
The originating provider may also bill, as appropriate, on the UB-04 paper claim form or as an 837I transaction for any clinical services provided on-site on the same day that a telemedicine originating site claim is made. The originating provider must submit two separate claims for the member’s two separate services.

Providers eligible for the originating site facility fee include:

Physician
Clinic
Osteopath
FQHC
Doctorate Psychologist
MA Psychologist
Physician Assistant
Nurse Practitioner
RHC

Provider types not listed above may facilitate Telemedicine Services with a distant provider but may not bill procedure code Q3014. Examples include Nursing Facilities, Intermediate Care Facilities, Assisted Living Facilities, etc.

When an originating site bills Q3014 (telemedicine originating site facility fee), there is generally no rendering provider actually involved in the service at the originating site. However, a rendering provider number is still required and must be affiliated with the billing provider. The facility may enter either the member’s usual provider’s number, or another provider number affiliated with that site as the rendering provider. When the member sees a rendering provider at the originating site and also uses the site as the telemedicine originating site, the facility bills the rendered service procedure code and Q3014 for the use of the telemedicine facility. The same rendering provider number is entered in field 19D.

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” 5/24. (Accessed Aug. 2024).

The state department shall establish rates for transmission cost reimbursement for telemedicine services, considering, to the extent applicable, reductions in travel costs by health care or mental health care providers and patients to deliver or to access such services and such other factors as the state department deems relevant.

SOURCE: CO Revised Statutes 25.5-5-320(3). (Accessed Aug. 2024).

Ambulatory Surgery Centers & Immunizations

Telemedicine: For originating provider use procedure code Q3014.

SOURCE: CO Dep. of Health Care Policy and Financing, Ambulatory Surgery Centers (ASC) Billing Manual, Last revised 5/18/23, & Immunizations Billing Manual, Last revised 7/5/24, (Accessed Aug. 2024).

READ LESS

Connecticut

Last updated 07/17/2024

POLICY

CT Medicaid is required to provide coverage for telehealth …

POLICY

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 Jul. 2024).

To the extent permissible under federal law, the commissioner shall provide Medicaid reimbursement for services provided by means of telehealth to the same extent as if the service was provided in person.

SOURCE: CT General Statute 17b, Sec. 245g. (Accessed Jul. 2024).

Effective for dates of service on and after May 12, 2023, which is the first day after the federal COVID-19 public health emergency declaration ends, in accordance with sections 17b-245e and 17b-245g of the Connecticut General Statutes, the Department of Social Services (DSS) is issuing new guidance for services eligible for reimbursement under the Connecticut Medical Assistance Program (CMAP) when rendered via telehealth. DSS will continue to reimburse for specified services when rendered via telehealth as detailed in Provider Bulletin 2023-38 and on the CMAP Telehealth Table. This guidance applies to services rendered under CMAP for all HUSKY Health members.

Telehealth includes:

telemedicine (synchronized audio-visual two-way communication services) and,
where specified by DSS, audio-only two-way synchronized communication services delivered via telephone.

DSS’ continued expectation is that enrolled CMAP providers will perform clinically appropriate services including, but not limited to, ensuring timely access to in-person services when medically necessary or requested by the HUSKY Health member for optimum quality of care. Therefore, all enrolled billing entities must have the capacity to deliver services in-person and must provide services in-person to the full extent that is clinically appropriate for their patients and to the full extent necessary if the HUSKY Health member does not consent to receiving one or more services via telehealth. Having the capacity means that the provider must have a physical location in CT, (or an approved applicable border state as approved as part of enrollment) where the provider has a room or set of rooms to see members in-person and can maintain the member’s privacy and confidentiality during the visit.

All applicable federal and state requirements for the equivalent in-person service apply to telehealth services. Therefore, consistent with all services billed to CMAP, all telehealth services must meet the statutory definition of medical necessity in section 17b-259b of the Connecticut General Statutes and all other applicable federal and state statutes, regulations, requirements, and guidance.

SOURCE: CT Policy – Provider Bulletin 2023-38. May 2023. (Accessed Jul. 2024).

Connecticut’s Medical Assistance Program will not pay for information or services provided to a client by a provider electronically or over the telephone. However, there is an exception for case management behavioral health services for clients age eighteen and under.

SOURCE: CT Provider Manual. Physicians and Psychiatrists. Sec. 17b-262-342. Pg. 9, Oct. 2020; CT Provider Manual. Psychologists. Sec. 17b-262-472. Oct. 2020. Pg. 7; & CT Provider Manual. Behavioral Health. Sec. 17b-262-918. Oct. 2020. Pg. 6. (Accessed Jul. 2024).

ELIGIBLE SERVICES/SPECIALTIES

See specified services reimbursed when rendered via telehealth as detailed in Provider Bulletin 2023-38 and on the CMAP Telehealth Table. Comprehensive information regarding the specific procedure codes eligible are posted on the CMAP Telehealth Webpage as well. This web page will provide information on telehealth requirements, approved procedure codes, required modifiers, specific policy criteria and/or limitations, effective dates, and other telehealth policy information, including the Telehealth FAQs.

Providers are responsible for verifying coverage of a specific procedure code as a telehealth service as well as a covered service on their applicable fee schedule prior to delivering and billing CMAP for the service. Billing for a service via telehealth that is not listed as an approved service on the CMAP Telehealth Table or listed as a covered service on the applicable fee schedule or failure to adhere to the policy and applicable telehealth criteria/limitations, may result in a denied claim or may be at-risk for a financial adjustment during a post-payment review.

Services rendered via telehealth will be reimbursed at the same rate as if the service was rendered in-person. Providers must refer to their applicable reimbursement methodology or fee schedule to ensure that the service identified as eligible to be rendered as a telehealth service is payable for their specific provider type and the reimbursement rate.

SOURCE: CT Policy – Provider Bulletin 2023-38. May 2023. (Accessed Jul. 2024).

Modifiers: One of the following telehealth modifiers should be used when submitting claims:

Modifier GT: Via interactive audio and video telecommunication systems
Modifier 95: Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system
Modifier FQ: This service was furnished using audio-only communication technology (use with applicable behavioral health services )

SOURCE: CMAP Telehealth Table. (Accessed Jul. 2024).

Effective June 12, 2023, providers must ensure that the provision of 90853 (group psychotherapy) is performed via telemedicine (synchronized audio-visual) only. Providers are encouraged to monitor the CMAP website (www.ctdssmap.com) frequently for updates to the DSS Telehealth policy and to ensure that you are accessing the most current version of the CMAP Telehealth Table.

SOURCE: CT Dept. of Social Services. Provider Message. June 2023. (Accessed Jul. 2024).

Effective June 21, 2023, and forward, providers eligible for reimbursement for procedure code T1017 (Targeted case management, 15 minutes) may perform this service via audio-only or telemedicine under the CMAP Telehealth policy.

SOURCE: CT Dept. of Social Services. Provider Message. June 2023. (Accessed Jul. 2024).

Effective for dates of service May 12, 2023, and forward, Medical Equipment Devices (MEDS) providers must comply with the face-to-face (F2F) requirements for certain DME as specified by 42 CFR 440.70. Compliance with this requirement includes the provision of the F2F encounter via telehealth as specified by 42 CFR 440.70(f)(6) when the service billed complies with the telehealth policies as outlined and specified by DSS.

Effective for dates of service May 12, 2023, and forward, physicians can conduct assessments for complex rehabilitative technology (CRT) equipment either in person or via synchronized telemedicine with the assistance of the physical therapist (PT) or occupational therapist (OT) which must be in person with the HUSKY Health member. The requirement of the PT or OT in-person with the member is to ensure the demonstration of the equipment and any features on a customized wheelchair will meet the clinical needs of members residing in skilled nursing facilities.

SOURCE: CT Policy – Provider Bulletin 2023-33. Apr. 2023. (Accessed Jul. 2024).

Effective for dates of service October 16, 2023, and forward, providers eligible for reimbursement for procedure code S0199 (Med abortion inc all ex drug) may perform this service via telemedicine only (synchronized audio-visual), under the CMAP Telehealth policy.

SOURCE: CT Policy – Provider Important Message. Oct. 2023. (Accessed Jul. 2024).

In addition to procedure code S0199, providers are permitted to provide & bill for the MAB medications (S0190 & S0191) as part of the overall MAB service.

SOURCE: CMAP Telehealth Table. (Accessed Jul. 2024).

Opioid Treatment Programs are required to perform a complete, fully documented physical evaluation prior to admission. The program physician may render the physical evaluation component of MAT services via telemedicine only when all of the following are met:

The CMAP member’s originating site is another CMAP-enrolled Opioid Treatment Program (Methadone Maintenance Clinic) that is part of the same billing entity as the originating site;
The originating site is providing all the other required components of MAT services including the intake and psychiatric evaluation;
As required by 42 CFR 8.12(f), an authorized healthcare professional under the supervision of a program physician is present with the member at the originating site; and
The distant site provider must be located at a different service location/address than the originating site.

Induction services must always be rendered face-to-face (in-person) and only after the physical and psychiatric evaluation has been performed. Once a CMAP member has been inducted, routine psychotherapy services may be rendered via telemedicine.

MAT services that may be rendered via telemedicine include medication management and psychotherapy services.

SOURCE: CT Policy – Provider Bulletin 2020-09. March 2020. (Accessed Jul. 2024).

CT does not pay for information or services furnished by a licensed behavioral health clinician to the client electronically or over the telephone, except for case management behavioral health services for clients age eighteen and under.

SOURCE: CT Provider Manual. Behavioral Health. Sec. 17b-262-918. Oct. 2020. Pg. 6. (Accessed Jul. 2024).

Outpatient Hospitals

With the exception of nutritional counseling and PT/OT/SLP services, medical telehealth services are considered professional services and therefore no reimbursement will be provided to the hospital. Behavioral health telehealth services, including medication management, are considered an all-inclusive rate to the hospital and therefore professional fees will not be paid separately.

SOURCE: CT Policy – Provider Bulletin 2023-38. May 2023. & CMAP Telehealth Table. (Accessed Jul. 2024).

Outpatient hospitals may bill for nutritional counseling services when rendered via telemedicine under procedure code G0463 – “clinic visit”. It should be noted that procedure code G0463 is approved for telemedicine nutritional counseling services only and that nutritional counseling can only be billed via telemedicine and cannot be billed via audio-only.

SOURCE: CT Medicaid Assistance Program Telehealth FAQ (May 2023), p. 3. (Accessed Jul. 2024).

Nursing Facility and Hospital Care

Subsequent nursing facility care services are limited to one telemedicine visit every 30 days. Subsequent hospital care services are limited to one telemedicine visit every 3 days.

End-State Renal Disease Services (ERSD)

ESRD services with multiple visits per month (two or more) may be reimbursed when rendered as telemedicine, however; at least one (1) visit must be rendered in-person to examine the vascular access site.

SOURCE: CMAP Telehealth Table. (Accessed Jul. 2024).

School Based Child Health Providers

School Based Child Health Providers are limited to the following services: 90791, 90832, 90847, 90853, H0031, H2014, 92507, 92521, 92522, 92523, 97110 – Refer to the policy guidelines in the CMAP Telehealth Table.

SOURCE: CT Policy – Provider Bulletin 2023-23. March 2023. & CMAP Telehealth Table. (Accessed Jul. 2024).

Targeted Case Management for Integrated Care for Kids (InCK) in New Haven

Monitoring and follow-up activities include making necessary adjustments in the care plan and related changes in the services performed by the provider, which may be performed by staff face-to-face, telehealth, or telephone contact with the individual; by chart review; by case conference; by collateral contact with individuals, family members, providers, legal representatives, or other persons or entities for the benefit of the Medicaid member; or any combination thereof. The care plan must be reviewed every 90 days and adjusted if needed. See bulletin for more information.

SOURCE: CT Policy – Provider Bulletin 2023-55. Jul. 2023. (Accessed Jul. 2024).

Sick Visits

Sick Visits for adults and children are allowed to be performed via telehealth. Refer to CMAP Telehealth Table.

Hospice and Home Health Services, and Well Visits

Hospice and home health services, in addition to Well Visits, cannot be performed via telemedicine. These services must be rendered in person. Refer to Provider Bulletin 2023-38.

SOURCE: CT Medicaid Assistance Program Telehealth FAQ (May 2023), p. 3. (Accessed Jul. 2024).

Children’s Mental Health Urgent Crisis Centers Services

Effective April 1, 2024, DSS will enroll and pay certified providers to deliver children’s mental health urgent crisis services. Claims submitted from DCF certified service location that is enrolled as a CMAP provider will be reimbursed for in-person or services performed via telehealth when billing identified billing/procedure codes listed in Provider Bulletin 2024-16.

SOURCE: CMAP Provider Bulletin 2024-16. Mar. 2024. (Accessed Jul. 2024).

ELIGIBLE PROVIDERS

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 Jul. 2024).

Medication Assisted Treatment

Eligible providers:

Physician
APRNs
PAs
Behavioral Health Clinics

Medication Management

Eligible Providers:

Physicians
PAs
APRNs
Medical Clinics – excluding SBHCs
Behavioral Health Clinics – including ECCs
Behavioral Health FQHCs
Outpatient Hospital BH Clinics
Outpatient Chronic Disease Hospitals

Eligible providers for out of state surgery and homebound patients include:

Physicians
PAs
APRNs
CNMs
Podiatrists

Eligible providers to determine if patient to be homebound and/or provide and bill for such service:

Physicians
PAs
APRNs
CNMs
Podiatrists

For homebound patients, provider must document the reason the member is being determined homebound.

Documentation must be maintained by both the originating site provider and the distant site provider to substantiate the services provided. Originating site documentation must indicate the member received or has been referred for telehealth services.

SOURCE: CT Policy – Provider Bulletin 2020-09. March 2020. (Accessed Jul. 2024).

Medication Assisted Treatment – Opioid Treatment Program

The distant site provider cannot bill for the physical evaluation component rendered via telemedicine.

SOURCE: CT Policy – Provider Bulletin 2020-09. March 2020. (Accessed Jul. 2024).

FQHCs

Federally Qualified Health Centers (FQHCs) are eligible to bill their encounter rate when an approved, medically necessary telehealth service is rendered. FQHCs must use the services identified on the Telehealth Table in combination with their approved scope of service to identify the services eligible to be rendered using telehealth. FQHCs must continue to bill HCPCS code, T1015 and all eligible telehealth procedure codes to reflect all of the services rendered during the telehealth visit.

SOURCE: CMAP Telehealth Table. (Accessed Jul. 2024).

ELIGIBLE SITES

There is no limitation on the originating site for a member receiving individual therapy, family therapy or psychotherapy with medication management.

Psychiatric diagnostic evaluations may be rendered via telemedicine only if the member is located at a CMAP-enrolled originating site.

Modifiers GT is used when the member’s originating site is located in a healthcare facility or office; or modifier 95 Is used when the member is located at home.

SOURCE: CT Policy – Provider Bulletin 2020-09. March 2020, (Accessed Jul. 2024).

Place of Service/Facility Type Code – Bill the appropriate POS/FTC code that is applicable to the location of the member at the time of the telehealth service.

SOURCE: CMAP Telehealth Table. (Accessed Jul. 2024).

A practitioner who is enrolled with CMAP as an independent provider or as part of an independent provider group, or as a FQHC or outpatient hospital and maintains an approved service location as part of the CMAP enrollment, has the flexibility to perform eligible telehealth services even when the performing/rendering practitioner is not physically in-person at one of the enrolled CT or border service locations at the time of the service, so long as the practitioner complies with all applicable state and federal requirements.

SOURCE: CT Policy – Provider Bulletin 2023-38. May 2023. (Accessed Jul. 2024).

Medication Assisted Treatment

Due to Opioid Treatment Programs (Methadone Maintenance Clinics) receiving a daily payment rate for all MAT services provided, the daily payment rate will continue to be paid to the originating site only. The distant site provider must be located at a different service location/address than the originating site.

SOURCE: CT Policy – Provider Bulletin 2020-09. March 2020. (Accessed Jul. 2024).

GEOGRAPHIC LIMITS

No Reference Found

FACILITY/TRANSMISSION FEE

The code (Q3014) for an originating site facility fee is not listed as eligible on the CMAP Telehealth Table.

SOURCE: CMAP Telehealth Table. (Accessed Jul. 2024).

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Delaware

Last updated 07/26/2024

POLICY

DMAP covers medically necessary telehealth services and procedures covered …

POLICY

DMAP covers medically necessary telehealth services and procedures covered under the Title XIX State Plan. Qualifying practitioner services include any covered State Plan service that would typically be provided to an eligible individual in an inperson setting by an enrolled practitioner. Telehealth is not limited based on the diagnosed medical condition of the eligible recipient. All telehealth services must be furnished within the limits of provider program policies and within the scope and practice of the referring provider’s and distant telehealth practitioner’s professional standards as described and outlined in DMAP Provider Manuals. The service provided by the consulting/rendering provider or distant telehealth practitioner must be a service covered by DMAP. If a service is not covered in a face-to-face setting, it is not covered if provided through telehealth. A service provided through telehealth is subject to the same program restrictions, limitations, and coverage exist for the service when not provided through telehealth.

SOURCE: DE Medical Assistance Program. Practitioner Provider Specific Manual, 1/12/24. Sec. 16.6.2, pg. 78. (Accessed Jul. 2024).

DMAP will reimburse up to three (3) different consulting/distant telehealth practitioners for separately identifiable telehealth services provided to a member per date of service.

SOURCE: DE Medical Assistance Program. Practitioner Provider Specific Manual, 1/12/24. Sec. 16.6.3, pg. 79; Adult Behavioral Health Service Certification and Reimbursement. Dec. 1, 2016. Sec. 1.8, p. 14. (Accessed Jul. 2024).

The same procedure codes and rates apply as for services delivered in person (enrolled providers will bill Usual and Customary). Practitioners should use 02 Modifier as Place of Service for all telehealth charges. When billing the DMAP, the provider must use the appropriate CPT® procedure codes.

SOURCE: DE Medical Assistance Program. Practitioner Provider Specific Manual, 1/12/24. Sec. 16.6.2, 16.6.5.2.1-3, pg. 78-80. (Accessed Jul. 2024).

The GT modifier (which indicates the service occurred via interactive audio and video telecommunication system) can be used for Early and Periodic Screening, Diagnostic and Treatment Services through the School Based Health Services program in Group Physical Therapy treatment utilizing code 97150 + the GT modifier.

SOURCE: DE Medical Assistance Program. School Based Health Services Specific Policy Manual, pg. 53 & 57 (4/1/16). (Accessed Jul. 2024).

The referring provider is not required to be present at the originating site, however the recipient of the services must be present. The Distant Site provider must be located within the continental United States.

Reimbursement to the referring provider will only occur when providing a separately identifiable covered service.

SOURCE: DE Medical Assistance Program. Practitioner Provider Specific Manual, 1/12/24. Ch. 16.5.1, 16.3.4, & 16.6.2, pg. 75-78. & Adult Behavioral Health Service Certification and Reimbursement. Dec. 1, 2016. Sec. 1.8, p. 12. (Accessed Jul. 2024).

Except for instances listed in 24 Del.C. Chapter 60, health-care providers may not deliver health-care services by telehealth and telemedicine in the absence of a health-care provider-patient relationship. A health-care provider-patient relationship may be established either in-person or through telehealth but must meet the requirements of Del.C. 24 §6003.

Consent is required to assure that the patient is a willing participant in the telehealth delivered service and to assure that the recipient retains a voice in their treatment plan. The patient must be informed and given an opportunity to request an in-person assessment before receiving a telehealth assessment. This consent must be documented in the patient’s record and must identify that the covered medical service was delivered by telehealth. The recipient must be able to adequately communicate, either directly or through a representative, with the originating and distant site practitioners.

The provision of services through telehealth must include accommodations, including interpreter and audio-visual modification, where required under the ADA, to ensure effective communication.

The distant site provider or other coverage must be available for appropriate followup care with the patient.

SOURCE: DE Medical Assistance Program. Practitioner Provider Specific Manual, 1/12/24. Ch. 16.4.1-2, 16.5.2, pg. 75-76 (Accessed Jul. 2024).

ELIGIBLE SERVICES/SPECIALTIES

The service must be medically necessary, written in the patient’s treatment plan and, follow generally accepted standards of care. The service provided by the distant provider must be a service covered by DMAP.

SOURCE: DE Medical Assistance Program. Practitioner Provider Specific Manual, 1/12/24. Sec. 16.4.1, 16.6.2, pg. 75, 78 & Adult Behavioral Health Service Certification and Reimbursement. Dec. 1, 2016. Sec. 1.8, p. 12. (Accessed Jul. 2024).

Interactive audio and video telecommunications can be used for group physical therapy in the Early and Periodic Screening, Diagnostic and Treatment Services through the School Based Health Services program for group physical therapy treatment.

SOURCE: DE Medical Assistance Program. School Based Health Services Specific Policy Manual, pg. 53 & 57 (4/1/16). (Accessed Jul. 2024).

Tele-Dentistry

Synchronous real-time tele-dentistry services must be provided in accordance with the recommendations provided by the American Dental Association. The evaluation is limited to a specific oral health problem or complaint.

SOURCE: DE Medical Assistance Program. Adult Dental Program Services Provider Specific Manual. 7/21/23. Sec. 4.2. p. 7-8 (Accessed Jul. 2024).

Adult Behavioral Health Service

Rate Methodologies for the CPT codes under the telemedicine section of the State Plan for Adult Behavioral Health Services are paid at a lower rate and provided in the manual.

SOURCE: DE Medical Assistance Program. Adult Behavioral Health Service Certification and Reimbursement. Dec. 1, 2016. Sec. 1.8. p. 14 (Accessed Jul. 2024).

Durable Medical Equipment

The face-to-face encounter may occur through telehealth; as implemented by DMAP. In addition, the face-to-face encounter occurred through telehealth may be performed by any of the practitioners described above with the exception of certified nurse-midwives.

SOURCE: DE Medical Assistance Program, Durable Medical Equipment Provider Specific Manual, 3.1.6, p. 20 (Feb. 26, 2024). (Accessed Jul. 2024).

Personal Assistance Services Agencies, Home Health Agencies and Aides

Follow-up visits, patient reassessments, and supervisory visits are authorized to be completed by telehealth mechanism.

SOURCE: 16 DE Admin. Code 3345, 3350, 3351. (Accessed Jul. 2024).

ELIGIBLE PROVIDERS

In order to provide telehealth under DMAP, providers at both the originating and distant site must be enrolled with DMAP and must meet all requirements for their discipline as specified in the Delaware Code and the Medicaid State Plan. For services delivered through telehealth technology to be covered, referring providers and distant telehealth practitioners (including out-of-region practitioners) must:

Act within their scope of practice;
Be licensed to provide telehealth services for which they bill DMAP in Delaware, or the State in which the provider is located if allowed under Delaware State law to provide telehealth services without a Delaware license through the Interstate Medical Licensure Compact or otherwise;
Be in good standing in all states in which provider is licensed;
Not be the subject of an administrative complaint or under investigation by another state’s licensing authority or board;
Be enrolled with DMAP; and
Have provider billing numbers (NPI and Taxonomy).

Distant telehealth practitioners may also need to enroll with the Department of Services for Children, Youth and their Families (DSCYF), Division of Prevention and Behavioral Health Services (DPBHS), and Division of Substance Abuse and Mental Health (DSAMH) as appropriate to provide and be reimbursed for behavioral health services.

The distant telehealth practitioner must be located within the continental United States. As required by §6505 of the Affordable Care Act, DMAP will not make any payments for items or services provided under the State Plan or under a waiver to any financial institution or entity located outside of the United States.

SOURCE: DE Medical Assistance Program. Practitioner Provider Specific Manual, 1/12/24. Sec. 16.3, pg. 74-75. (Accessed Jul. 2024).

To receive payment for services delivered through telemedicine technology from DMAP or MCOs, healthcare practitioners must:

Act within their scope of practice;
Be licensed (in Delaware, or the State in which the provider is located if exempted under Delaware State law to provide telemedicine services without a Delaware (license) for the service for which they bill DMAP;
Be enrolled with DMAP/MCOs;
Be located within the continental United States;
Be credentialed by DMMA-contracted MCOs, when needed;
Submit a DMMA Disclosure Form.

SOURCE: DE Medical Assistance Program. Adult Behavioral Health Service Certification and Reimbursement. Dec. 1, 2016. Sec. 1.8. Pg. 11 (Accessed Jul. 2024).

Eligible distant site providers include:

Inpatient/outpatient hospitals (including ER)
Physicians (or PAs under the physician’s supervision)
Certified Nurse Practitioners
Nurse Midwives
Licensed Psychologists
Licensed Clinical Social Workers
Licensed Professional Counselors of Mental Health
Speech Language Therapists
Audiologists
Other providers as approved by the DMAP

SOURCE: DE Medical Assistance Program. Adult Behavioral Health Service Certification and Reimbursement. Dec. 1, 2016. Sec. 1.8. Pg. 12 (Accessed Jul. 2024).

ELIGIBLE SITES

Originating Site refers to where the patient is located at the time health care services are provided to the patient by means of telehealth. An approved originating site may include the DMAP member’s place of residence, day program, or alternate location in which the member is physically present, and telehealth can be effectively utilized.

Distant Site refers to the site at which a health care practitioner, legally allowed to practice in the state of Delaware or the state in which the provider is located if allowed under Delaware State law to provide telehealth services without a Delaware license through the Interstate Medical Licensure Compact or otherwise, is located while providing health care services by means of telehealth.

All telehealth sites, both originating and distant sites, must have a written procedure detailing a contingency plan for when a failure or interoperability of the transmission or other technical difficulties render the service undeliverable. Telehealth services are not billable to DMAP or MCOs when technical difficulties preclude the delivery of part or all of the telehealth session.

The referring provider’s medical records must document all components of the services being billed. All distant telehealth practitioners are required to develop and maintain written documentation in the form of evaluations and progress notes, the same as if the documentation had originated during an in-person visit or consultation, including the mode of communication (telehealth). Distant telehealth practitioners may opt to use electronic medical records in place of paper-based written records.

SOURCE: DE Medical Assistance Program. Practitioner Provider Specific Manual, 1/12/24. Sec. 16.2.5-6, 16.5.3.7, 16.5.4.1-2, pg. 73-74, 77. (Accessed Jul. 2024).

An originating site refers to the facility in which the Medicaid patient is located at the time the telemedicine service is being furnished. An approved originating site may include the DMAP member’s place of residence, day program, or alternate location in which the member is physically present and telemedicine can be effectively utilized.

Medical Facility Sites:

Outpatient Hospitals
Inpatient Hospitals
Federally Qualified Health Centers
Rural Health Centers
Renal Dialysis Centers
Skilled Nursing Facilities
Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID)
Intermediate Care Facilities/Institutions for Mental Diseases (ICF/IMDs)
Outpatient Mental Health/Substance Abuse Centers/Clinics
Community Mental Health Centers/Clinics
Public Health Clinics
PACE Centers
Assisted Living Facilities
School-Based Wellness Centers
Patient’s Home (must comply with HIPAA, privacy, secure communications, etc., and does not warrant an originating site fee)
Other Sites as approved by the DMAP

Medical Professional Sites:

Physicians (or Physicians Assistants under the supervision of a physician)
Certified Nurse Practitioners
Medical and Behavioral Health Therapists

SOURCE: DE Medical Assistance Program. Adult Behavioral Health Service Certification and Reimbursement. Dec. 1, 2016. Sec. 1. 8. pg. 11 & 12 (Accessed Jul. 2024).

GEOGRAPHIC LIMITS

There are no geographical limitations within Delaware regarding the location of an originating site provider.

SOURCE: DE Medical Assistance Program. Adult Behavioral Health Service Certification and Reimbursement. Dec. 1, 2016. Sec. 1.8, p. 12. (Accessed Jul. 2024).

SOURCE: DE Medical Assistance Program. Practitioner Provider Specific Manual, 1/12/24. Sec. 16.3.4 pg. 75. (Accessed Jul. 2024).

FACILITY/TRANSMISSION FEE

DMAP reimburses the originating site fee for telehealth services per completed transmission to licensed practitioners that are enrolled in DMAP. A facility fee for the originating site is covered, unless the originating site is the patient’s home. Although a home can be considered an originating site, it is not eligible for reimbursement of the originating site fee.

DMAP will reimburse the originating site fee for up to three (3) different originating site providers for separately identifiable telehealth services provided to a member per date of service. Each originating site provider will only be reimbursed one (1) originating site fee per member per day. DMAP will not reimburse the referring provider at the originating site on the same date of service unless the referring provider is billing for a separate identifiable covered service. Medical records must document that all components of the service being billed were provided to the recipient.

Practitioners should use HCPCS Level II procedure code Q3014 when billing for the facility fee.

SOURCE: DE Medical Assistance Program. Practitioner Provider Specific Manual, 1/12/24. Sec. 16.6.2-3, 16.6.5.1.1, pg. 79. (Accessed Jul. 2024).

A facility fee is covered for originating sites.

Facility fees for the distant site are not covered.

Only one facility fee is permitted per date, per member.

SOURCE: DE Medical Assistance Program. Adult Behavioral Health Service Certification and Reimbursement. Dec. 1, 2016. Sec. 1.8, p. 11. (Accessed Jul. 2024).

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District of Columbia

Last updated 06/05/2024

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 Jun. 2024).

The DC Medical Assistance Program will reimburse telemedicine services, if the Medicaid beneficiary meets the following conditions:

Be enrolled in the DC Medicaid Program;
Be physically present at the originating site at the time the telemedicine service is rendered; and
Provide written or verbal consent to receive telemedicine services in lieu of in-person healthcare services, consistent with all applicable DC laws.

SOURCE: DC Municipal Regulation. Title 29, Ch. 9, Sec. 910.5, Physicians Billing Manual. DC Medicaid. Jan. 2024, Sec. 15.2. P. 51 & Department of Health Care Finance – Telemedicine Provider Guidance, Jan. 2023, pg. 2, Clinic Billing Manual (Sept. 2023) 15.2, P. 49; Behavioral Health Billing Manual (Feb. 2024) 14.2, p. 68. FQHC Billing Manual (Oct. 2023), 15.2, P 51. (Accessed Jun. 2024).

ELIGIBLE SERVICES/SPECIALTIES

Medicaid shall cover and reimburse for healthcare services appropriately delivered through telehealth if the same services would be covered when delivered in person.

SOURCE: DC Code Sec. 31-3863 (Accessed Jun. 2024)

Covered Services:

Evaluation and management
Consultation of an evaluation and management of a specific healthcare problem requested by an originating site provider
Behavioral healthcare services including, but not limited to, psychiatric evaluation and treatment, psychotherapies, and counseling
Speech therapy (Outpatient Hospital Billing Guide states: Rehabilitation services including speech therapy)

SOURCE: DC Municipal Regulation. Title 29, Ch. 9, Sec. 910.11 & Physicians Billing Manual. DC Medicaid. (Jan. 2024) Sec. 15.7. P. 53-54, Clinic Billing Manual, DC Medicaid (Sept. 2023), Sec. 15.7, P. 51-52. FQHC Billing Manual, DC Medicaid 15.6.1, P. 53-54. (Oct. 2023), Behavioral Health Billing Manual (Feb. 2024) 14.7, p. 70-71. & Department of Health Care Finance – Telemedicine Provider Guidance, Jan. 2023, pg. 5-6, Outpatient Hospital Billing Guide, 15.8.5, p. 75 (Apr. 2024), Inpatient Hospital Billing Guide, 11.7, p. 62-63 (Apr. 2024), Long-Term Care Billing Manual, 15.7, p. 53-54 (Sept. 2023). (Accessed Jun. 2024).

The provider shall determine if the service can reasonably be delivered at the standard of care via telemedicine.

SOURCE: Department of Health Care Finance – Telemedicine Provider Guidance, Jan. 2023, pg. 6. Physicians Billing Manual. DC Medicaid. (Jan. 2024) Sec. 15.7. P. 54, Clinic Billing Manual, DC Medicaid (Sept. 2023), Sec. 15.7, P. 51-52 . FQHC Billing Manual, DC Medicaid 15.6.1, P. 54. (Oct. 2023), Behavioral Health Billing Manual (Feb. 2024) 14.7, p. 71, Inpatient Hospital Billing Guide, 11.7, p. 63 (Apr. 2024), L ong-Term Care Billing Manual, 15.7, p. 54 (Sept. 2023) (Accessed Jun. 2024).

Distant site providers may only bill for the appropriate codes outlined.

SOURCE: DC Municipal Regulation. Title 29, Ch. 9, Sec. 910.12.(Accessed Jun. 2024).

Telemedicine listed as a covered service in the following manuals, but no other information is provided.

Education-Related Services

Office of the State Superintendent of Education shall only bill for distant site services that are allowable healthcare services to be delivered by the individual fee-for-service providers delivering Strong Start DC Early Intervention Program (DC EIP) services under them and can be delivered at the standard of care via telemedicine.

The following reimbursement parameters apply for services delivered under the Office of the State Superintendent of Education through the Strong Start DC Early Intervention Program:

The LEA shall only bill for distant site services that are allowable healthcare services to be delivered at DCPS/DCPCS and can be delivered at the standard of care via telemedicine;
The LEA shall provide an appropriate primary support professional to attend the medical encounter with the member at the originating site. In instances where it is clinically indicated, an appropriate healthcare professional shall attend the encounter with the member at the originating site.

SOURCE: Department of Health Care Finance – Telemedicine Provider Guidance, Jan. 2023, pg. 5. Physicians Billing Manual. DC Medicaid. (Jan. 2024) Sec. 15.6. P. 53, Clinic Billing Manual, DC Medicaid (Sept. 2023), Sec. 15.6, P. 51. FQHC Billing Manual, DC Medicaid 15.6, P. 53. (Oct. 2023), Behavioral Health Billing Manual (Feb. 2024) 14.6, p. 70 , Inpatient Hospital Billing Guide, 11.6, p. 62 (Apr. 2024), L ong-Term Care Billing Manual, 15.6, p. 53 (Sept. 2023) (Accessed Jun. 2024).

Excluded Services

The Program will not reimburse telemedicine providers for the following:

Incomplete delivery of services via telemedicine, including technical interruptions that result in partial service delivery.
When a provider is only assisting the beneficiary with technology and not delivering a clinical service.
For a telemedicine transaction fee and/or facility fee.
For store and forward and remote patient monitoring

SOURCE: Department of Health Care Finance – Telemedicine Provider Guidance, Jan. 2023, pg. 6, Physicians Billing Manual. DC Medicaid. (Jan. 2024) Sec. 15.8. P. 54, Clinic Billing Manual, DC Medicaid (Sept. 2023), Sec. 15.8, P. 52. FQHC Billing Manual, DC Medicaid 15.6.2, P. 54. (Oct. 2023), Behavioral Health Billing Manual (Feb. 2024) 14.8, p. 71, Outpatient Hospital Billing Guide, 15.8.6, p. 75 (Apr. 2024), Inpatient Hospital Billing Guide, 11.8, p. 63 (Apr. 2024), L ong-Term Care Billing Manual, 15.8, p. 54 (Sept. 2023). (Accessed Jun. 2024).

Mental Health Rehabilitation Services Provider Certification Standards

Telemedicine/telehealth are included under reimbursable services. See rule for specific requirements.

SOURCE: DC Municipal Regulation, Title 22, Ch. 34, Sec. 3434. (Accessed Jun. 2024).

Mental Health Crisis/Emergency Services

A Crisis/Emergency Service is an immediate response face-to-face or via telehealth in accordance with 29 DCMR Â§ 910 to an emergency situation involving a consumer with mental illness or emotional disturbance that is available twenty-four (24) hours per day, seven (7) days per week.

SOURCE: DC Municipal Regulation, Title 22, Ch. 34, Sec. 3422. (Accessed Jun. 2024).

Clinical Care Coordination (CCC)

CCC may be rendered by a qualified practitioner pursuant to § 3432.8 practicing within the scope of their license in person or through telehealth in accordance with 29 DCMR § 910.

Qualified practitioners providing CCC shall:

Communicate treatment needs, assessments and treatment information to healthcare providers external to the consumer’s CSA or specialty provider;
Facilitate appropriate linkages for the consumer with other healthcare professionals external to the consumer’s CSA or specialty provider; and
Provide planning and Plan of Care implementation activities separate from the diagnostic assessment service when the clinician and consumer meet face-to-face or through telehealth pursuant to 29 DCMR § 910.

Providers must document CCC in an encounter note that meets the requirements of § 3413.19 and indicates the intended purpose of the service, the modality of communication, time spent reviewing or preparing records, the actions taken, and the result(s) achieved.

SOURCE: DC Municipal Regulation, Title 22, Ch. 34, Sec. 3432. (Accessed Jun. 2024).

Assertive Community Treatment (ACT)

During the calendar month billing cycle, the ACT provider must deliver at least five contacts face-to-face and may deliver up to three contacts via telehealth, including collateral contacts and the monthly MD/APRN contact. At least three contacts must be delivered by distinct qualified practitioners eligible to deliver ACT services pursuant to Title 22-A DCMR Chapter 34. See provider transmittals 23-39, 23-50, and 24-11 and rule for specific requirements.

SOURCE: DC Municipal Regulation, Title 29, Ch. 52, Sec. 5210.2 & Department of Health Care Finance, Notice of Final Rulemaking – Amending 29 DCMR Chapter 52 – Governing Assertive Community Treatment. Mar. 2024; Title 22, Chap. 22-A34, Sec. 3426, 3434, & Title 22, Chap. 22-A37, Sec. 3708, 3711 & Department of Behavioral Health – Notice of Final Rulemaking – Amending 22-A DCMR Ch. 34 and 37 – Assertive Community Treatment. Dec. 2023. (Accessed Jun. 2024).

ELIGIBLE PROVIDERS

Telemedicine providers must comply with the following:

Be an enrolled Medicaid provider and comply with requirements including having a completed, signed Medicaid Provider Agreement
Comply with technical, programmatic and reporting requirements
Be licensed; and
Appropriately document the beneficiary’s written or verbal consent.
Comply with any other applicable consent requirements under District laws, including but not limited to Section 3026 of Title 5-E of the District of Columbia Municipal Regulations if providing telemedicine services at a District of Columbia Public School (DCPS) or District of Columbia Public Charter School (DCPCS).

SOURCE: DC Municipal Regulation. Title 29, Ch. 9, Sec. 910.6. (Accessed Jun. 2024)

D.C. Medicaid enrolled providers are eligible to deliver telemedicine services, using fee-for-service reimbursement, at the same rate as in-person consultations. All reimbursement rates for services delivered via telemedicine are consistent with the District’s Medical State Plan and implementing regulations.

The eligible distant site providers include but are not limited to the following:

Hospital
Nursing facility
Federally Qualified Health Center
Clinic
Physician Group/Office
Nurse Practitioner Group/Office
DCPS
DCPCS; and
MHRS provider, ASARS provider and ASTEP provider certified by DBH and eligible to provide behavioral health services set forth under the State Plan

SOURCE: DC Municipal Regulation. Title 29, Ch. 9, Sec. 910.7 & Department of Health Care Finance – Telemedicine Provider Guidance, Jan. 2023, pg. 3-4. Physicians Billing Manual. DC Medicaid. (Jan. 2024) Sec. 15.3. P. 52, Clinic Billing Manual, DC Medicaid (Sept. 2023), Sec. 15.3, P. 50. FQHC Billing Manual, DC Medicaid 15.3, P. 52. (Oct. 2023), Behavioral Health Billing Manual (Feb. 2024) 14.3, p. 69, Outpatient Hospital Billing Guide, 15.8.3, p. 74-75 (Apr. 2024), Inpatient Hospital Billing Guide, 11.3, p. 61 (Apr. 2024), L ong-Term Care Billing Manual, 15.3, p. 52 (Sept. 2023). (Accessed Jun. 2024).

At the discretion of the rendering provider, personnel delivering telemedicine services may work remotely, as long as all other requirements in the rule are met. See sections on technology, documentation in medical records, and confidentiality in guidance document for further specifications.

SOURCE: Department of Health Care Finance – Telemedicine Provider Guidance, Jan. 2023, pg. 3-4. Physicians Billing Manual. DC Medicaid. (Jan. 2024) Sec. 15.3. P. 52, Clinic Billing Manual, DC Medicaid (Sept. 2023), Sec. 15.3, P. 50. FQHC Billing Manual, DC Medicaid 15.3, P. 52. (Oct. 2023), Behavioral Health Billing Manual (Feb. 2024) 14.3, p. 69, Inpatient Hospital Billing Guide, 11.3, p. 61 (Apr. 2024), L ong-Term Care Billing Manual, 15.3, p. 52 (Sept. 2023) (Accessed Jun. 2024).

When a beneficiary’s home is the originating site, the distant site provider shall ensure the technology in use meets the minimum requirements.

SOURCE: DC Municipal Regulation. Title 29, Ch. 9, Sec. 910.30. (Accessed Jun. 2024).

Federally Qualified Health Center (FQHC) Reimbursement

In accordance with the District’s Prospective Payment System (PPS) or alternative payment methodology (APM) for FQHCs, the following reimbursement parameters apply:

Originating Site: An FQHC provider must deliver an FQHC-eligible service in order to be reimbursed the appropriate PPS, APM, or fee-for-service (FFS) rate at the originating site;
Distant Site: An FQHC provider must deliver an FQHC-eligible service that is listed in Appendix A in order to be reimbursed the appropriate PPS, APM, or FFS rate; and
Originating and Distant Site: If both the originating and the distant site are FQHCs, for both to receive reimbursement, each site must deliver a different PPS or APM service (e.g. medical or behavioral). If both sites submit a claim for the same PPS or APM service (e.g. medical), then only the distance site will be eligible to receive reimbursement.

SOURCE: Department of Health Care Finance – Telemedicine Provider Guidance, Jan. 2023, pg. 4-5.,Physicians Billing Manual. DC Medicaid. (Jan. 2024) Sec. 15.5. P. 53, Clinic Billing Manual, DC Medicaid (Sept. 2023), Sec. 15.5, P. 51. FQHC Billing Manual, DC Medicaid 15.5, P. 53. (Oct. 2023), Behavioral Health Billing Manual (Feb. 2024) 14.5, p. 70. Inpatient Hospital Billing Guide, 11.5, p. 62 (Apr. 2024), Long-Term Care Billing Manual, 15.5, p. 53 (Sept. 2023) (Accessed Jun. 2024).

ELIGIBLE SITES

Eligible services can be delivered via telemedicine when the beneficiary is at the originating site, while the eligible “distant” provider renders services via the audio/video or audio-only connection.

When clinically indicated, an originating site provider or its designee shall be in attendance during the patient’s medical encounter with the distant site professional. An originating site provider shall not be required to be in attendance when the beneficiary prefers to be unaccompanied because the beneficiary feels the subject is sensitive. An originating site provider shall note their attendance status in the patient’s medical record.

To receive reimbursement, originating site providers must deliver an eligible service, distinct from the service delivered at the distant site, in order to receive reimbursement.

Telemedicine providers will submit claims in the same manner the provider uses for in person services.

When billing for services delivered via video-audio telemedicine, distant site providers shall enter the “GT” procedure modifier on the claim. When billing for any audio-only telemedicine services, distant site providers shall enter the “93” procedure modifier on the claim.

Additionally, the distant site provider must appropriately specify the place of service (POS) using the following POS codes:

In the event the beneficiary’s home is the originating site, the distant site provider must specify the place of service “10” which is defined as “telehealth provided in patient’s home”.
In the event a DCPS or a DCPCS is the originating site, the distant site provider must specific the place of service “03” which is defined as “school”.
In the event the beneficiary is at any other eligible originating site (see section IV above), the distant site provider must specify the place of service “02” which is defined as “telehealth provided other than in patient’s home”. When utilizing place of service “02”, the distant site provider must also report the National Provider Identifier (NPI) of the originating site provider in the “referring provider” portion of the claim.

Services billed where telemedicine is the mode of service delivery, but the claim form and/or service documentation do not indicate telemedicine (using the appropriate procedure modifiers and appropriate POS codes) are subject to disallowances in the course of an audit.

The Program will implement this telemedicine service for both providers and participants in the Medicaid fee-for-service, Medicaid managed care, Health Care Alliance, and Immigrant Children’s programs. All requirements stipulated in this provider guidance apply to all programs DHCF administers.

SOURCE: Department of Health Care Finance – Telemedicine Provider Guidance, Jan. 2023, pg. 1-4. Physicians Billing Manual. DC Medicaid. (Jan. 2024) Sec. 15.4. P. 52-53, Clinic Billing Manual, DC Medicaid (Sept. 2023), Sec. 15.4, P. 50-51. FQHC Billing Manual, DC Medicaid 15.4, P. 52-53. (Oct. 2023), Behavioral Health Billing Manual (Feb. 2024) 14.4, p. 69-70, Inpatient Hospital Billing Guide, 11.4, p. 61-62 (Apr. 2024), Long-Term Care Billing Manual, 15.4, p. 52-53 (Sept. 2023) (Accessed Jun. 2024).

Effective March 1st, 2023, District health care providers rendering services to beneficiaries in Medicaid fee-for-service, Medicaid managed care, Health Care Alliance, and Immigrant Children’s programs must comply with these revised billing requirements. Refer to Transmittal #23-11 for additional information.

SOURCE: Physicians Billing Manual. DC Medicaid. (Jan. 2024) Sec. 15.4. P. 52-53, Clinic Billing Manual, DC Medicaid (Sept. 2023), Sec. 15.4, P. 50-51. FQHC Billing Manual, DC Medicaid 15.4, P. 52-53. (Oct. 2023), Behavioral Health Billing Manual (Feb. 2024) 14.4, p. 69-70, Inpatient Hospital Billing Guide, 11.4, p. 61-62 (Apr. 2024), Long-Term Care Billing Manual, 15.4, p. 52-53 (Sept. 2023) (Accessed Jun. 2024).

The beneficiary’s home, or other settings authorized by DHCF, may serve as the originating site. When the originating site is the beneficiary’s home the distant site provider is responsible for ensuring that the technology in use meets the minimum requirements set forth in Subsection 910.13.

SOURCE: DC Municipal Regulation. Title 29, Ch. 9, Sec. 910.7 & 910.30. (Accessed Jun. 2024).

POS 02 (telehealth) and POS 10 (telehealth provided in patient’s home) are listed as a valid place of service code in multiple DC Medicaid manuals.

SOURCE: DC Medicaid, Provider Specific Information, See each individual manual. (Accessed June 2024).

DHCF defines “the definition of “the beneficiary’s home or other settings” to include temporary lodging, such as hotels and homeless shelters. Additionally, for circumstances where the patient, for privacy or other personal reasons, chooses to travel a short distance from the exact home location during a telehealth service, the service is still considered to be furnished” in the home of an individual.

SOURCE: Department of Health Care Finance. Telemedicine Provider Guidance Clarification “Beneficiary’s Home or Other Settings”. March 2023. (Accessed Jun. 2024).

Must be an approved telemedicine provider. The following providers are considered an eligible originating site:

Hospital
Nursing facility
Federally Qualified Health Center
Clinic
Physician Group/Office
Nurse Practitioner Group/Office
District of Columbia Public Schools (DCPS)
District of Columbia Public Charter Schools (DCPCS)
Mental Health Rehabilitation Service (MHRS) provider, Adult Substance Abuse Rehabilitation Service (ASARS) provider, and Adolescent Substance Abuse Treatment Expansion Program (ASTEP) provider certified by the Department of Behavioral Health (DBH) and eligible to provide behavioral health services set forth under the District of Columbia Medicaid State Plan (State Plan).
The beneficiary’s home or other settings identified in guidance published on the DHCF website.

SOURCE: DC Municipal Regulation. Title 29, Ch. 9, Sec. 910.7, Department of Health Care Finance – Telemedicine Provider Guidance, Jan. 2023, pg. 2-3. Physicians Billing Manual. DC Medicaid. (Jan. 2024) Sec. 15.3. P. 52, Clinic Billing Manual, DC Medicaid (Sept. 2023), Sec. 15.3, P. 50. FQHC Billing Manual, DC Medicaid 15.3, P. 52. (Oct. 2023), Behavioral Health Billing Manual (Feb. 2024) 14.3, p. 69. Outpatient Hospital Billing Guide, 15.8.3, p. 74 (Apr. 2024), Inpatient Hospital Billing Guide, 11.3, p. 61 (Apr. 2024), Long-Term Care Billing Manual, 15.3, p. 52 (Sept. 2023). (Accessed Jun. 2024).

When a beneficiary’s home is the originating site, the distant site provider shall ensure the technology in use meets the minimum requirements set forth in Subsection 910.13.

SOURCE: Department of Health Care Finance – Telemedicine Provider Guidance, Jan. 2023, pg. 7. (Accessed Jun. 2024).

When DCPS or DCPCS is the originating site provider, a primary support professional (an individual designated by the school) shall be in attendance during the patient’s medical encounter.

An originating site provider shall not be required to be in attendance when the beneficiary prefers to be unaccompanied because the beneficiary feels the subject is sensitive. Sensitive topics may include counseling related to abuse, or other psychiatric matters. An originating site provider shall note their attendance status in the patient’s medical record.

SOURCE: DC Municipal Regulation. Title 29, Ch. 9, Sec. 910.16-17. (Accessed Jun. 2024).

GEOGRAPHIC LIMITS

No Reference Found

FACILITY/TRANSMISSION FEE

No transaction or facility fee.

SOURCE: DC Municipal Regulation. Title 29, Ch. 9, Sec. 910.28, Department of Health Care Finance – Telemedicine Provider Guidance, Jan. 2023, pg. 6, Physicians Billing Manual. DC Medicaid. (Jan. 2024) Sec. 15.8. P. 54, Clinic Billing Manual, DC Medicaid (Sept. 2023), Sec. 15.8, P. 52. FQHC Billing Manual, DC Medicaid 15.6.2, P. 54. (Oct. 2023), Behavioral Health Billing Manual (Feb. 2024) 14.8, p. 71, Outpatient Hospital Billing Guide, 15.8.6, p. 75 (Apr. 2024), Inpatient Hospital Billing Guide, 11.8, p. 63 (Apr. 2024), L ong-Term Care Billing Manual, 15.8, p. 54 (Sept. 2023). (Accessed Jun. 2024).

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Florida

Last updated 11/11/2024

POLICY

During the federal PHE, the Agency provided expansive coverage …

POLICY

During the federal PHE, the Agency provided expansive coverage for telemedicine services. Effective May 11, 2023, Florida Medicaid will cover telehealth services in accordance with the Agency’s promulgated Telemedicine rule and will no longer cover audio-only telehealth services. Florida Medicaid will continue to cover store-and-forward and remote patient monitoring services.

As a reminder, Statewide Medicaid Managed Care (SMMC) plans may provide more expansive coverage than what is in Agency rule, including telemedicine and waiving co-payments. However, SMMC plans may not be more restrictive than Agency rule.

SOURCE: FL Medicaid, Alert, Ending of Federal Public Health Emergency: Updated Co-Payment and Telemedicine Guidance for Medical and Behavioral Health Providers, May 4, 2023, (Accessed Nov. 2024).

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

Providers must include the GT modifier.

SOURCE: FL Admin Code 59G-1.057. (Accessed Nov. 2024).

ELIGIBLE SERVICES/SPECIALTIES

List of eligible community behavioral health services is provided in Provider Alert. See alert for procedure codes, modifiers and telemedicine modifiers.

SOURCE: FL Medicaid, Alert, Community Behavioral Health Telemedicine-Eligible Services, May 12, 2023, (Accessed Nov. 2024).

Florida Medicaid reimburses the practitioner who is providing the evaluation, diagnosis, or treatment recommendation located at a site other than where the recipient is located.

SOURCE: FL Admin Code 59G-1.057. (Accessed Nov. 2024).

Behavioral Analysis

The Lead Analyst may provide up to two hours per week of training to parents or guardians via telemedicine in accordance with Rule 59G-1.057, Florida Administrative Code (F.A.C.).

SOURCE: FL Medicaid, Behavior Analysis Services Coverage Policy, Sept. 2023, (Accessed Nov. 2024).

ELIGIBLE PROVIDERS

Telemedicine is available for use by all providers of Florida Medicaid services that are enrolled in or registered with the Florida Medicaid program and who are licensed within their scope of practice to perform the service.

SOURCE: FL Admin Code 59G-1.057. (Accessed Nov. 2024).

ELIGIBLE SITES

No Reference Found

GEOGRAPHIC LIMITS

No Reference Found

FACILITY/TRANSMISSION FEE

No Reference Found

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Georgia

Last updated 05/20/2024

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 (Apr. 1, 2024). (Accessed May. 2024).

Medicaid covered services are provided via telehealth for eligible members when the service is medically necessary, the procedure is individualized, specific, and consistent with symptoms or confirmed diagnosis of an illness or injury under treatment, and not in excess of the member’s needs.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 5 (Apr. 1, 2024). (Accessed May 2024).

ELIGIBLE SERVICES/SPECIALTIES

An interactive telecommunications system is required as a condition of payment. The originating site’s system, at a minimum, must have the capability of allowing the distant site provider to visually examine the patient’s entire body including body orifices (such as ear canals, nose and throat). The distant site provider should also have the capability to hear heart tones and lung sounds clearly (using a stethoscope) if medically necessary and currently within the provider’s scope of practice. The telecommunication system must be secure and adequate to protect the confidentiality and integrity of the information transmitted.

SOURCE: GA Dept. of Community Health, Physician Services Manual, p. 168 (Apr. 1, 2024). (Accessed May. 2024).

Claims for telehealth services must use the appropriate CPT or HCPCS code for the professional service. The GT modifier is required as applicable, and/or the use of either POS 02 or POS 10. POS 02 will indicate Telehealth services that were utilized at a location other than at the patient’s home. The GQ modifier is still required as applicable. By coding and billing with the covered telehealth procedure code, providers are certifying that the member was present at an eligible originating site when you furnished the telehealth service. CPT modifier ‘‘93’’ can be appended to claim lines, as appropriate, for services furnished using audio only communications technology. Interactive audio and video telecommunications must be used, permitting real time communications between the distant site provider or practitioner and the member.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 8, 10 (Apr. 1, 2024). (Accessed May. 2024).

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.

An interactive telecommunications system is required as a condition of payment. The originating site’s system, at a minimum, must have the capability of allowing the distant site provider to visually examine the patient’s entire body including body orifices (such as ear canals, nose, and throat). Depending upon an enrolled provider’s specialty and scope of practice, the distant provider should also have the capability to hear heart tones and lung sounds clearly (using stethoscope) if medically necessary and currently within the provider’s scope of practice. The telecommunication system must be secure and adequate to protect the confidentiality and integrity of the information transmitted.

Providers may not bill for services or charge a fee for missed appointments. Cost associated with the
use of technology or data transmission are not covered under Medicaid and cannot be charged to the
member.

See telehealth manual for list of eligible telehealth services and codes for specific programs.

Non-Covered Service Modalities:

Telephone conversations.
Electronic mail messages.
Facsimile.
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.
Video cell phone interactions.
The cost of telehealth equipment and transmission.
Failed or unsuccessful transmissions.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance, p. 5, 8, 10 (Apr. 1, 2024). (Accessed May 2024).

Nursing Facilities

Though not available in all areas of the State, Medicare-funded mental health services are currently provided to nursing home residents via telehealth (telemedicine), face-to-face visits by providers in the nursing home, and nursing home resident visits to psychiatric/mental health clinics/offices for those individuals able to travel outside the nursing facility. See manual for codes.

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 telemedicine procedure codes.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 23-25 (Apr. 1, 2024) & GA Dept. of Community Health, Division of Medical Assistance, Part II Policies and Procedures for Nursing Facility Services, p. H-1 , H-7 (p. 145, 151). (Apr. 1, 2024). (Accessed May 2024).

Teledentistry

See dental services manual for teledentistry codes.

SOURCE: GA Dept. of Community Health, Division of Medical Assistance, Part II Policies and Procedures for Dental Services, IX-21, p. 60 (Apr. 2024). GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 19 (Apr. 1, 2024). (Accessed May 2024).

GT modifier to be used in conjunction with the appropriate codes for Telemedicine following full
implementation of HIPAA compliance (see “Telemedicine Consultations.”).

SOURCE: GA Dept. of Community Health, Division of Medical Assistance, Part II: Policies and Procedures: Oral Maxillofacial Surgery Services (April 2024), p. G-2. (Accessed May. 2024).

Autism Spectrum Disorder Services

Practitioners of Autism Spectrum Disorder (ASD) services can use telehbehavioealth to assess, diagnose and provide therapies to patients. Prior authorization is required for all Medicaid-covered adaptive behavior services, behavioral assessment and treatment services (not telehealth specific). See manual for eligible codes.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 13 (Apr. 1, 2024). (Accessed May 2024).

Community Behavioral Health and Rehabilitation Services (CBHRS)

The Departments of Community Health and Behavioral Health and Developmental Disabilities have authorized telemedicine to be used to provide some services in the CBHRS program. See Behavioral Health and Development Disabilities manual for more detailed information.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 17-19 (Apr. 1, 2024). GA Department of Community Health for CBHRS, p. 99-101 (Apr. 1, 2024). GA Dept. of Behavioral Health & Developmental Disabilties, Provider Manual for Community Behavioral Health Providers (Mar 1. 2023). (Accessed May 2024).

Those residents whose interest is best served by receiving mental health services in the nursing facility or in a nearby telemedicine site can receive services in either of those locations, with the practitioner using out-of-clinic or telehealth/telemedicine procedure codes.

SOURCE: GA Dept. of Community Health, Division of Medical Assistance, Part II Policies and Procedures for Community Behavioral Health Rehabilitation Services, p. 69, (Apr. 1, 2024). (Accessed May 2024).

Dialysis Services

The Centers for Medicaid and Medicare Services (CMS) has added Dialysis Services to the list of services that can be provided under Telehealth. The distant site/physician providing the service via a telecommunications
system will bill using Place of Service 02 to indicate Telehealth.See manual for list of eligible CPT codes.

SOURCE: GA Dept. of Community Health, GA Medicaid Telemedicine Guidance Handbook, p. 17-18 (Apr. 1, 2024). (Accessed May. 2024).

School Based Services

Telehealth benefits are allowed if all the following criteria are met:

The provider is an authorized health-care provider enrolled in Georgia Medicaid
The client is a child who is receiving the service in a primary or secondary school-based setting
The parent or legal guardian of the client provides consent before the service is provided.

Speech Language Pathology Services involve the identification of children with speech and/or language disorders, diagnosis and appraisal of specific speech and/or language disorders, referral for medical and other professional attention necessary for the rehabilitation of speech and/or language disorders, provision of speech or language services for the prevention of communicative disorders. The speech language pathologist must bill for time spent in hands on activities or via telehealth services with the student. 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. 26-27 (Apr. 1, 2024). (Accessed May. 2024).

The rendering provider serving as the telemedicine distant site should report the E/M office visit code (992xx) along with the GT modifier (including any other applicable modifiers), the appropriate POS, and the ICD-10 diagnosis code(s). See manual for more details.

SOURCE: GA Dept. of Community Health, EPSDT Health Check Program , p. 68 (Apr. 2024). (Accessed May 2024).

Durable Medical Equipment Services

A face-to-face encounter may be made through the use of telehealth technology by reporting the appropriate E&M code.

SOURCE: GA Dept. of Community Health, GA Medicaid Durable Medical Equipment Services Manual, p. 34 (Apr. 1, 2024). (Accessed May 2024).

Elderly and Disabled Waiver EDWP Traditional/Enhanced Case Management

Members must be seen by their PCP annually, either in the office of the PCP or via Telehealth with the SNS provider RN performing the call.

SOURCE: GA Dept of Community Health, Division of Medicaid, Policies and Procedures for Elderly and Disabled Waiver EDWP – (CCSP) Traditional/Enhanced Case Management (Apr. 1, 2024), p. 23. (Accessed May 2024).

EDWP (CCSP and Source) Skilled Nursing Services by Private Home Care Providers

Registered Nurse Responsibilities include facilitating telehealth visits with the member and the member’s PCP.

SOURCE: GA Dept of Community Health, Division of Medicaid, Policies and Procedures for EDWP (CCSP and SOURCE): General Services (Apr.1, 2024), p. 211-212; Skilled Nursing Services by Private Home Care Providers (Apr. 1, 2024), p. 7, 11-12.; (Accessed May 2024).

Department of Community Health

The Department of Community Health (DCH) will allow medically necessary services to be rendered via telehealth. Each billed procedure code must be submitted with the usual program modifier(s). Place of service code 02 must be added to the allowed procedure codes to indicate the services are related to telehealth services.

SOURCE: GA Dept of Community Health: Early Intervention Case Management Program, p. 25 (Apr. 1, 2024). (Accessed May. 2024).

Children’s Intervention Services

The Department of Community Health will allow some speech therapy, therapy and audiology services to be rendered via telehealth. See manual for appropriate codes.

SOURCE: GA Dept. of Community Health, Division of Medicaid, Children’s Intervention Services (Apr. 1, 2024), p. 47. GA Dept. of CommunityHealth, Childrens Intervention School Services (Apr. 1, 2024), p. 39-40. (Accessed May 2024).

Comprehensive Supports Waiver Program (COMP)

All components of Adult Occupational Therapy, Adult Physical Therapy, Speech and Language Therapy, Adult Nutrition Services, Interpreter Services can be safely provided via telehealth modalities according to prevailing best practice standards published by the American Speech and Language Hearing (Occupational or Physical Therapy) Association and in accordance with the Georgia license requirements under O.C.G.A. § 43-44-7. Therapists are expected to use synchronous “in real time” audio/video technology for telehealth sessions. Telephone calls and store and forward (asynchronous) modalities are not allowed for billable therapy evaluation and services.

Payment is not made for feeding and swallowing evaluation and treatment via any telehealth modality. (Adult Speech and Language).

Some components of Behavior Supports Services can be provided via a telehealth modality to supplement in-person service delivery. The following components are the only components that are allowable for a telehealth option:

Indirect assessment component for functional behavior assessment;
Follow up or refresher staff training for behavior support plans;
Additional fidelity monitoring of plan implementation and oversight;
Distant site observations of the individual for the purposes of consultation, modeling, and recommendations for interventions to staff/caregivers in real time;
Team meetings for the purpose of gathering feedback related to behavior support plans effectiveness; and
Review of data analysis summaries and behavior graphing.

See manual for more details.

SOURCE: GA Dept. of Community Health, Comprehensive Supports Waivers Program (COMP) Chapters 1300-3700 (Apr. 1, 2024), GA Dept. of CommunityHealth, New Options Waiver Program (NOW) (Apr. 1, 2024). (Accessed May 2024).

Independent Care Waiver Services

Counseling and Behavioral Management services are available to members needing treatment for personal, social or behavioral disorders to maintain and improve effective functioning. Counseling services can be provided via telehealth with or without a visual component.

SOURCE: GA Dept. of Community Health, Independent Care Waiver Services (Apr. 1, 2024), p. 87 & 92. (Accessed May. 2024).

ELIGIBLE PROVIDERS

The consulting provider must be an enrolled provider in Medicaid in the state of Georgia and must document all findings and recommendations in writing, in the format normally used for recording services in the member’s medical records. The provider at the distant site must obtain prior approval when services require prior approval. Both the originating site and distant site must document and maintain the member’s medical records. The report from the distant site provider may be faxed to the originating provider.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 9 (Apr. 1, 2024). (Accessed May. 2024).

Autism Spectrum Disorder Services

Practitioners of ASD services can use telehealth to assess, diagnose and provide therapies to patients. Providers must hold either a current and valid license to practice Medicine in Georgia, hold a current and valid license as a Psychologist as required under Georgia Code Chapter 39 as amended, or hold a current and valid Applied Behavior Analysis (ABA) Certification. In addition to licensed Medicaid enrolled Physicians and Psychologists, Georgia Medicaid will enroll Board Certified Behavioral Analysts (BCBAs) as Qualified Health Care Professionals (QHCPs) to provide ASD treatment services. The BCBA must have a graduate-level certification in behavior analysis. Providers who are certified at the BCBA level are independent practitioners who provide behavior-analytic services. In addition, BCBAs supervise the work of Board-Certified Assistant Behavior Analysts (BCaBAs), and Registered Behavior Technicians (RBTs) who implement behavior-analytic interventions.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 13 (Apr. 1, 2024). (Accessed May 2024).

Community Behavioral Health and Rehabilitation Services

See manual for eligible practitioner types and levels for CBHRS.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 19 (Apr. 1, 2024). (Accessed May 2024).

Teledentistry

Licensed dentists and dental hygienists are eligible providers.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 19 (Apr. 1, 2024). (Accessed May 2024).

Federally Qualified Health Center (FQHC)/Rural Health Center (RHC)

FQHCs and RHCs can serve as the originating or distant site. They cannot bill an originating site fee and distant site fee for telehealth services on the same encounter.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 20 (Apr. 1, 2024) & GA Dept. of Community Health, Policies and Procedures for Federally Qualified Health Center Services and Rural Health Clinic Services, p. 30, (Apr. 1, 2024). (Accessed May 2024).

Nursing Facility Specialized Services

See manual for eligible providers and levels.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 23 (Apr. 1, 2024). (Accessed May. 2024).

Advanced Nurse Practitioner & Nurse Midwifery Services

GT modifier must be used in conjunction with the appropriate codes for Telemedicine following full implementation of HIPAA compliance (see “Telemedicine Consultations.”).

SOURCE: GA Dept. of Community Health, GA Medicaid Division, Advanced Nurse Practitioner Services (Apr 16, 2024), p. 24. GA Dept. of Community Health, GA Medicaid Division, Nurse Midwifery Services, p. 36 (Apr, 16, 2024). (Accessed May 2024).

School-Based Settings (Local Education Agencies)

Telehealth services are allowed in school-based settings upon enrollment into COS 600. The following requirements must be met:

The provider is an authorized health-care provider enrolled in Georgia Medicaid
The client is a child who is receiving the service in a primary or secondary school-based setting
The parent or legal guardian of the client provides consent before the service is provided

Telehealth services provided in a school-based setting are also a benefit if the referring provider delegates provision of services to a nurse practitioner, clinical nurse specialist, physician assistant, or other licensed specialist as long as the above-mentioned providers are working within the scope of their professional license and within the scope of their delegation agreement with the provider.

The school must enroll as a Health Check Provider in order to bill the telehealth originating site facility fee.

LEAs must submit an Attestation Form for the provision of telehealth services.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 26 (Apr. 1, 2024).(Accessed May 2024).

ELIGIBLE SITES

Originating sites are paid an originating site facility fee for telehealth services as described by HCPCS code Q3014 with a payment of $20.52. Hospitals are eligible to receive reimbursement for a facility fee for telehealth when operating as the originating site. Claims must be submitted with revenue code 780 (telehealth) and type of bill 131. There is no separate reimbursement for telehealth serves when performed during an inpatient stay, outpatient clinic or emergency room visit or outpatient surgery, as these are all-inclusive payments.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 8 (Apr. 1, 2024). (Accessed May 2024).

Ambulance Providers

They may serve as originating sites and the ambulance may bill a separate origination site fee. They are not authorized to provide distant site services.

Limitation (Emergency Ambulance Services Handbook): Emergency ambulance services are reimbursable only when medically necessary. The recipient’s physical condition must prohibit use of any method of transportation except emergency for a trip to be covered. See Emergency Ambulance Handbook for more specific information.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 12 (Apr. 1, 2024). & Emergency Ambulance Services Handbook, p. 17-18 (Apr. 1, 2024). (Accessed May 2024).

Community Behavioral Health and Rehabilitation Services

Member may be located at home, schools and other community-based settings or at traditional sites named in the Department of Community Health Telehealth Guidance. See manual for detailed instructions explanation for when and which type of practitioner can bill for telehealth services.

Traditional sites include:

Physician and Practitioner’s Offices;
Hospitals;
Rural Health Clinics;
Federally Qualified Health Centers;
Local Education Authorities and School Based Clinics;
County Boards of Health;
Emergency Medical Services Ambulances; and
Pharmacies.

SOURCE: GA Dept. of Community Health, Community Behavioral Health Rehabilitation Services Handbook Appendix O, p.99 (Apr. 1, 2024). GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 18 (Apr. 1, 2024). (Accessed May 2024).

Teledentistry

D9996 is the originating site fee…D9996 is used by the Dental Hygienist when dental information is sent to a licensed Dentist for review via telemedicine technology. The Dentist that does the requested exam then bills the Department D0140 for the exam and report.

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, Polices & Procedures II: Dental Services p. 60 (Apr. 1, 2024). (Accessed May 2024).

Federally Qualified Health Center (FQHC)/Rural Health Center (RHC)

FQHCs and RHCs can serve as originating sites and are paid an originating site facility fee. They cannot bill an originating site fee and distant site fee for telehealth services on the same encounter.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 20 (Apr. 1, 2024). & GA Dept. of Community Health, Policies and Procedures for Federally Qualified Health Center Services and Rural Health Clinic Services, p. 23, (Apr. 1, 2024). (Accessed May 2024).

Dialysis Services

Dialysis facilities are eligible originating sites for dialysis services.

SOURCE: GA Dept. of Community Health, GA Medicaid Telemedicine Guidance Handbook, p. 20 (Apr. 1, 2024). & GA Dept. of Community Health, GA Medicaid Dialysis Services Handbook, p. 17 (IX-10). (Apr. 1, 2024) (Accessed May 2024).

Nursing Facility Specialized Services

Nursing facilities can be eligible sites for nursing facility specialized services.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 23 (Apr. 1, 2024). & GA Dept. of Community Health, Nursing Facility Services, p. H-7 (p. 151). (Apr. 1, 2024). (Accessed May 2024).

School-Based Settings (Local Education Agencies)

Telehealth services are allowed in school-based settings upon enrollment into COS 600. The following requirements must be met:

The provider is an authorized health-care provider enrolled in Georgia Medicaid
The client is a child who is receiving the service in a primary or secondary school-based setting
The parent or legal guardian of the client provides consent before the service is provided

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. 26 (Apr. 1, 2024)., GA Dept. of CommunityHealth, Childrens Intervention School Services (Apr. 1, 2024), p. 9. (Accessed May 2024).

GEOGRAPHIC LIMITS

No Reference Found

FACILITY/TRANSMISSION FEE

Cost associated with theuse of technology or data transmission are not covered under Medicaid and cannot be charged to the member.

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 (Apr. 1, 2024). (Accessed May 2024).

Community Behavioral Health and Rehabilitation Services

Originating fees (as referenced in some of the other Georgia Medicaid programs) are not offered for telemedicine when utilized in the CBHRS category of service. Telemedicine costs are attributed to the services intervention rates.

SOURCE: GA Dept. of Community Health: Community Behavioral Health and Rehabilitation Services, p. 100 (Apr. 1, 2024), GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 18 (Apr. 1, 2024). (Accessed May 2024).

School-Based Settings (Local Education Agencies)

LEAs that enroll as Health Check providers to serve as telehealth originating sites only will be allowed to bill the originating site facility fee. The telehealth originating facility fee is reimbursed at the current DEFAULT rate.

SOURCE: GA Dept. of Community Health, GA Medicaid Telemedicine Guidance Handbook, p. 26 (Apr. 1, 2024). & GA Dept. of Community Health, Children’s Intervention Services, p. 47 (Apr. 1, 2024) GA Dept. of CommunityHealth, Childrens Intervention School Services (Apr. 1, 2024), p. 9. (Accessed May 2024).

Ambulance Providers

Ambulances may bill a separate origination site fee. The Telehealth originating fee (Q3014) cannot be billed in combination with other rendered EMS services.

SOURCE: GA Dept. of Community Health, GA Medicaid Telemedicine Guidance Handbook, p. 21 (Jan. 1, 2024). & Emergency Ambulance Services Handbook p. 17 (Jan. 1, 2024). (Accessed Jan 2024).

Dialysis Services

The originating facility/site (Dialysis Facility) will bill with the revenue code and procedure codes listed in the manual.

SOURCE: GA Dept. of Community Health, GA Medicaid Telemedicine Guidance Handbook, p. 12 (Apr. 1, 2024). & GA Dept. of Community Health, GA Medicaid Dialysis Services Handbook, p. IX-10 (17) (Apr. 1, 2024). (Accessed Apr 2024).

FQHC/RHC

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

FQHCs and RHCs cannot bill an originating site fee and distant site fee for telehealth services on the same encounter.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 20 (Apr. 1, 2024). GA Dept. of Community Health, GA Medicaid Federally Qualified Health Centers and Rural Health Clinics (Apr. 1, 2024), p. 23. (Accessed May 2024).

EPSDT Services – Health Check Program

LEAs enrolled as Health Check providers to serve as telemedicine originating sites only will be allowed to bill the telemedicine originating site facility fee (procedure code Q3014).

SOURCE: GA Dept. of Community Health, EPSDT Services – Health Check Program, p. 68 (X-7). (Apr. 1, 2024). (Accessed May 2024).

Children’s Intervention Services

Originating sites are paid an originating site facility fee for telehealth services by billing procedure code Q3014.

SOURCE: GA Dept. of Community Health, Division of Medicaid, Children’s Intervention Services (Apr. 1, 2024), p. 47. (Accessed Apr. 2024).

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Hawaii

Last updated 06/03/2024

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.

(Repeal and reenactment on December 31, 2025) Reimbursement for services provided through telehealth via an interactive telecommunications system shall be equivalent to reimbursement for the same services provided via in-person contact between a health care provider and a patient; provided that reimbursement for the diagnosis, evaluation, or treatment of a mental health disorder delivered through an interactive telecommunications system using two-way, real-time audio-only communication technology shall meet the requirements of title 42 Code of Federal Regulations section 410.78. Nothing in this section shall require a health care provider to be physically present with the patient at an originating site unless a health care provider at the distant site deems it necessary.

SOURCE: HI Revised Statutes § 346-59.1 (a & b). Amended by HB 907 HD2 SD 2 (Repeal date of December 31, 2025). (Accessed Jun. 2024).

Reimbursement for services provided through telehealth via an interactive telecommunications system shall be equivalent to reimbursement for the same services provided via in-person contact between a health care provider and a patient; provided that reimbursement for two-way, real-time audio-only communication technology for purposes of diagnosis, evaluation, or treatment of a mental health disorder to a patient in the patient’s home shall be equivalent to eighty per cent of the reimbursement for the same services provided via in-person contact between a health care provider and a patient.

To be reimbursed for telehealth via an interactive telecommunications system using two-way, real-time audio-only communication technology in accordance with this subsection, the health care provider shall first conduct an in-person visit or a telehealth visit that is not audio only, within six months prior to the initial audio-only visit, or within twelve months prior to any subsequent audio-only visit. The telehealth visit required prior to the initial or subsequent audio-only visit in this subsection shall not be provided using audio-only communication. Nothing in this section shall require a health care provider to be physically present with the patient at an originating site unless a health care provider at the distant site deems it necessary.

SOURCE: HI Revised Statutes § 431:10A-116.3(c). Amended by HB 907 HD2 SD 2 (Repeal date of December 31, 2025). (Accessed Jun 2024).

Interactive audio and video telecommunication systems must be used. Interactive telecommunications systems must be multi-media communications that, at a minimum, include audio and video equipment, permitting real-time consultation among the patient, consulting practitioner, and referring practitioner. Telephones, facsimile machines, and electronic mail systems do not meet the requirements of interactive telecommunications system. As a condition of payment the patient must be present and participating in the telehealth visit.

SOURCE: Code of HI Rules 17-1737-51.1(c). (Accessed Jun. 2024). (NOTE: Recent legislation not yet reflected in Rules)

Eligible providers are health care providers who are eligible to bill Hawai’i Medicaid; practicing within their scope; and delivering services which can be appropriately and effectively administered through telehealth.

Services provided by telehealth must be appropriate for the telehealth modality, clinically appropriate for the patient, rendered in conformance with the full description of the procedure code, and performed by a health care provider eligible to bill Hawai’i Medicaid. Services provided shall be consistent with all federal and state privacy, security, and confidentiality laws.

SOURCE: HI Dept of Human Services, Med-QUEST, Memo No. QIk-2338/FFS 23-22, CCS-2311. (Accessed Jun. 2024).

As noted in the Overview, due to the Maui fires, a public health emergency (PHE) was declared on August 8, 2023. Certain waivers were put into place for telehealth policies. See Med-Quest Memo QI-2335A for more information.

ELIGIBLE SERVICES/SPECIALTIES

SOURCE: HI Dept of Human Services, Med-QUEST, Memo No. QI-2338/FFS 23-22, CCS-2311. (Accessed Jun. 2024).

Dentistry

The eligible codes for reimbursement will remain consistent with Memo QI-1702A (see Attachment A) with the addition of code D0145. All eligible codes are subject to the processing policies as defined in Chapter 14 of the Medicaid Dental Provider Manual. See Manual also for codes.

CDT code D9999 must be used to identify the claim for PPS payment by FQHCs and RHCs.

While the reimbursement for radiographic services is traditionally based on the date that the radiograph is read by the dentist providing the diagnosis, to minimize confusion that may potentially arise with asynchronous technology, the following protocol will be used when filing claims:

Only one claim submission is allowed for each patient visit. All services to be claimed must be included in that single submission.
The service date on the claim is the date that the patient was treated at the originating site regardless of whether asynchronous or synchronous technology was used.
When asynchronous technology is used and the service date on the claim does not match the clinical notes (interpretation of the x-rays was done on a different day from when the patient was seen), a notation in clinical records should explain the discrepancy for auditing purposes.

The FFS reimbursement fee is based on the location of the eligible Medicaid provider at the time of service, Oahu or Neighboring Island.

SOURCE: HI Med-QUEST Medicaid Provider Manual: Dental, pg. 37-38 (Apr. 2024). HI Dept of Human Services, Med-QUEST, Memo No. QI-2338/FFS 23-22, CCS-2311. (Accessed Jun. 2024).

Applied Behavioral Analysis & Autism Spectrum Disorder

Applied behavioral analysis services (including family adaptive behavior treatment guidance) can be provided through telehealth. MedQuest provides some areas of consideration when approving ABA services through telehealth (see memo). Memo QI 2301/FFS 23-01 Updates policy.

SOURCE: QI-2020 (Jun. 17, 2020), HI Med-Quest memo QI-2301/FFS 23-01.(January 13, 2023) (Accessed Jun. 2024).

Federally Qualified Health Centers

Providers who are eligible to bill for Hawaii Medicaid services are also eligible providers who can bill for telehealth. Eligible services will be consistent with Memo QI-1702A and FFS 19-01. See memo for specific billing scenarios. Memo QI- 2139/FFS 21-15 replaces Memo QI-1702A. See Attachment C in QI-2338/FFS 23-22, CCS-2311.

SOURCE: Med-QUEST Memo 20-07 (Mar. 16, 2020), QI-2139 Tele-Health Law (Act 226, SLH 2016) Implementation (Replaces QI-1702A) HI Dept of Human Services, Med-QUEST, Memo No. QI-2338/FFS 23-22, CCS-2311. (Accessed Jun. 2024).

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 was replaced with QI-2338/FFS 23-22/CCS 2311). 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 Jun. 2024).

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 Jun. 2024).

QUEST Integration Health Plans & Community Case Management Agencies

Assessments and re-assessments may be conducted using telehealth and telecommunications technology only if an in-person interaction is not an option and should only be used on an exception basis. In-person interactions with members using appropriate safety precautions is the current expectation. Where possible, members at greatest risk and need should be prioritized to receive in-person interactions before members at lower risk and need.

The health plan must document the reason for conducting an interaction using a technology option.

SOURCE: Memo QI-2107A (April 29, 2021). (Accessed Jun. 2024).

Chronic Hepatitis C Infection

An in-person or telehealth/phone visit may be scheduled, if needed, for patient support, assessment of symptoms, and/or new medications.

SOURCE: HI Med-Quest Memo QI-2227/FFS 22-08 (December 30, 2022). (Accessed Jun. 2024).

Health and Functional Assessments

The assessment should include a face-to-face interview. Assessments and reassessments may be conducted by telehealth, based on member’s choice and preference. If using telehealth, it must meet privacy requirements.

SOURCE: HI Med-Quest Memo QI-2406, (Feb. 28, 2024), pg. 49, (Accessed Jun. 2024).

ELIGIBLE PROVIDERS

SOURCE: HI Dept of Human Services, Med-QUEST, Memo No. QI-2338/FFS 23-22, CCS-2311. (Accessed Jun. 2024).

Dentistry

SOURCE: HI Med-QUEST Medicaid Provider Manual: Dental, pg. 38 (Apr. 2024) (Accessed Jun. 2024).

Federally Qualified Health Centers

Providers who are eligible to bill for Hawaii Medicaid services are also eligible to bill for telehealth. Refer to HRS §346-53.64 (5) for the list of providers who may provide PPS services. See Attachment C in QI-2338/FFS 23-22, CCS-2311.

SOURCE: Med-QUEST FFS Memo 20-03 (Mar. 16, 2020), HI Med-QUEST Medicaid Provider Manual: Federally Qualified Health Centers, Chapter 21 (21.2.1),pg. 2 , HI Dept of Human Services, Med-QUEST, Memo No. QI-2338/FFS 23-22, CCS-2311. (Accessed Jun. 2024).

ELIGIBLE SITES

All providers prescribing controlled substances must be located in the State of Hawai’i. Until December 31, 2024, Federally Qualified Health Center (FQHC) behavioral health providers may be located at a non-HRSA approved site or satellite within the United States and the United States’ territories. If the FQHC provider is prescribing controlled substances, they must be located in the State of Hawai’i.

Originating/Spoke Site – The location where the patient is located, whether accompanied or not by a health care provider, at the time services are provided by a health care provider through telehealth, including but not limited to a health care provider’s office, hospital, critical access hospital, rural health clinic, federally qualified health center, a patient’s home, and other nonmedical environments such as school-based health centers, university-based health centers, or the work location of the patient. The originating site includes a patient’s residence. The U.S. Department of Health and Human Services Office for Civil Rights expects that patients should not receive telehealth services in public or semi-public settings, absent patient consent or exigent circumstances.

Distant/Hub Site – The location of the enrolled Hawai’i Medicaid provider delivering Medicaid eligible services through telehealth. The U.S. Department of Health and Human Services Office for Civil Rights expects health care providers will implement HIPAA safeguards and conduct telehealth in private settings, such as a doctor in a clinic or office connecting to a patient who is at home or at another clinic.

Non-FQHC Providers

With one exception, the provider must be located within the United States and the United States’ territories is eligible to be a distant site for delivery and payment purposes. Exception: If prescribing controlled substances, the provider must be located in the State of Hawai’i.

FQHC Providers

With exceptions, the FQHC provider must be located at their contracted FQHC’s HRSA approved site or satellite.

Exceptions:

Until December 31, 2024, FQHC behavioral health providers may be located at a non-HRSA approved site or satellite within the United States and the United States’ territories.
If prescribing controlled substances, the provider must be located in the State of Hawai’i.

SOURCE: HI Dept of Human Services, Med-QUEST, Memo No. QI-2338/FFS 23-22, CCS-2311. (Accessed Jun. 2024).

Eligible originating sites listed in the Administrative Rules:

The office of a physician or practitioner
Hospitals;
Critical Access Hospitals;
Rural Health Clinics;
Federally Qualified Health Centers;
Federal telehealth demonstration project sites.

SOURCE: Code of HI Rules 17-1737-51.1(d), p. 70 – Law passed & state plan amendment accepted prohibiting this limitation, however the prohibiting language is still present in regulation (Accessed Jun. 2024).

In statute, these locations are also included:

A patient’s home;
Other non-medical environments such as school-based health centers, university-based health centers, or the work location of a patient.

SOURCE: HI Revised Statutes § 346-59.1. (Accessed Jun. 2024).

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

SOURCE: HI State Plan Amendment 16-0004. (Accessed Jun. 2024).

Federally Qualified Health Centers:

The criteria for sites eligible to receive PPS payment is the same regardless whether or not tele-health is utilized. The services must be provided at an HRSA approved site or satellite. 5C (Other Activities/Locations) sites are not eligible to receive PPS reimbursement in Hawaii and therefore are not eligible to receive PPS for tele-health services.

The spoke (originating site) is the location where the patient is located whether accompanied or not by a health care provider through telehealth. The originating site includes a patient’s residence.

SOURCE: HI Med-QUEST FFS Memo 20-03. (Accessed Jun. 2024).

Dental

The Medicaid rules for claims for teledentistry-related services will be consistent with the State’s rules on where teledentistry may be used.

The FFS reimbursement fee is based on the location of the eligible Medicaid provider at the time of service, Oahu or Neighboring Island.

Clinics that qualify for FQHC Prospective Payment System (PPS) reimbursement may submit telehealth claims using PPS reimbursement, as long as both the patient and dentist were each physically located at separate eligible FQHC/RHC sites during the encounter and the diagnosis. (Form 5b service sites registered with Med-QUEST as a Medicaid location and issued a HRSA Notice of Award identifying the specific service location address). Refer to Provider Memo QI-2338/ FFS 23-22. The first lines of these claims should be D9999 or D0140, according to PPS claim submission rules.

Claims for patients that were located at “public health settings” not federally registered as a FQHC or RHC service site are not eligible for PPS reimbursement.

All claims must indicate the treatment location in the “Remarks” section of the claim form. This is the location of the patient, including the name and address of “public health setting.” For example: Roosevelt High School, 1120 Nehoa Street, Honolulu, 96822. Claims that do not include the specific location of the patient will be denied.

SOURCE: HI Med-QUEST Medicaid Provider Manual: Dental, pg. 37-38 (Apr. 2024) (Accessed Jun. 2024).

GEOGRAPHIC LIMITS

Originating/Spoke Site – The location where the patient is located, whether accompanied or not by a health care provider, at the time services are provided by a health care provider through telehealth, including but not limited to a health care provider’s office, hospital, critical access hospital, rural health clinic, federally qualified health center, a patient’s home, and other nonmedical environments such as schoolbased health centers, university-based health centers, or the work location of the patient. The originating site includes a patient’s residence. The U.S. Department of Health and Human Services Office for Civil Rights expects that patients should not receive telehealth services in public or semi-public settings, absent patient consent or exigent circumstances.

Non-FQHC Providers

FQHC Providers

With exceptions, the FQHC provider must be located at their contracted FQHC’s HRSA approved site or satellite.

Exceptions:

Until December 31, 2024, FQHC behavioral health providers may be located at a non-HRSA approved site or satellite within the United States and the United States’ territories.
If prescribing controlled substances, the provider must be located in the State of Hawai’i.

SOURCE: HI Dept of Human Services, Med-QUEST, Memo No. QI-2338/FFS 23-22, CCS-2311. (Accessed Jun. 2024).

Telehealth services may only be provided to patients if they are presented from an originating site located in either:

A federally designated Rural Health Professional Shortage Area;
A county outside of a Metropolitan Statistical Area;
An entity that participates in a federal telemedicine demonstration project.

SOURCE: Code of HI Rules 17-1737.-51.1. (Accessed Jun. 2024). – Law passed (HI Statute Section 346-59.1(c) & state plan amendment accepted prohibiting this limitation, however the prohibiting language is still present in regulation.)

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

SOURCE: HI State Plan Amendment 16-0004. (Accessed Jun. 2024).

Teledentistry

The Medicaid rules for claims for teledentistry-related services will be consistent with the State’s rules on where teledentistry may be used.

The FFS reimbursement fee is based on the location of the eligible Medicaid provider at the time of service, Oahu or Neighboring Island.

SOURCE: HI Med-QUEST Medicaid Provider Manual: Dental, pg. 37 (Apr. 2024) (Accessed Jun. 2024).

FACILITY/TRANSMISSION FEE

No reference found.

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Idaho

Last updated 06/17/2024

POLICY

Services delivered through virtual care will be considered for …

POLICY

Services delivered through virtual care will be considered for reimbursement when rendered within the provider’s scope of practice and billed according to all applicable administrative rules, policy, federal and state regulations. Any covered service may be delivered via virtual care when:

The service can be safely and effectively delivered via virtual care and the medium utilized;
The service fully meets the code definition when provided via virtual care;
The service is billed with the FQ or GT modifier; and
All other existing coverage criteria are met.

Video must be provided in real-time with full motion video and audio that delivers high-quality video images that do not produce lags, choppy, blurry, or grainy images, or irregular pauses in communication. Transmission of voices must be clear and audible. Reimbursement is also not available for services that are interrupted and/or terminated early due to equipment difficulties.

SOURCE: Idaho Medicaid Provider Handbook. General Information and Requirements for Providers. (Jan. 30, 2024), Section 9.12 & 9.12.1 p. 133-134. Idaho MedicAide (May 2023). (Accessed Jun. 2024).

Services delivered via virtual care as defined in Title 54, Chapter 57, Idaho Code, must be identified as such in accordance with billing requirements published in the Idaho Medicaid Provider Handbook. Virtual care services billed without being identified as such are not covered. Virtual care services may be reimbursed within limitations defined by the Department in the Idaho Medicaid Provider Handbook. Fee-for-service reimbursement is not available for asynchronous services except remote monitoring. (NOTE: The term “telehealth” had been changed to “virtual care” in 2023, but the Administrative Code does not reflect that change in the currently posted version.)

SOURCE: ID Administrative Code 16.03.09 Sec. 210 (09), Pg. 25 (Accessed Jun. 2024).

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

SOURCE: ID Administrative Code 16.03.09 Sec. 723 (02)(b), Pg. 101, ID Medicaid Provider Handbook: Home Health and Hospice Services, 1.2.4.1, p. 6. (Mar. 2, 2021). (Accessed Jun. 2024).

ELIGIBLE SERVICES/SPECIALTIES

Any covered service may be delivered via virtual care when:

The service can be safely and effectively delivered via virtual care and the medium utilized;
The service fully meets the code definition when provided via virtual care;
The service is billed with the FQ or GT modifier; and
All other existing coverage criteria are met.

Reporting of test results only is not covered as a telehealth service.

Only one eligible provider may be reimbursed per service per participant per date of service. No reimbursement is available for the use of equipment at the originating or remote sites. Reimbursement is also not available for services that are interrupted and/or terminated early due to equipment difficulties. Claims for services delivered via virtual care will be reimbursed at the same rate as face-to-face services.

Idaho Medicaid uses places of service 02 (Telehealth provided other than in patient’s home) and 10 (Telehealth provided in patient’s home). Providers must use these places of service on claims for virtual care. Claims for virtual care must include one of the following modifiers:

FQ – A telehealth service was furnished using real-time audio-only communication technology.
GT – A telehealth service was furnished using real-time audio-visual communication technology.

Additionally, providers can also use the following modifier in conjunction with one of the above:

FR – A supervising practitioner was present through a real-time two-way, audio/video communication technology.

SOURCE: Idaho Medicaid Provider Handbook. General Information and Requirements for Providers. (Jan. 30, 2024), Sections 9.12 & 9.12.3 p. 133-134, Idaho MedicAide May 2023. (Accessed Jun. 2024).

Physician/Non-Physician Practitioner Services:

Stand-alone vaccine counseling is also reimbursable when delivered as virtual care services.

Services in the National Diabetes Prevention Program are eligible for virtual care.

Physicians and non-physician practitioners are eligible to receive reimbursement for telehealth services.

Physicians and psychiatric nurse practitioners may provide psychotherapy (CPT® 90839 and 90840) to participants in crisis via virtual care. The medical record of the participant must support a crisis service was provided for the full duration billed and demonstrate that an urgent assessment of the participant’s mental state was necessary, and/or their health or safety was at risk. The participant must be in the room for the duration of the visit or a majority of the service, which is focused on the individual. 90839 is a stand-alone code not to be reported with psychotherapy or psychiatric diagnostic evaluation codes, the interactive complexity code, or any other psychiatry section code.

SOURCE: ID Medicaid Provider Handbook: Physician and Non-Physician Practitioner (May 1, 2024), p. 51, 58, 79, 86. (Accessed Jun. 2024).

Crisis Intervention

Crisis intervention is an eligible virtual care service. If crisis intervention is provided via virtual care, all requirements must be followed under the Idaho Medicaid virtual care services policy. Further information about Virtual Care Services can be found in the General Information and Requirements for Providers, Idaho Medicaid Provider Handbook.

SOURCE: ID Medicaid Provider Handbook Agency Professional (Feb. 5. 2024), p. 28. (Accessed Jun. 2024).

Therapy Services (Occupational, Physical Therapists & Speech Language Pathologists)

Virtual care services covered for therapies are real-time communication through interactive technology that enables a provider and a patient at two locations separated by distance to interact simultaneously through two-way video and audio transmission. Evaluations and reevaluations may be provided by virtual care. The therapist must certify that the services can safely and effectively be done with virtual care services and the physician or non-physician practitioner order must specifically allow the services to be provided by virtual care services. Therapists must adhere to all requirements of their licensing board for virtual care services.

Specific service codes found in manual.

SOURCE: ID Medicaid Provider Handbook, Therapy Services (May 16, 2024) pg 38 , (Accessed Jun. 2024).

Psychiatric Crisis

SOURCE: ID Medicaid Provider Handbook: Physician and Non-Physician Practitioner (May 1, 2024), p. 79. (Accessed Jun. 2024).

Laboratory Services

To be reimbursable, drug tests must be ordered by a licensed or certified healthcare professional who has performed a face-to-face evaluation of the participant (this may include telehealth if the requirements of the telehealth policy are met).

SOURCE: ID Medicaid Provider Handbook: Laboratory Services (Mar. 1, 2024), p. 22. (Accessed Jun. 2024).

Eye and Vision Services

Vision therapy is not covered for group therapy, telehealth or with home computer programs.

SOURCE: ID Medicaid Provider Handbook: Eye and Vision Services (Jan. 8, 2024), p. 54. (Accessed Jun. 2024).

Early Intervention Services (IDEA)

Medicaid reimburses for early intervention services in accordance with Medicaid established rates and reimbursement methodology. The ITP must provide virtual care servcies in accodance with the Idahol Medicaid Provider Handbook.

SOURCE: SOURCE: Idaho Medicaid Provider Handbook. General Information and Requirements for Providers. 9.9.7, p. 128 (Jan. 30, 2024), (Accessed Jun. 2024).

Interpretative Services

Idaho Medicaid will reimburse for interpretation, translation, Braille and sign language services provided to participants in person or through virtual care. Reimbursement is also available when interpretive services are provided to the parent or guardian of a child under 18. The service is only eligible for reimbursement if the provider has no alternative means of oral or written communication. No additional reimbursement is available for multilingual providers that share a language with the participant. Interpreters and translators must meet state and professional licensure requirements and be at least eighteen years of age. See the Virtual Care Services section for more information about reimbursement eligibility using virtual care services.

SOURCE: SOURCE: Idaho Medicaid Provider Handbook. General Information and Requirements for Providers. 9.10.3, p. 129 (Jan. 30, 2024), (Accessed Jun. 2024).

ELIGIBLE PROVIDERS

Only one eligible provider may be reimbursed for the same service per participant per date of service.

SOURCE: Idaho Medicaid Provider Handbook. General Information and Requirements for Providers. (Jan 30, 2024), Sections 9.12.3 p. 134, Idaho MedicAide (May 2023). (Accessed Jun. 2024).

Idaho Medicaid therapy services, see manual for specific codes.

SOURCE: ID Medicaid Provider Handbook, Therapy Services (May 16, 2024) pg 38 (Accessed Jun. 2024).

Physicians and psychiatric nurse practitioners may provide psychotherapy to participants in crisis via telehealth, using CPT 90839 and 90840.

Physicians and non-physician practitioners are eligible to receive reimbursement for telehealth services.

SOURCE: ID Medicaid Provider Handbook, Physician and Non-Physician Practitioner. Sec. 4.34.3, Pg. 79, (4.38) 86. (May 1, 2024), (Accessed Jun. 2024).

FQHCs, RHCs & IHS

Telehealth services provided as an encounter by a facility are reimbursable if the services are delivered in accordance with the Idaho Medicaid Telehealth Policy and applicable handbooks.

FQHC, RHC or IHS providers should not report the GT or FQ modifier with encounter code T1015 but should include it with each applicable supporting codes.

SOURCE: ID Medicaid Provider Handbook: IHS, FQHC, and RHC Services, (Nov. 18, 2022), p. 30. Idaho Medicaid Provider Handbook. General Information and Requirements for Providers. (Jan. 30, 2024), Sections 9.12.3 p. 134, Idaho MedicAide (May 2023). (Accessed Jun. 2024).

ELIGIBLE SITES

FQ – A telehealth service was furnished using real-time audio-only communication technology.
GT – A telehealth service was furnished using real-time audio-visual communication technology.

SOURCE: Idaho Medicaid Provider Handbook. General Information and Requirements for Providers. (Jan. 30, 2024), Sections 9.12.3 p. 134, Idaho MedicAide May 2023. (Accessed Jun. 2024).

Idaho Medicaid reduces physician and non-physician practitioner reimbursement when certain procedures are provided in a facility setting. For these procedure codes there is a 30 percent reduction for physicians, and a 40 percent reduction for non-physician practitioners, of the Idaho Medicaid Numerical Fee Schedule in the following places of service (POS) including POS 02 Telehealth (Not recognized by Idaho Medicaid).

SOURCE: Idaho Medicaid Provider Handbook: Physician and Non-Physician Practitioner. 9.2, p. 131. (May 1, 2024). (Accessed Jun. 2024).

GEOGRAPHIC LIMITS

No Reference Found

FACILITY/TRANSMISSION FEE

Therapy Services

Therapy services covered via virtual care are listed in the table below. Reimbursement is according to the numerical fee schedule. There is no additional fee for either the originating or the distant site.

SOURCE: ID Medicaid Provider Handbook, Therapy Services (May 16, 2024) pg 38 (Accessed Jun. 2024).

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Illinois

Last updated 07/09/2024

POLICY

Recent Legislation Effective Jan. 1, 2024

The Department and …

POLICY

Recent Legislation Effective Jan. 1, 2024

The Department and any managed care plans under contract with the Department for the medical assistance program shall provide for coverage of mental health and substance use disorder treatment or services delivered as behavioral telehealth services as specified in this Section. The Department and any managed care plans under contract with the Department for the medical assistance program may also provide reimbursement to a behavioral health facility that serves as the originating site at the time a behavioral telehealth service is rendered.

SOURCE: Illinois 305 ILCS 5/5-47 (Accessed Jul. 2024).

The Department of Healthcare and Family Services shall reimburse psychiatrists, federally qualified health centers as defined in Section 1905(l)(2)(B) of the federal Social Security Act, clinical psychologists, clinical social workers, advanced practice registered nurses certified in psychiatric and mental health nursing, and mental health professionals and clinicians authorized by Illinois law to provide behavioral health services to recipients via telehealth. The Department shall reimburse epilepsy specialists, as defined by the Department by rule, who are authorized by Illinois law to provide epilepsy treatment services to persons with epilepsy or related disorders via telehealth. The Department, by rule, shall establish: (i) criteria for such services to be reimbursed, including appropriate facilities and equipment to be used at both sites and requirements for a physician or other licensed health care professional to be present at the site where the patient is located; however, the Department shall not require that a physician or other licensed health care professional be physically present in the same room as the patient for the entire time during which the patient is receiving telehealth services; (ii) a method to reimburse providers for mental health services provided by telehealth; and (iii) a method to reimburse providers for epilepsy treatment services provided by telehealth.

SOURCE: 305 ILCS 5/5-5.25.(b) (Accessed Jul. 2024).

Health insurance providers must include coverage for licensed dietitians, nutritionists, and diabetes educators who counsel diabetes patients, via telehealth, in the patients’ homes to remove the hurdle of transportation for patients to receive treatment.

SOURCE: 215 ILCS 5/356z.22.(g) (Accessed Jul. 2024).

Covered services under the Medical Assistance Programs include telehealth services pursuant to Sectin 140.403.

SOURCE: IL Admin Code, Title 89, Chapter 1, Subch d, Part 140, Sec. 140.3(b)(22) & c(18). (Accessed Jul. 2024).

Illinois Medicaid will reimburse for live video under the following conditions:

A physician or other licensed health care professional or other licensed clinician, mental health professional or qualified mental health professional must be present with the patient at all times with the patient at the originating site;
The distant site provider must be a physician, physician assistant, podiatrist or advanced practice nurse who is licensed by Illinois or the state where the patient is located. For telepsychiatry, it must be a physician who has completed an accredited general psychiatry residency program or an accredited child and adolescent psychiatry residency program;
The originating and distant site provider must not be terminated, suspended or barred from the Department’s medical programs;
Telepsychiatry: The distant site provider must personally render the telepsychiatry service;
Medical data may be exchanged through a telecommunication system. For telepsychiatry it must be an interactive telecommunication system;
The interactive telecommunication system must, at a minimum, have the capability of allowing the consulting distant site provider to examine the patient sufficiently to allow proper diagnosis of the involved body system. The system must also be capable of transmitting clearly audible heart tones and lung sounds, as well as clear video images of the patient and any diagnostic tools, such as radiographs;
Telepsychiatry: Group psychotherapy is not a covered telepsychiatry service.

SOURCE: IL Admin. Code Title 89, 140.403(b). (Accessed Jul. 2024).

For telemedicine services, a physician or other licensed health care professional must be present at all times with the patient at the originating site.

For telepsychiatry services, a staff member meeting the minimum qualifications of a mental health professional (MHP) must be present at all times with the patient at the originating site.

When medically appropriate, more than one Distant Site provider may bill for services rendered during the telehealth visit.

Enrolled distant site providers may not seek reimbursement from the Department for their services when the originating site is an encounter clinic. The originating site encounter clinic is responsible for reimbursement to the distant site provider.

SOURCE: IL Dept. of Healthcare and Family Svcs., Handbook for Practitioners. Ch. A-200 Policy and Procedures, 220.5.7 p. 26-27, (June 2021). (Accessed Jul. 2024).

See regulations for requirements during a public health emergency.

SOURCE: IL Admin. Code, Title 89,140.403. (Accessed Jul. 2024).

ELIGIBLE SERVICES/SPECIALTIES

Appropriate CPT codes must be billed with the GT modifier for telemedicine and telepsychiatry services and the appropriate Place of Service code, 02, telehealth. Enrolled distant site providers may not seek reimbursement from the Department for their services when the originating site is an encounter clinic. The originating site encounter clinic is responsible for reimbursement to the distant site provider. Non-enrolled providers rendering services as a distant site provider shall not be eligible for reimbursement from the Department, but may be reimbursed by the originating site provider from their facility fee payment.

SOURCE: IL Dept. of Healthcare and Family Svcs., Handbook for Practitioners. Ch. A-200 Policy and Procedures, 220.5.7 p. 26, (June 2021), IL Dept. of Healthcare and Family Svcs, Handbook for Podiatric Services, Ch F-200 Policy and Procedures 220.6.2, p. 27. (Oct. 2016). (Accessed Jul. 2024).

See Encounter Clinic Services Appendices and Handbook Supplement (Sept. 2020) for billing examples.

SOURCE: Handbook for Encounter Clinic Services, Chapter D-200, Sept. 23, 2020 (Accessed Jul. 2024).

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

SOURCE: IL Admin. Code Title 89, 140.403. (Accessed Jul. 2024).

Modifier GT – identifies telehealth interactions using both audio and video telecommunications systems.

Modifier 93 (Effective with dates of service beginning July 1, 2022) – identifies telehealth interactions using an audio-only telecommunications system.

The system updates allow providers to bill a service with modifier “GT” or “93” and a service without modifier “GT” or “93” for the same customer, same date of service, and same procedure code and get reimbursed for both services.

SOURCE: Provider Notice Rate Adjustment and Telehealth Billing Guidance (Jan. 9, 2023). (Accessed Jul. 2024).

Interprofessional Consultation for Psychiatric Services

Certain procedure codes for interprofessional consultation is allowed for the delivery of psychiatric services. See memo for codes.

SOURCE: IL HFS Provider Notice (Feb. 3, 2023). (Accessed Jul. 2024).

Recent Legislation Effective Jan. 1, 2024

Mental Health and Substance Use Disorder

For purposes of reimbursement, the Department and any managed care plans under contract with the Department for the medical assistance program shall reimburse a behavioral health care professional or behavioral health facility for behavioral telehealth services on the same basis, in the same manner, and at the same reimbursement rate that would apply to the services if the services had been delivered via an in-person encounter by a behavioral health care professional or behavioral health facility. This subsection applies only to those services provided by behavioral telehealth that may otherwise be billed as an in-person service.

SOURCE: Illinois 305 ILCS 5/5-47 (Accessed Jul. 2024).

Fee Schedules Indicate telehealth eligible services with appropriate modifiers or service code.

SOURCE: Adaptive Behavior Support Services (Jan. 26, 2022), Dental (Jan. 1, 2023), (Accessed Jul. 2024).

Podiatry

Codes and billing examples for podiatry services.

SOURCE: Handbook for Podiatric Services (Appendices), Appendix F-6 (p. 35). (Accessed Jul. 2024).

Home Health Services

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

SOURCE: IL Dept. of Healthcare and Family Svcs., Handbook for Home Health Services. Ch. R-200 Policy and Procedures, R-205.1 p. 19, (May 2016). IL Dept. of Healthcare and Family Svcs., Handbook for Care Coordination and Support Organization Provider (Oct. 5, 2022), p. 31. IL Admin Code, Title 89, Chapter 1, Subch d, Part 140, 140.471(d)(2)(C). (Accessed Jul. 2024).

POS 10 is a new place of service code that specifies a distant site telehealth service rendered to a patient who is located in their home. It does not replace POS 02. The description for POS 02 has been changed to, “Telehealth Provided Other than in Patient’s Home” and it is still a valid distant site telehealth service POS code. POS 10, when applicable, should be submitted for claims with dates of service beginning April 1, 2022.

SOURCE: Provider Notice Issued 3/21/22: Modifier 93 and Place of Service Code 10 Implementation. (Accessed Jul. 2024).

Community Based Behavioral Services

Effective with dates of service beginning October 1, 2021, providers delivering services via audio or video communication must utilize the appropriate telehealth POS code, consistent with Section 207.3.7, when billing for services. Providers submitting claims for ‘on-site’ services that include services rendered both by telehealth and face-to-face must exclude the telehealth services from the “roll up” combination of on-site units. Rather, services delivered via telehealth must be billed with the appropriate telehealth modifier (GT or 93) and POS (02 or 10) on a service line separate from other ‘rolled up’ on-site services rendered face-to-face to the same recipient for the same procedure code and modifier combination.

Providers billing a service that was performed via audio or video communication must append the procedure code with appropriate modifier and POS to indicate telehealth as the mode of service delivery. This coding is needed for HFS to track the mode of service delivery. The modifier and place of service codes are for reporting purposes only and do not affect current payment methodology. Additional telehealth modifiers and POS have been adopted effective with dates of service beginning July 1, 2022. The table below provides guidance to providers utilizing telehealth on the appropriate telehealth modifiers and POS based upon the date of service. (See manual for additional information).

The new billing instructions apply to any service being billed as a telehealth service, whether it is:

A code identified in the Community Based Behavioral Services Handbook that historically could be provided via phone and/or video delivery modes independent of the current public health emergency, or
A behavioral health service allowed via telehealth per the current public health emergency telehealth policy stated in the March 20, 2020 provider notice. This list of codes includes the following services from the CBS Fee Schedule: 96110, 96112, 96127 and H1000.

SOURCE: Medicaid Provider Notice “Use of Modifier GT and Place of Service Code 02 to Specify Telehealth Delivery Mode for Behavioral Health Services” & IL Dept. of Healthcare and Family Svcs., Handbook for Community-Based Behavioral Services Providers, 208.3.1 pg. 23-26 (June 6, 2022). (Accessed Jul. 2024).

The Department shall reimburse epilepsy specialists, as defined by the Department by rule, who are authorized by Illinois law to provide epilepsy treatment services to persons with epilepsy or related disorders via telehealth.

SOURCE: ILCS 5/5.25, (Accessed Jul. 2024).

Department provides coverage for epilepsy treatment services via telehealth as required under Public Act 102-0207. Coverage is provided under both Medicaid fee-for-service and the managed care plans.

SOURCE: Medicaid Provider Notice “Confirmation of Reimbursement for Epilepsy Specialists via Telehealth (9/24/21)” (Accessed Jul. 2024).

Telehealth services for persons with intellectual and developmental disabilities. The Department shall file an amendment to the Home and Community-Based Services Waiver Program for Adults with Developmental Disabilities authorized under Section 1915(c) of the Social Security Act to incorporate telehealth services administered by a provider of telehealth services that demonstrates knowledge and experience in providing medical and emergency services for persons with intellectual and developmental disabilities. The Department shall pay administrative fees associated with implementing telehealth services for all persons with intellectual and developmental disabilities who are receiving services under the Home and Community-Based Services Waiver Program for Adults with Developmental Disabilities.

For dates of service on and after January 1, 2025, the Department shall pay negotiated, agreed upon administrative fees associated with implementing telehealth services for persons with intellectual and developmental disabilities who are receiving Community Integrated Living Arrangement residential services under the Home and Community-Based Services Waiver Program for Adults with Developmental Disabilities. The implementation of telehealth services shall not impede the choice of any individual receiving waiver-funded services through the Home and Community-Based Services Waiver Program for Adults with Developmental Disabilities to receive in-person health care services at any time. The Department shall ensure individuals enrolled in the waiver, or their guardians, request to opt-in to these services. For individuals who opt in, this service shall be included in the individual’s person-centered plan. The use of telehealth services shall not be used for the convenience of staff at any time nor shall it replace primary care physician services.

SOURCE: 305 ILCS 5/5-5a.1 as amended by SB 3268. (Accessed Jul. 2024).

Diabetes Prevention Program (DPP) & Diabetes Self-Management Education and Support (DSMES)

DPP services are provided in-person or via telehealth/virtually during sessions that occur at regular, periodic intervals over the course of one year.

DSMES services may be provided in the home, clinic, hospital outpatient facility, via telehealth, or any other setting as authorized and include: counseling related to long-term dietary change, increased physical activity, and behavior change strategies for weight control; counseling and skill building to facilitate the knowledge, skill and ability necessary for diabetes self-care; and nutritional counseling services.

SOURCE: Medicaid Provider Notice “Billing Update for Diabetes Prevention and Management Programs (7/29/22)” (Accessed Jul. 2024).

Care Coordination and Support Organization (CCSO)

Care Coordination and Support (CCS) services are reimbursed if certain requirements met, including completing two oral communications with family within the calendar month via telephonic, video or in-person.

SOURCE: IL Dept. of Healthcare and Family Services, Care Coordination and Support Organization Provider Handbook (Oct. 5, 2022), p. 56-57. (Accessed Jul. 2024).

Medical Equipment

Effective July 1, 2017, to be eligible for reimbursement by the Department, certain medical equipment and supplies will be subject to a face-to-face encounter. The Department will, at a minimum, require a face-to-face encounter for equipment and supplies for which Medicare requires a face-to-face encounter. The face-to-face patient encounter may occur through telehealth, in compliance with Section 140.403.

SOURCE: IL Admin Code, Title 89, Chapter 1, Subchapter d, Part 140, Sec. 140.475(g)(3). (Accessed Jul. 2024).

ELIGIBLE PROVIDERS

The Department of Healthcare and Family Services required to reimburse psychiatrists, federally qualified health centers, clinical psychologists, clinical social workers, advanced practice registered nurses certified in psychiatric and mental health nursing and mental health professionals and clinicians authorized by Illinois law to provide behavioral health services via telehealth. The Department shall reimburse epilepsy specialists, as defined by the Department by rule, who are authorized by Illinois law to provide epilepsy treatment services to persons with epilepsy or related disorders via telehealth.

SOURCE: 305 ILCS 5/5.25, (Accessed Jul. 2024).

For telemedicine services, the distant site provider must be a physician, physician assistant, podiatrist, or advanced practice nurse who is licensed by the State of Illinois or by the state where the patient is located.

Practitioner Handbook: When medically appropriate, more than one Distant Site provider may bill for services rendered during the telehealth visit. Enrolled distant site providers may not seek reimbursement from the Department for their services when the originating site is an encounter clinic. The originating site encounter clinic is responsible for reimbursement to the distant site provider. Non-enrolled providers rendering services as a distant site provider shall not be eligible for reimbursement from the Department, but may be reimbursed by the originating site provider from their facility fee payment.
Podiatry Handbook: Services rendered by an APN can be billed under the collaborating physician’s NPI, or if the APN is enrolled, under the APN’s NPI. When medically appropriate, more than one Distant Site provider may bill for services rendered during the telehealth visit.

For telepsychiatry, the distant site provider must be a physician who is licensed by the State of Illinois or by the state where the patient is located who has completed an accredited general psychiatry residency program or an accredited child and adolescent psychiatry residency program.

Practitioner Handbook: To be eligible for reimbursement for telepsychiatry services, physicians must enroll in the correct specialty/sub-specialty in IMPACT.
Encounter Clinic Handbook: Telepsychiatry is not a covered service when rendered by an APN or PA. Group psychotherapy is not a covered telepsychiatry service.

SOURCE: IL Admin. Code Title 89, 140.403(b); IL Dept. of Healthcare and Family Svcs., Handbook for Podiatrists (physician services only), F-200, F-220.6.2 p. 28 (Oct. 2016); IL Dept Of Healthcare and Family Svcs, Handbook for Providers of Podiatric Services (Oct 2016), p. 27, & Handbook for Practitioner Services. Ch. 200, 220.5.7 p. 26 (June 2021) & Handbook for Encounter Clinic Services. Ch. 200, 210.2.2 pg. 17. (Aug. 2016). (Accessed Jul. 2024).

An encounter clinic serving as the distant site shall be reimbursed as follows:

If the originating site is another encounter clinic, the distant site encounter clinic shall receive no reimbursement from the Department. The originating site encounter clinic is responsible for reimbursement to the distant site encounter clinic; and
If the originating site is not an encounter clinic, the distant site encounter clinic shall be reimbursed for its medical encounter. The originating site provider will receive a facility fee.

See Encounter Clinic Services Appendices supplement for telehealth billing examples for encounter clinics.

SOURCE: IL Admin. Code Title 89, 140.403; IL Dept. of Healthcare and Family Svcs., Expansion of Telehealth Services, Informational Notice, Jan. 1, 2010; Handbook for Encounter Clinic Services. Ch. 200, pg. 17. Aug. 2016 & IL All Providers Handbook Supplement (Sept. 2020), pg. 43-45. (Accessed Jul. 2024).

Effective with dates of service beginning October 1, 2021, providers billing a service from the Community Based Behavioral Services Fee Schedule that was performed via audio or video communication must append the procedure code with modifier GT and use Place of Service Code 02. This coding is needed for HFS to track the mode of service delivery. The GT modifier and Place of Service Code 02 are for reporting purposes only and do not affect current payment methodology.

The new billing instructions apply to any service being billed as a telehealth service, whether it is:

A code identified in the Community Based Behavioral Services Handbook that historically could be provided via phone and/or video delivery modes independent of the current public health emergency, or
A behavioral health service allowed via telehealth per the current public health emergency telehealth policy stated in the March 20, 2020 provider notice. This list of codes includes the following services from the CBS Fee Schedule: 96110, 96112, 96127 and H1000.

The following providers billing from the Community Based Behavioral Services Fee Schedule are impacted:

Community Mental Health Centers
Behavioral Health Clinics
Physicians
Licensed Clinical Psychologists
Licensed Clinical Social Workers

SOURCE: Medicaid Provider Notice “Use of Modifier GT and Place of Service Code 02 to Specify Telehealth Delivery Mode for Behavioral Health Services” (Accessed Jul. 2024)

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

SOURCE: IL Admin. Code Title 89, 140.403(c)(1)(B). (Accessed Jul. 2024).

ELIGIBLE SITES

The Department shall reimburse any Medicaid certified eligible facility or provider organization that acts as the location of the patient at the time a telehealth service is rendered, including substance abuse centers licensed by the Department of Human Services’ Division of Alcoholism and Substance Abuse.

SOURCE: ILCS 5/5.25(c), (Accessed Jul. 2024).

SOURCE: Provider Notice Issued 3/21/22: Modifier 93 and Place of Service Code 10 Implementation. (Accessed Jul. 2024).

For telemedicine services, a physician or other licensed health care professional must be present at all times with the patient at the originating site.

For telepsychiatry services, A physician, licensed health care professional or other licensed clinician, mental health professional (MHP), or qualified mental health professional (QMHP), must be present at all times with the patient at the originating site.

SOURCE: IL Admin. Code Title 89, 140.403(b) & IL Dept. of Healthcare and Family Svcs., Handbook for Practitioners. Ch. A-200 Policy and Procedures, 220.5.7 p. 25, (June 2021). (Accessed Jul. 2024).

IL Healthcare and Family Services recognizes the following as valid originating sites: physician’s office, podiatrist’s office, local health department, Community Mental Health Center, Encounter Rate Clinics, and outpatient hospital.

For telepsychiatry services, a staff member meeting the minimum qualifications of a mental health professional (MHP) must be present at all times with the patient at the originating site.

SOURCE: IL Dept. of Healthcare and Family Svcs., Handbook for Practitioners. Ch. A-200 Policy and Procedures, 220.5.7 p. 25, (June 2021). (Accessed Jul. 2024).

See handbook supplement for telehealth billing examples.

SOURCE: All Providers Handbook Supplement (Sept. 2020), pg. 43-45. (Accessed Jul. 2024).

An encounter clinic is eligible as an originating site and is responsible for ensuring and documenting that the distant site provider meets the department’s requirements for telehealth and telepsychiatry services since the clinic is responsible for reimbursement to the distant site provider.

See Encounter Clinic Services Appendices supplement for telehealth billing examples for encounter clinics.

SOURCE: IL Dept. of Healthcare and Family Svcs., Expansion of Telehealth Services, Informational Notice, Jan. 1, 2010; IL Dept. of Healthcare and Family Svcs., Handbook for Practitioners. (June 2021) Ch. 200, p. 25; Handbook for Podiatrists, F-200, p. 27 (Oct. 2016); & Handbook for Encounter Clinic Services. Ch. D-200, pg. 17. Aug. 2016. (Accessed Jul. 2024).

Recent Legislation Effective Jan. 1, 2024

Mental Health and Substance Use Disorder

There shall be no restrictions on originating site requirements for behavioral telehealth coverage or reimbursement to the distant site under this Section other than requiring the behavioral telehealth services to be medically necessary and clinically appropriate.

SOURCE: Illinois 305 ILCS 5/5-47 (Accessed Jul. 2024).

GEOGRAPHIC LIMITS

No Reference Found

FACILITY/TRANSMISSION FEE

Originating site providers may submit claims for a facility fee for each telehealth service encounter using HCPCS Code Q3014/Telehealth Originating Site Facility Fee.

Eligible facilities include:

Physician’s office;
Podiatrist’s office
Local health departments
Community mental health centers
Outpatient hospitals

SOURCE: IL Handbook for Practitioners Rendering Medical Services, Ch. 200, p. 26 (June 2021) & Handbook for Podiatrists, F-200, p. 27 (Oct. 2016). (Accessed Jul. 2024).

Hospitals Billing with Revenue Code 0780 and HCPCS Code Q3014

HCPCS code Q3014 must be identified on the same revenue line with Revenue Code 0780. If any other procedure code is billed with Revenue Code 0780, the claim will be rejected with error code T55 – Missing/Invalid HCPCS for Revenue Code 0780.

Other services may be billed as necessary on the same outpatient claim with a telehealth facility fee, but the telehealth service must be identified as described in this provider notice. No modifier is required for the telehealth service.

SOURCE: Medicaid Provider Notice “Hospitals Billing as the Telehealth Originating Site” (Mar. 2, 2021). (Accessed Jul. 2024)

Sites approved as valid originating facility sites were expanded. The March 20, 2020 notice contained a list of sites that included “providers who receive reimbursement for a patient’s room and board, including nursing facilities and Intermediate Care Facilities for the Developmentally Disabled.” For further clarification, this category would also include Family Support Program residential providers, Medically Complex Facilities for Persons with Developmental Disabilities, and Specialized Mental Health Rehabilitation Facilities.

Facility Fee Billing Instructions for Hospice Agencies:

In situations where a hospice patient in a long term care facility is in need of a telehealth service, the hospice may submit charges for the facility fee as an originating telehealth site.

Use Revenue Code 0657 in conjunction with HCPCS code Q3014 and identify the number of Service Units (telehealth occurrences) provided in the billing period.

The telehealth facility fee service cannot be billed separately and must be included on a claim containing the hospice’s usual charges.

Facility Fee Billing Instructions for Hospitals:

Hospitals are already able to bill as a non-institutional provider originating site, as stated in the Handbook for Practitioner Services, topic 202.1.4 – Allowable Fee-for-Service Charges by Hospitals.

All Other Originating Facility Sites – The Department is currently working to implement a facility fee payment system for these sites and additional information will be forthcoming.

SOURCE: Provider Notice Telehealth Expansion Billing Instructions (March 30, 2020). (Accessed Jul. 2024).

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Indiana

Last updated 08/06/2024

POLICY

The Indiana Health Coverage Programs (IHCP) covers select medical, …

POLICY

The Indiana Health Coverage Programs (IHCP) covers select medical, dental and remote patient monitoring services delivered via telehealth. IHCP coverage is also available for the virtual delivery of certain nonhealthcare services (such as case management) for members who are eligible to receive such services. For applicable procedure codes, see Telehealth and Virtual Services Codes, accessible from the Code Sets page at in.gov/medicaid/providers. Most telehealth services must be provided via video and audio, although a few designated telehealth services can be provided via audio only. Audio-only delivery is allowable for all nonhealthcare virtual services.

SOURCE: Indiana Health Coverage Programs, Telehealth and Virtual Services, Provider Reference Module (Feb. 29, 2024), p. 1. (Accessed Aug. 2024).

Indiana Code requires reimbursement for medically necessary telehealth services for Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs), Community Mental Health Centers, Critical Access Hospitals, a home health agency under IC 16-27-1, and a provider determined by the office to be eligible, providing a covered telehealth service.

SOURCE: IN Code, 12-15-5-11 (Accessed Aug. 2024).

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

SOURCE: Indiana Health Coverage Programs (IHCP) Bulletin, BT202142, June 8, 2021, (Accessed Aug. 2024).

In any telemedicine encounter, there will be the following:

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

SOURCE: IN Admin. Code, “Article 5,” Title 405, 5-38-3 & 4., p. 199 (Accessed Mar. 2024).

ELIGIBLE SERVICES/SPECIALTIES

Providers are allowed to use telehealth for the medical, dental and remote patient monitoring services listed in Telehealth and Virtual Services Codes, accessible from the Code Sets page at in.gov/medicaid/providers. The following services may not be provided using telehealth:

Surgical procedures
Radiological services
Laboratory services
Anesthesia services
Durable medical equipment (DME)/home medical equipment (HME) services
Transportation services

Office visits conducted via telehealth are subject to existing service limitations for office visits. Telehealth office visits billed using applicable codes from Telehealth and Virtual Services Codes (accessible from the Code Sets page at in.gov/medicaid/providers) are counted toward the member’s office visit limit. See the Evaluation and Management Services module for information about office visit limitations.

SOURCE: Indiana Health Coverage Programs, Telehealth and Virtual Services, Provider Reference Module (Feb. 29, 2024), p. 2-3. Indiana Health Coverage Programs (IHCP) Bulletin, BT202142, p. 2 June 8, 2021, (Accessed Aug. 2024).

Group psychotherapy services and 2024 Annual HCPCS Codes Update – new codes added.

SOURCE: Indiana Health Coverage Programs (IHCP) Bulletin, BT202425 (Feb. 29, 2024). (Accessed Aug. 2024).

IHCP reimbursement for telehealth services is limited to the medical, dental and remote patient monitoring procedure codes listed in the telehealth code set (see the Telehealth Services Allowed and Excluded section). Additionally, the rendering NPI on the claim must be enrolled in the IHCP under one of the specialties allowable for telehealth services (see the Practitioners Eligible to Provide Telehealth Services section). All services delivered via telehealth must be billed with one of the following place of service (POS) codes:

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

The procedure code billed must appear on the telehealth code set (Tables 1–3 of Telehealth and Virtual Services Codes, accessible from the Code Sets page at in.gov/medicaid/providers). IIn addition, an appropriate telehealth modifier may be required, depending on the type of service:

Medical services – All medical services delivered via telehealth (with the exception of services delivered through a Home- and Community-Based Services [HCBS] or Money Follows the Person [MFP] program) require one of the following modifiers:

95 – Synchronous telemedicine service rendered via real-time interactive audio and video telecommunications system
93 – Synchronous telemedicine service rendered via telephone or other real-time interactive audio-only telecommunications system

SOURCE: Indiana Health Coverage Programs, Telehealth and Virtual Services, Provider Reference Module (Feb. 29, 2024), p. 3-4 Indiana Health Coverage Programs ICHP Bulletin BT202249 (June 30, 2022). (Accessed Aug. 2024).

In December 2022, IHCP expanded and clarified telehealth coverage and note it will be effective December 9, 2022. The updated coverage applies to all IHCP programs that offer such services – including but not limited to Healthy Indiana Plan (HIP), Hoosier Care Connect, Hoosier Healthwise and Traditional Medicaid. The telehealth and virtual services code set is used by both fee-for-service (FFS) and managed care delivery systems. This updated code set will remain in place for the remainder of 2022 and 2023, and will be reevaluated by the Office of Medicaid Policy and Planning (OMPP) at the end of 2023.

Updated Code Set as of May 16, 2024, (Accessed Aug. 2024).

SOURCE: Indiana Health Coverage Programs (IHCP) Bulletin, BT202425 (Feb. 29, 2024). IN Health Coverage Programs (IHCP) Bulletin BT 202297 (Nov 8, 2022). Past bulletins: Indiana Health Coverage Programs (IHCP) Bulletin, BT202142, p. 2 June 8, 2021, ICHP BT2020106 Indiana Health Coverage Programs ICHP Bulletin BT 202239 (May 19, 2022). (Accessed Aug. 2024).

As published in IHCP Bulletin BT202239, for a practitioner to receive reimbursement for telehealth services, the procedure code must be listed in the telehealth and virtual services code set, and must be a service for which the member is eligible. Additionally, the claim detail must have:

One of the following place of service (POS) codes:

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

One of the following modifiers:

95 – Synchronous telemedicine service rendered via real-time interactive audio and video telecommunications system
93 – Synchronous telemedicine service rendered via telephone or other real-time interactive audio-only telecommunications system

Modifier 93 (audio-only) is allowable only for certain, designated telehealth services. Effective Dec. 9, 2022, the IHCP will allow reimbursement for the telehealth services specified in Table 1 when billed with the appropriate POS code and the audio-only modifier (93).

SOURCE: Indiana Health Coverage Programs ICHP Bulletin BT202297 (Nov 8, 2022), p. 1. (Accessed Aug. 2024).

A valid FQHC or RHC encounter is defined as a face-to-face visit (either in person or via telehealth) between an IHCP member and a qualifying practitioner (see the Rendering Providers section) at an FQHC, RHC or other qualifying, non-hospital setting. When billing valid encounters provided by telehealth, When billing valid telehealth encounters, the encounter code (T1015 or D9999) should be billed as usual, and each service provided during the encounter must include an appropriate telehealth POS code (02 or 10) and telehealth modifier (93 or 95), as described in the FQHC and RHC Telehealth Services section of the Telehealth and Virtual Services module.

SOURCE: Medicaid Federally Qualified Health Centers and Rural Health Clinics Module, (Jan 2022 edition, published May 7, 2024), p. 10, 12, (Accessed Aug. 2024).

When the FQHC or RHC is the distant site, the service provided by the FQHC or RHC must meet the requirements both for a valid encounter and for an approved telehealth service. The claim must include the following:

Encounter code T1015 (or D9999 for valid dental encounters), billed with POS code 02, 03, 04, 10, 11, 12, 31, 32, 50 or 72
One or more appropriate procedure codes for the specific services rendered, billed with modifier 93 or 95, and a POS code of either 02 or 10, depending on the originating site/location of the patient

SOURCE: Indiana Health Coverage Programs, Telehealth and Virtual Services, Provider Reference Module (Feb. 29, 2024), p. 6 (Accessed Aug. 2024).

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

SOURCE: IN Code, 12-15-5-11(f) IHCP Division of Mental Health and Addiction, Adult Mental Health Habilitation Services (July 25, 2024), p. 20; IHCP Division of Mental Health and Addiction, Behavioral and Primary Healthcare Coordination Service (July 1, 2023), p. 26. (Accessed Mar. 2024).

Adult Mental Health Habilitation Services

Adult Mental Health Habilitation (AMHH) Home- and Community-Based Habilitation and Support services are individualized services provided face to face or via telehealth according to Indiana Administrative Code (IAC) that are focused on the member’s health, safety and welfare. Valid telehealth services can be found on Telehealth and Virtual Services Codes, accessible from the Code Sets page at in.gov/medicaid/providers

Program standards for Adult Mental Health Habilitation (AMHH) Therapy and Behavioral Support Services and Addiction Counseling include the following:

Services may be provided face to face or with telehealth according to the IAC with the member or with family members or nonprofessional caregivers with or without the member present.

For Medication Training and Support, program standard for these services include that services provided that are not face-to-face or telehealth, according to the IAC, with the member must meet the following standards:

The member must be the focus of the service.
Documentation must support how the service benefits the member.

SOURCE: IHCP Division of Mental Health and Addiction, Adult Mental Health Habilitation Services (July 25, 2024), p. 61, 63, 69, 73, 86 (Accessed Aug. 2024).

Behavioral and Primary Healthcare Coordination (BPHC) Services

Telehealth may be used for clinical evaluations in the BPHC application process, for developing the Individualized Integrated Care Plan (IICP), and ongoing review of the IICP.

SOURCE: Indiana Health Coverage Programs, Provider Reference Module, Behavioral and Primary Healthcare Coordination Services (October 26, 2023), p. 33, 41, 46. 71 (Accessed Aug. 2024).

The Indiana Family and Social Services Administration (FSSA) Office of Medicaid Policy and Planning (OMPP) and Division of Mental Health and Addiction (DMHA) received approval from the Centers for Medicare & Medicaid Services (CMS) to renew the Behavioral and Primary Healthcare Coordination (BPHC) service program. The renewal will go into effect on June 1, 2024. The renewal of BPHC programming and services allows for an additional five years of the BPHC service. The BPHC service program offers one service, which consists of coordinated healthcare activities to manage the behavioral health/addiction and physical healthcare needs of eligible members. The service includes logistical support, advocacy and education to assist individuals in navigating the healthcare system, and activities that help members gain access to needed physical and behavioral health services to manage their health conditions. The following updates are included in the BPHC program:

Quality improvement (QI) activities will verify services provided fulfill the person-centered plan (PCP) established with the individual receiving services.
Medicaid allowances for telehealth services.

SOURCE: Indiana Health Coverage Programs, IHCP Bulletin, BT202440 (April 4, 2024). (Accessed Aug. 2024).

Nonhealthcare Virtual Services

Nonhealthcare virtual services are services centering on patient wellness and case management that are delivered between a patient and a provider via interactive electronic communications technology. A licensed practitioner listed under IC 25-1-9.5-3.5 is not required to perform these services, as they are not considered healthcare services under the definition listed in IC 25-1-9.5-2.5. For a list of nonhealthcare procedure codes allowable for virtual delivery, see the Procedure Codes for Nonhealthcare Virtual Services table in Telehealth and Virtual Services Codes, accessible from the Code Sets page at in.gov/medicaid/providers.

Nonhealthcare virtual services must be billed with POS code 02 or 10. These services and do not require modifiers 93 or 95. All services in this category can be provided either through audio and video technology or via audio only.

SOURCE: Indiana Health Coverage Programs, Telehealth and Virtual Services, Provider Reference Module (Feb. 29, 2024), p. 5 (Accessed Aug. 2024).

Nonhealthcare virtual services take place between a patient and a provider via interactive electronic communications technology. These services do not require a licensed practitioner listed in IC 25-1-9.5-3.5 to perform the service virtually, as the services are not considered healthcare services under the definition listed in IC 25-1-9.5-2.5 and, therefore, do not fall under the definition of telehealth by the IHCP. As specified in Table 2, nonhealthcare virtual services must be billed with a POS of 02 or 10, and do not require modifiers 93 or 95. All services in this category can be provided via audio only.

SOURCE: Indiana Health Coverage Programs IHCP Bulletin BT 202239 (May 19, 2022). (Accessed Aug. 2024).

Telehealth Dental Services

The use of modifiers 95 or 93 is not required for dental services delivered via telehealth. Dental services cannot be delivered via audio-only telehealth.

SOURCE: Indiana Health Coverage Programs, Telehealth and Virtual Services, Provider Reference Module (Feb. 29, 2024), p. 4, Indiana Health Coverage Programs IHCP Bulletin BT 202239 (May 19, 2022). (Accessed Aug. 2024).

Intensive Outpatient Treatment via Telehealth

The IHCP reimburses for intensive outpatient treatment (IOT) services (procedure codes H0015 and S9480) when delivered via telehealth. The IHCP is approaching this temporary policy expansion as a pilot initiative, where any healthcare provider engaging in telehealth IOT will be opting in to the analysis of the efficacy of this model through data collection and analysis. This data collection and analysis will be administered through the state and is intended to have a minimal administrative impact on providers. All providers submitting claims for telehealth IOT will automatically be included in the study and are expected to participate by providing data if requested. Telehealth IOT will be available for 12 months after which the data collected will be analyzed by the Division of Mental Health and Addiction (DMHA). IOT requires prior authorization for medical necessity, regardless of whether it is delivered in person or via telehealth. See manual for other criteria.

SOURCE: Indiana Health Coverage Programs, Telehealth and Virtual Services, Provider Reference Module (Feb. 29, 2024), p. 7 (Accessed Aug. 2024).

After receiving feedback from providers over an allotted 30-day period, the IHCP has determined that IOT services (procedure codes H0015 and S9480) will be reimbursable when delivered via telehealth. This service will be added to the 2022 telehealth and virtual services code set. See bulletin for more instructions.

SOURCE: Indiana Health Coverage Programs IHCP Bulletin BT 202239 (May 19, 2022). (Accessed Aug. 2024).

With the exception of services billed by a federally qualified health center (FQHC) or rural health clinic (RHC) (see the Telehealth Services for FQHCs and RHCs section) or RPM services billed by a home health agency (see the RPM Billing and Reimbursement for Home Health Agencies section), the payment for telehealth services is equal to the current Fee Schedule amount for the procedure codes billed (see the IHCP Fee Schedules page at in.gov/medicaid/providers).

SOURCE: Indiana Health Coverage Programs, Telehealth and Virtual Services, Provider Reference Module (Feb. 29, 2024), p. 3, (Accessed Aug. 2024).

Skills Training and Development Rendered Via Telehealth

As published in BT202249, the IHCP reimburses for H2014 – Skills training and development, per 15 minutes when the service is rendered through an audiovisual telehealth modality. Skills training and development is covered only for members who have access to Medicaid Rehabilitation Option (MRO) services. The OMPP, in partnership with the Division of Mental Health and Addiction (DMHA), developed the following service parameters for when telehealth delivery satisfies the “face-to-face” contact required for this service. Providers are expected to have these service parameters in place by Dec. 9, 2022, when rendering skills training and development via telehealth. See bulletin for additional information.

SOURCE: IHCP Expands and Clarifies Telehealth Coverage BT 202297 (Nov. 8, 2022), p. 2-3. (Accessed Aug. 2024).

Home and Community-Based Services

Caregiver Coaching provided in the home of the participant, virtually or telephonically and through Health Insurance Portability and Accountability Act (HIPAA) secure communication platforms that allow for real time and asynchronous communication between caregivers and caregiver coaches and collaboration with waiver care managers/service coordinators.

Caregiver Coaching services may be delivered telephonically and through HIPPA secure electronic communication platforms that enable a caregiver coach and a caregiver to communicate efficiently and in a manner convenient to the caregiver.

SOURCE: IHCP Office of Medicaid Policy and Planning, Home and Community Based Services: Indiana PathWays for Aging Waiver, p. 50-51. (Accessed Aug. 2024).

Mobile Crisis Intervention Services

Follow-up stabilization services: Follow up contacts in-person, via phone, or telehealth up to 14 days following initial crisis intervention and can be billable up to 90 days.

SOURCE: IHCP Adding Coverage for Mobile Crisis Intervention Services BT 202364 (Jun. 15, 2023) & IHCP Bulletin ICHP Covers Mobile Intervention Services Retroactive to July 1, 2023 (Dec. 12, 2023). (Accessed Aug. 2024).

Home Health Services

The IHCP covers telehealth services provided by home health agencies.

SOURCE: IHCP Home Health Services Module (Oct. 3, 2023), p. 8. (Accessed Aug. 2024).

Opioid Treatment Program

POS codes 02 – Telehealth provided other than in patient’s home and 10 – Telehealth provided in patient’s home can be used when billing OTP services. It should be noted that by end of 2023, the Office of Medicaid Policy and Planning will be reevaluating the telehealth service codes. If any changes to these POS codes occur, it will be noted in a future bulletin.

SOURCE: IHCP Bulleting BT 2023151 (Nov. 2, 2023), p. 2. (Accessed Aug. 2024).

Behavioral and Primary Healthcare Coordination Service

Evaluations and meetings with patient maybe conducted face-to-face or with telehealth.

SOURCE: Division of Mental Health and Addiction Behavioral and Primary Healthcare Coordination Service (Oct. 26, 2023), p. 33, 46. (Accessed Aug. 2024).

Adult Mental Health Habilitation Services

Evaluations and reassessments may be conducted face-to-face or via telehealth. Certain information must be included and in some cases specific requirements must be met. See manual for more information.

All clients being considered for telehealth services must be given the option of in-person services prior to telehealth being selected as modality.

The number of in-person visits and the percentage of time telehealth will be the delivery method of service will be based on what is clinically appropriate and in agreement with the consumer and/or legal guardian.

The use of telehealth should protect against isolating participants by offering services that are in person and shall be invoked to prioritize and facilitate community integration.

Telehealth services shall consider and respond to all accessibility needs, including whether hands-on or physical assistance is needed to render the service.

Telehealth services must ensure the health and safety of the individual receiving services by adhering to all abuse, neglect and exploitation prevention practices that apply to in-person treatment, as well as by providing participants with resources on how to report incidences of abuse, neglect and exploitation.

Habilitation and support is not permissible via audio-only telehealth modalities. The IHCP reimburses for H2014 – Skills training and development, per 15 minutes (see Table 2) when the service is rendered through an audiovisual telehealth modality.

These services (specific HPCCS Codes listed on pages 70, 75, 87) cannot be delivered via audio-only telehealth per IHCP policy, but can be delivered via audiovisual telehealth. If a member has eligibility to receive these services in person through the IHCP, then they are eligible to receive these services via telehealth. For more information, see Telehealth and Virtual Services Codes, accessible from the Code Sets page at in.gov/medicaid/providers.

Adult Mental Health Habilitation (AMHH) Addiction Counseling services consist of a series of planned and organized face-to-face or telehealth, according to Indiana Administrative Code. Addiction professionals and other clinicians provide counseling interventions that work toward the member’s recovery goals identified in the Individualized Integrated Care Plan (IICP) as they pertain to substance use-related disorders. Valid telehealth services can be found on Telehealth and Virtual Services Codes, accessible from the Code Sets page at in.gov/medicaid/providers

T1016 – Care Coordination – If a member has eligibility to receive these services in person through the IHCP, then they are eligible to receive these services via telehealth. For more information, see Telehealth and Virtual Services Codes, accessible from the Code Sets page at in.gov/medicaid/providers. (See manual for more detail).

Adult Mental Health Habilitation (AMHH) Medication Training and Support services involve face-to-face or telehealth according to Indiana Administrative Code, services provided to the member, in an individual or group setting, for the purpose of:

Monitoring medication compliance
Providing education and training about medications
Monitoring medication side effects
Providing other nursing or medical assessment

SOURCE: Division of Mental Health and Addiction, Adult Mental Health Habilitation Services Module (July 25, 2024), p. 20, 41, 56, 63-64, 69, 70, 73, 75, 81, 83, 85, 86, 87. (Accessed Aug. 2024).

Outpatient Institutional Claims for Telehealth Services

For providers that use the outpatient institutional claim (UB-04 claim form, IHCP Provider Healthcare Portal institutional claim or 837I electronic transaction), services delivered via telehealth should be billed as follows:

If the service can be billed with a procedure code, providers should enter the procedure code and, if applicable, use the appropriate modifier (93 or 95) to indicate that the service was delivered via telehealth. POS codes are not used on outpatient claims.
If the service cannot be billed with a procedure code (for example, procedure codes cannot be used with revenue codes 905 or 906), the service should be billed as it normally would if delivered in person. Procedure code, modifier and POS code requirements do not apply in this case. Providers are advised to mark in their patient records that the service was delivered via telehealth.

In either case, the service provided must be a one that is allowable for telehealth delivery, as indicated on the telehealth code set (Tables 1–3 of Telehealth and Virtual Services Codes, accessible from the Code Sets page at in.gov/medicaid/providers).

SOURCE: Indiana Health Coverage Programs, Telehealth and Virtual Services, Provider Reference Module (Feb, 29. 2024), p. 4-5, (Accessed Aug. 2024).

Applied Behavioral Analysis Therapy Services via Telehealth

The IHCP provides coverage for applied behavior analysis (ABA) therapy when medically necessary for the treatment of autism spectrum disorder (ASD). All ABA therapy services require prior authorization. Besides the PA criteria outlined in the Behavioral Health Services module, procedure codes 97155 and 97156 are subject to the following additional requirements when rendered via telehealth:

Credentialed registered behavior technicians (RBTs) may not deliver any ABA service via telehealth. Only a health service provider in psychology (HSPP) or a licensed or board-certified behavior analyst (BCBA) are eligible for using telehealth when supervising the delivery of ABA services remotely.
Procedure code 97155 is reimbursable via telehealth only when an HSPP or BCBA is providing guidance/supervision to an RBT remotely, and the RBT is rendering adaptive behavioral treatment in person to the member.
All ABA services must include synchronous audiovisual interaction. No ABA services are reimbursable when delivered via audio-only telehealth.

The complete list of procedure codes for applied behavior analysis therapy can be found in Behavioral Health Services Codes, accessible from the Code Sets page at in.gov/medicaid/providers. Procedure codes 97155 and 97156 are the only two ABA services that are allowable as telehealth.

For dates of service on and after Jan. 1, 2024, all ABA services must be billed with an appropriate modifier to indicate the credentials of the practitioner delivering the service. When ABA services are delivered via telehealth, modifier 95 must also be included.

SOURCE: Indiana Health Coverage Programs, Telehealth and Virtual Services, Provider Reference Module (Feb 29, 2024), p. 8, (Accessed Aug. 2024).

Addiction Counseling, Behavioral Health Counseling & Therapy, Medication Training and Support

Addiction Counseling, Behavioral Health Counseling, Medication Training and Support, and Skills and Training Development may be delivered via an audiovisual telehealth modality. This service is not permissible via audio-only telehealth modalities. If behavioral health assistance needs to be rendered via audio-only telehealth modalities, the following procedure codes are reimbursable via audio-only telehealth:

H0038 – Self-help/peer service, per 15 minutes

H2011 – Crisis intervention service, per 15 minutes

See the Behavioral Health Services module for more information on the peer recovery and crisis intervention services. See the Telehealth and Virtual Services module for more information about rendering and billing for telehealth services.

Skills Training and Development may be delivered via an audiovisual telehealth modality when the following service parameters are met:

All members being considered for telehealth services must be given the option of in-person services prior to telehealth being selected as the modality.
The member must indicate that telehealth is their preferred method for receiving services.
The member must have documented acknowledgement of receipt of informed consent about risks and benefits of the telehealth modality.
Within 30 days of the first telehealth session occurring, a licensed behavioral health practitioner, HSPP or overseeing psychiatric medical professional must document verification that telehealth is thought to be an effective modality for the member based on symptoms, severity and access to services.
Use of the telehealth modality must be formally reviewed with the member every 90 days and adjusted based on need or efficacy.
If the member is not progressing or stabilizing, evaluation of how treatment will be adjusted must be documented. This adjustment may include increasing in-person sessions.
All Skills Training and Development sessions should have clearly documented connection to diagnosis and/or treatment goals.
At minimum, the member must have an in-person session with a member of the treatment team every 90 days. This session may be in the home, community or office setting.

SOURCE: IHCP Medicaid Rehabilitation Option Services, p. 10, 14, 22, 29. (Feb. 27, 2024). (Accessed Aug. 2024).

ELIGIBLE PROVIDERS

In response to Indiana House Enrolled Act 1352 (2023), the Indiana Health Coverage Programs (IHCP) has implemented a new telehealth-only provider enrollment for providers that wish to perform only telehealth services (with no physical site where patients are seen) and that meet the Indiana licensure and other special requirements outlined in this bulletin. This telehealth-only provider enrollment option is currently available on the IHCP Provider Healthcare Portal. See bulletin for more details.

SOURCE: IHCP Bulletin: IHCP to Begin Enrollment for Telehealth-Only Providers BT202417 (Feb. 15, 2024). (Accessed Aug. 2024).

The practitioners listed in IC 25-1-9.5-3.5 are authorized to provide telehealth services under the scope of their licensure within the state of Indiana.

The IHCP will allow these practitioners to provide telehealth services and receive reimbursement for IHCP services, within the established IHCP billing rules and policies. Providers not on this list are not allowed to practice telehealth or receive IHCP reimbursement for such services, even under the supervision of one of these listed practitioners. Providers rendering services within the state of Indiana are 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; see the Out-of-State Telehealth Providers section for more information.

NOTE: Not all practitioners that are authorized to provide telehealth services are allowed to enroll as rendering providers in the IHCP. Those that are not eligible for IHCP enrollment must bill under the IHCP-enrolled supervising practitioner’s National Provider Identifier (NPI), using the appropriate modifiers (as applicable). The rendering NPI entered on the claim must be enrolled under a specialty that is allowable for telehealth.

SOURCE: Indiana Health Coverage Programs, Telehealth and Virtual Services, Provider Reference Module (Feb. 29, 2024), p. 2, (Accessed Aug. 2024).

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. 2024).

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. 2024).

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. 2024).

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.
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. 199-200 & IN Code, 12-15-5-11. (Accessed Aug. 2024).

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

SOURCE: IN Code, 12-15-5-11 (Accessed Aug. 2024).

Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs)

Special billing considerations apply for federally qualified health center (FQHC) and rural health clinic (RHC) providers. FQHC and RHC providers may bill for telehealth services if the service rendered is considered a valid FQHC or RHC encounter (as defined in the Federally Qualified Health Centers and Rural Health Clinics module) and a covered telehealth service (as defined by the Telehealth and Virtual Services Codes, accessible from the Code Sets page at in.gov/medicaid/providers). Subject to the following criteria, reimbursement is available to FQHCs and RHCS when they are serving as either the distant site or the originating site for telehealth services.

Encounter code T1015 (or D9999 for valid dental encounters), billed with POS code 02, 03, 04, 10, 11, 12, 31, 32, 50 or 72
One or more appropriate procedure codes for the specific services rendered, billed with modifier 93 or 95, and a POS code of either 02 or 10, depending on the originating site/location of the patient

SOURCE: Indiana Health Coverage Programs, Telehealth and Virtual Services, Provider Reference Module (Feb. 29, 2024), p. 6, Indiana Health Coverage Programs, Federally Qualified Health Centers and Rural Health Clinics, p. 6 (May 7, 2024). (Accessed Aug. 2024).

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

SOURCE: Medicaid Federally Qualified Health Centers and Rural Health Clinics Module, Jan. 1, 2022 (published May 7, 2024), p. 4, (Accessed Mar. 2024).

Non-Eligible Providers

IHCP does not reimburse the following provider types for telemedicine:

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

SOURCE: IN Admin. Code, “Article 5” Title 405, 5-38-4, p. 200 (Accessed Aug. 2024).

ELIGIBLE SITES

Telehealth services may be rendered in an inpatient, outpatient or office setting. The provider and/or patient may be located in their home during the time of these services. For IHCP reimbursement of telehealth services, the member must be physically present at the originating site and must participate in the visit.

SOURCE: Indiana Health Coverage Programs, Telehealth and Virtual Services, Provider Reference Module (Feb. 29, 2024), p.1 , (Accessed Aug. 2024).

SOURCE: IN Code, 12-15-5-11 (Accessed Aug. 2024).

Per Indiana Code IC 25-1-9.5-3, “originating site” means any site at which a patient is located at the time healthcare services through telehealth are provided to the individual. Accordingly, eligible providers may be reimbursed for procedure code Q3014 when the provider location is acting as an originating site for telehealth services.

SOURCE: ICHP Expands Procedure Code Q3014 to Additional Providers BT 202332 (Apr. 25, 2023). (Accessed Aug. 2024).

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

SOURCE: IN Admin. Code, “Article 5” Title 405, 5-38-4, p. 199 (Accessed Aug. 2024).

GEOGRAPHIC LIMITS

SOURCE: IN Code 12-15-5-11 (Accessed Aug. 2024)

Medicaid may not require:

A provider that is licensed, certified, registered, or authorized with the appropriate state agency or board and exclusively offers telehealth services (as defined in IC 12-15-5-11(a)) to maintain a physical address or site in Indiana to be eligible for enrollment as a Medicaid provider.
A telehealth provider group with providers that are licensed, certified, registered, or authorized with the appropriate state agency or board to have an in-state service address to be eligible to enroll as a Medicaid vendor or Medicaid provider group.

SOURCE: IN Code 12-15-11-10 (Accessed Aug. 2024).

FACILITY/TRANSMISSION FEE

If the member is located in a medical facility (such as a hospital, clinic or physician’s office) while receiving the telehealth service, and it is medically necessary for a medical professional to be physically present with the member during the service, the IHCP covers Healthcare Common Procedure Coding System (HCPCS) code Q3014 – Telehealth originating site facility fee, billed with modifier 95, for the provider e at the originating site.

If the originating site is a hospital or other location that bills on an institutional claim, HCPCS code Q3014 is reimbursable when billed with revenue code 780 – Telemedicine – General. If a different, separately reimbursable treatment room revenue code is provided on the same day as the telehealth service, the appropriate treatment room revenue code should also be included on the claim. Documentation must be maintained in the patient’s record to indicate that services were provided separately from the telehealth visit.

If the originating site is a physician’s office, clinic or other location that bills on a professional claim, POS code 02 must be used for Q3014, along with modifier 95. If other services are provided on the same date as the telehealth service, the medical professional should bill Q3014 as a separate line item from other professional services.

If the originating site is an FQHC or RHC, additional billing requirements apply. See the Telehealth Services for FQHCs and RHCs section.

SOURCE: Indiana Health Coverage Programs, Telehealth and Virtual Services, Provider Reference Module (Feb. 29, 2024), p. 5. (Accessed Aug. 2024).

Effective immediately, and retroactive to dates of services (DOS) on or after July 21, 2022, the following specialties under provider type 11 – Behavioral Health Provider will be able to receive reimbursement for procedure code Q3014 when their offices or facilities are acting as an originating telehealth site for members:

616 – Licensed Psychologist
617 – Licensed Independent Practice School Psychologist
618 – Licensed Clinical Social Worker (LCSW)
619 – Licensed Marriage and Family Therapist (LMFT)
620 – Licensed Mental Health Counselor (LMHC)
621 – Licensed Clinical Addiction Counselor (LCAC)

SOURCE: ICHP Expands Procedure Code Q3014 to Additional Providers BT 202332 (Apr. 25, 2023). (Accessed Aug. 2024).

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

Encounter code T1015 (or D9999 for valid dental encounters), billed with POS code 02, 03, 04, 11, 12, 31, 32, 50 or 72
Procedure code Q3014 – Telehealth originating site facility fee, billed with POS code 02 and modifier 95
One or more appropriate procedure codes for the specific services rendered, billed with modifier 93 or 95, and a POS code of either 02 or 10, depending on the originating site/location of the patient

Note: The procedure code must appear on one of the code tables in this bulletin, and must be on the list of procedure codes allowable for an FQHC/RHC medical or dental encounter.

SOURCE: Indiana Health Coverage Programs IHCP Bulletin BT 202239 (May 19, 2022). IHCP Bulletin BT 202253 (July 14, 2022). (Accessed Aug. 2024).

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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, as well as being in accordance with provisions under rule 653—13.11(147,148,272C). Health care services provided through in-person consultations or through telehealth shall be treated as equivalent services for the purposes of reimbursement

SOURCE: IA Admin Code Sec. 441, 78.55 (249A). (Accessed Dec. 2024).

Based on this rule [see above], there is no additional payment for the telehealth components of service, associated with the underlying service being rendered. Payment for a service rendered via telehealth is the same as payment made for that service when rendered in a face-to-face (i.e., in-person) setting.

SOURCE: IA Dep. of Human Services. Informational Letter No. 1815-MC-FFS, Aug. 10, 2017, (Accessed Dec. 2024).

Crisis Response Services and Subacute Mental Health Services.

“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; IA Admin Code Sec. 441-24.20; Subacute Mental Health Services. May 1, 2018, p. 9. (Accessed Dec. 2024).

ELIGIBLE SERVICES/SPECIALTIES

See approved procedure code list.

SOURCE: IA Medicaid. New Telehealth Approved Codes [see quarterly codes dropdown], 8/8/24, (Accessed Dec. 2024).

Please visit the Iowa Medicaid PHE unwind webpage for telehealth service codes continuing post-PHE. The effective date for the discontinued telehealth service codes is December 31, 2023. After this date, claims submitted with discontinued service codes, when billed as telehealth (place of service 02 or 10), will be denied.

SOURCE: IA Dep. of Human Services. Informational Letter No. 2457-MC-FFS, Jun. 2, 2023 (Effective Dec. 31, 2023), (Accessed Dec. 2024).

IA Medicaid covers teledentistry synchronous real time encounter.

SOURCE: IA Dep. of Human Services. Informational Letter No. 2124-MC-FFS, April 6, 2020, (Accessed Dec. 2024).

Please be aware that while some services such as teledentistry will continue after the PHE, billing requirements for some other services provided via telehealth may change when the PHE is lifted.

SOURCE: IA Dep. of Human Services. Informational Letter No. 2323-MC-FFS, Mar. 11, 2022 (Effective April 1, 2023), (Accessed Dec. 2023).

Pursuant to the authority of Iowa Code section 249A.4, HHS has amended the 1915(C) HCBS AIDS/HIV, Brain Injury (BI), Health and Disability (HD), Intellectual Disability (ID) and Physical Disability (PD) Waivers. The Centers for Medicaid and Medicare services approved these amendments on April 23, 2024, retroactive to November 1, 2023. As part of the amendments the Department has made the changes listed below to the waivers. …

“Telehealth” means the delivery of SCL services using real-time interactive audio and video, or other real-time interactive electronic media, regardless of where the health care professional and the covered person are each located.
“Telehealth” does not include the delivery of health care services delivered solely through an audio-only telephone, electronic mail message or facsimile transmission.
See letter for list of eligible codes.

SOURCE: IA Dep. of Human Services. Informational Letter No. 2588-MC-FFS, June 4, 2024, (Accessed Dec. 2024).

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 Dec. 2024).

ELIGIBLE SITES

All services delivered via telehealth must be billed with one of the following POS codes:

02 – telehealth provided other than in the patient’s home
- The location where health services and health-related services are provided or received, through telecommunication technology. The patient is not located in their home when receiving health services or health-related services through telecommunication technology.
10 – telehealth provided in the patient’s home
- The location where health services and health-related services are provided or received through telecommunication technology. The patient is in their home (which is a location other than a hospital or other facility where the patient receives care) when receiving health services or health related services through telecommunication technology.

As announced in IL 24573, claims submitted with service codes not included in the telehealth approved list continuing post-Public Health Emergency (PHE) and billed as telehealth (Place of service 02 or 10) after December 31, 2023 will be denied.

SOURCE: Iowa Dep. of Human Services. Informational Letter No. 2472-MC-FFS. (Sept. 11, 2023). (Accessed Dec. 2024).

The following locations may serve as the originating site:

The offices of physicians and other practitioners (psychologists, social workers, behavioral health providers, habilitation services providers, and advanced registered nurse practitioners (ARNPs)).
Hospitals
Critical Access Hospitals
Community Mental Health Centers
Federally Qualified Health Centers
Rural Health Clinics
Area Education Agencies (AEAs) and Local Education Agencies

SOURCE: Iowa Dep. of Human Services. Informational Letter No. 2103-MC-FFS. (Feb. 20, 2020). (Accessed Dec. 2024).

For the purpose of this provision, a “facility” place of service (POS) is defined as any of the following (consistent with “POS” definitions under Medicare, per the Medicare Claims Processing Manual, Chapter 12, Section 20.4.2, revised as of May 2017):

Telehealth (POS 02).

SOURCE: IA Statute 441.79.1, (Accessed Dec. 2024).

The Centers for Medicare and Medicaid (CMS) has added a new POS for telehealth to identify when individuals are receiving services via telehealth in their homes. Iowa Medicaid will adopt this POS effective April 1, 2022. The provider will bill the applicable Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) codes with POS code 02 (telehealth) if the member is receiving services anywhere other than home. The provider will bill the applicable HCPCS/CPT codes with POS code 10 (telehealth patient in home) if the member is in their home. An originating site charge will not be applicable with a POS code 10. However, a distant site charge may be applicable.

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

SOURCE: IA Dep. of Human Services. Informational Letter No. 2323-MC-FFS, Mar. 11, 2022 (Effective April 1, 2023), (Accessed Dec. 2024).

Effective March 13, 2020, the site of service differential was removed from place of service 02 (please refer to Informational Letter 1815-MC-FFS2 [see below). As discussed during the April 27, 2023, provider town hall event, the site of service differential with the place of service 02 and 10 will not be applied to telehealth claims.

SOURCE: IA Dep. of Human Services. Informational Letter No. 2457-MC-FFS, Jun. 2, 2023 (Effective Dec. 31, 2023), (Accessed Dec. 2024).

POS code 02 is defined as, “the location where health services and health related services are provided or received, through a telecommunication system”. POS code 02 is used to report that a billed service was furnished as a telehealth service from a distant site. The only portion that is considered telehealth services is when the patient was present and interacting with the distant site physician or practitioner.

An originating site is the location of a Medicaid member at the time the telehealth service is furnished. CMHCs can be an originating site. Other originating sites can include: physician offices, hospitals, and critical access hospitals (CAHs). The “telehealth” POS code (i.e., “02”) would not be used by an originating site that can bill a facility fee (i.e., Q3014), instead the originating site would continue to use the POS code that applies to the type of facility where the patient is located. Under these circumstances, a CMHC would bill POS 53 (CMHC).

CMHCs billing for services under the CMHC provider category will not have payments cut back for the SoS differential, in cases where the service is provided at POS 02 (Telehealth). Consistent with the immediately preceding paragraph, the “distant” provider would bill POS 02 for the telehealth service and the CMHC would bill POS 53. In these cases, under Medicaid, there is no separate facility bill to account for the overhead, and therefore no SoS cut would be taken, consistent with the intent of this policy.

SOURCE: IA Dep. of Human Services. Informational Letter No. 1815-MC-FFS, Aug. 10, 2017, (Accessed Dec. 2024).

GEOGRAPHIC LIMITS

No Reference Found

FACILITY/TRANSMISSION FEE

Originating sites are paid a facility fee for telehealth services. FQHCs and RHCs would not bill Q3014 as a separate service because reimbursement for the related costs would occur through the annual cost settlement process.

SOURCE: Iowa Dep. of Human Services. Informational Letter No. 2103-MC-FFS. (Feb. 20, 2020). (Accessed Dec. 2024).

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Kansas

Last updated 07/03/2024

POLICY

No individual or group health insurance policy, medical service …

POLICY

No individual or group health insurance policy, medical service plan, contract, hospital service corporation contract, hospital and medical service corporation contract, fraternal benefit society, health maintenance organization or the Kansas medical assistance program shall exclude an otherwise covered healthcare service from coverage solely because such 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 Nov. 2024).

ELIGIBLE SERVICES/SPECIALTIES

Office visits, individual psychotherapy, and pharmacological management services are examples of services which may be reimbursed when provided via telecommunication technology. The provider at the distant side must bill an appropriate code from the lists below with place of service (02) designating a telemedicine service provided other than in the patient’s home OR place of service (10) designating a telemedicine service provided in the patient’s home. (Please note: the GT modifier is no longer used to designate a telemedicine service.) Services delivered via telemedicine will be reimbursed at the same rate as a face-to-face (in the same physical location) service. Documentation requirements are the same as an in-person service.

See manual for eligible codes.

QMB only codes are not noted in these tables. Additionally, telemedicine rules governing HCBS waiver codes may change depending on waiver submissions; therefore, the specific HCBS waiver manual needs to be consulted for current code status allowances.

KMAP does not recognize AMA CPT consultation codes 99242, 99243, 99244, 99245, 99252, 99253, 99254, and 99255 for payment.

SOURCE: Dept. of Health and Environment, Kansas Medical Assistance Program, Provider Manual, General Benefits, (Nov. 2024), pg. 2-28 to 29, (Accessed Nov. 2024).

Note: Refer to Section 2720 of the General Benefits Fee-for-Service Provider Manual for complete details regarding Telemedicine.

SOURCE: KS Dept. of Health and Environment, Kansas Medical Assistance Program, Provider Manual, FQHC/RHC, p. 8-14 (May 2024); Provider Manual, Substance Use Disorder, p. A-2, (May. 2024); Local Education Agency (Oct. 2024), pg. 8-7; Provider Manual, Certified Community Behavioral Health Clinic (CCBHC), p. 8-5 (May 2024); Home Health Agency, p. 8-29 (Oct 2024), Mental Health, p. 8-3, 8-21, A-I, (Oct. 2024), Rehabilitative Therapy Services, (May 2024), pg. 8-5, (Accessed Nov. 2024).

Mobile Response Stabilization Services/Mobile Crisis Response (MRSS/MCR) H2011 U1

MRSS/MCR services are to be provided in person by teams of at least two individuals, at the preferred location of the individual or family (home, school, or other community-based setting). In circumstances where face to face service by a LMHP is not viable, the medical record should reflect the reason that a LMHP was unable to respond in person to the crisis. In those cases, utilization of telemedicine delivery by the LMHP is allowed, however, an in-person response should be made that would provide the telemedicine access to a LMHP.

SOURCE: KS Dept of Health and Environment, KS Medical Assistance Program, Provider Manual, Mental Health, p. 8-3, 8-21, A-I, (Oct. 2024), (Accessed Nov. 2024).

Stand-alone vaccine counseling may also be covered when provided via telehealth.

The face-to-face encounter [for home health] may occur through telehealth, as implemented by the State.

Telehealth and transportation codes are covered codes for OTP services. Please refer to the Kansas Medicaid Telehealth and Non-Emergency Medical Transportation (NEMT) policies

SOURCE: KS Dept. of Health and Environment, Provider Manual, Professional, (Sept. 2024). (Accessed Jul. 2024).

Stand-alone vaccine counseling will be covered only when the vaccine counseling and the administration of the vaccine occurs on two separate visits. Vaccine counseling is content of service when the vaccine counseling and administration of the vaccine occur at the same visit. Stand-alone vaccine counseling may also be covered when provided via telehealth.

SOURCE: KS Dept. of Health and Environment, Provider Manual, KAN Be Health EPSDT, (9/24), (Accessed Nov. 2024).

Autism Services

Family Adjustment Counseling Limitations – Delivery of this service may occur via telemedicine, telehealth, or other modes of video distance monitoring methods that adhere to all required HIPAA 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.

Parents Support and Training – Delivery of this service may occur via telemedicine, telehealth, or other modes of video distance monitoring methods that adhere to all required HIPAA 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, HCBS Autism Services, p. 8-5 & 8-8 (Sept. 2024). (Accessed Nov. 2024).

Intellectual/Developmentally Disabled Services

All functional assessments must be conducted in-person at a location of the individual’s choosing, or, if available, through the use of real-time interactive telecommunications equipment that includes, at a minimum, audio and video equipment. Those responsible for conducting the assessment will be flexible in accommodating the individual’s preference for the meeting location and time of assessment.

SOURCE: KS Dept. of Health and Environment, Provider Manual, HCBS Intellectual/Developmentally Disabled, p. I-1 (Oct. 2024). (Accessed Nov. 2024).

Prenatal Care At Risk Enhanced Care Coordination

Effective with dates of service on and after May 1, 2023, procedure code H1002 will be covered for telemedicine for video and audio transmissions. Existing provisions for the delivery of this service will remain in effect. Place of service (POS) code 10 (telehealth services provided in patient’s home) will be covered for code H1002.

SOURCE: KS Department of Health and Environment, KMAP Bulletin 23051, Prenatal Care At Risk Enhanced Care Coordination, Mar. 2023, (Accessed Nov. 2024).

Lactation Counseling

Effective with dates of service on or after April 1, 2023, lactation counseling services (utilizing procedure code S9443) for nonphysician lactation counselors will be additionally covered via telemedicine. Both video and audio transmissions will be covered. The home setting is allowed for this service delivery. Existing provisions for the delivery of this service will remain in effect until specifically rescinded.

Telemedicine Place of Service (POS) codes include:

02 – Telehealth
10 – Telehealth in patient home

SOURCE: KS Department of Health and Environment, KMAP Bulletin 23042, Lactation Counseling Via Telemedicine, Feb. 2023, (Accessed Nov. 2024).

HCBS Appendix K

The service delivery options that will continue after November 11 include the following: …

A Remote Option for Receiving Services:

Members will be able to receive some in-home services through tele-video. The State is currently working to receive approval from the federal government for this. Managed Care Organization (MCO) Care Coordinators will provide members more information when this option is approved.

SOURCE: KMAP General Bulletin 23302 HCBS Appendix K – COVID Measure Rescinding (PHE Changes Ending), Nov. 2023, (Accessed Nov. 2024).

Non-Waiver Mental Health Attendant Care Service

Telehealth services are excluded from the EVV process for Non-Waiver Mental Health Attendant Care. Centers will continue to submit claims for Non-Waiver Mental Health Attendant Care until otherwise instructed.

SOURCE: KMAP General Bulletin 23326 Non-Waiver Mental Health Attendant Care Service Code – EVV Implementation Resuming, Dec. 2023, (Accessed Nov. 2024).

Advance Directives

The face-to-face encounter may occur through telehealth, as implemented by the State.

SOURCE: Dept. of Health and Environment, Kansas Medical Assistance Program, Provider Manual, Home Health, (Oct 2024), pg. 8-7. (Accessed Nov. 2024).

Serious Emotional Disturbances

Wraparound Facilitation: Meetings can be telehealth or by conference call by member’s choice when the meeting is not the initial or 6-month review.

SOURCE: Dept. of Health and Environment, Kansas Medical Assistance Program, Provider Manual, HCBS Serious Emotional Disturbances (SED), (Oct. 2023), pg. 7-3. (Accessed Nov. 2024).

Medication Assisted Treatment

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: Dept. of Health and Environment, Kansas Medical Assistance Program, Provider Manual, Mental Health, (Nov. 2024), pg. 8-15; & Substance Use Disorder Provider Manual, (May 2024), pg. 7-6. (Accessed Nov. 2024).

Mobile Crisis Intervention Services

MCR services are to be provided in person by teams of at least two individuals at the preferred location of the individual or family (home, school, or other community-based setting). In circumstances where face-to-face service by a LMHP is not available, the medical record should reflect the reason that an LMHP was unable to respond in person to the crisis. In those cases, utilization of telemedicine delivery by the LMHP is allowed; however, an in-person response should be made to provide telemedicine access to an LMHP.

SOURCE: Dept. of Health and Environment, Kansas Medical Assistance Program, Bulletin, Mobile Crisis Intervention Services, Bulletin 24162, Aug. 2024, (Accessed Nov. 2024).

ELIGIBLE PROVIDERS

Provisions in the Kansas Telemedicine Act will allow speech-language pathologists and audiologists licensed by KDADS to provide services via telemedicine. Services must be provided via real-time, interactive (synchronous) audio-video telecommunication equipment that is compliant with HIPAA.

Note: See specific Telemedicine code allowances and guidelines under Section 2720 of this manual.

The provider at the distant side must bill an appropriate code from the lists below with place of service (02) designating a telemedicine service provided other than in the patient’s home OR place of service (10) designating a telemedicine service provided in the patient’s home. (Please note: the GT modifier is no longer used to designate a telemedicine service.) Services delivered via telemedicine will be reimbursed at the same rate as a face-to-face (in the same physical location) service. Documentation requirements are the same as an in-person service.

“Distant site” means a site at which a healthcare provider is located while providing healthcare services by means of telemedicine.

“Healthcare provider” means an individual appropriately licensed, registered, certified, or otherwise authorized to provide a specifically designated telemedicine service.

SOURCE: Dept. of Health and Environment, Kansas Medical Assistance Program, Provider Manual, General Benefits, (Nov 2024), pg. 2-27 to 29, (Accessed Nov. 2024).

ELIGIBLE SITES

The originating site provider, with the patient present, may bill Q3014 with the appropriate place of service code denoted.

Codes S9453 and T2011 are allowed but not in the home.

“Originating site” means a site at which a patient is located at the time healthcare services are provided by means of telemedicine.

SOURCE: Dept. of Health and Environment, Kansas Medical Assistance Program, Provider Manual, General Benefits, (Nov 2024), pg. 2-27 to 29, (Accessed Nov. 2024).

Effective with dates of service on and after July 24, 2024, one of the following Place of Service (POS) codes should be utilized for all visits in AuthentiCare: …

02: Telehealth Provided Other than in Patient’s Home …
10: Telehealth Provided in Patient’s Home

SOURCE: KS KMAP General Medicaid Bulletin 24100, Jul. 2024, (Accessed Nov. 2024).

Adding Place of Service Code 10 to Home Telehealth Nursing Services

Effective with dates of processing on and after January 1, 2022, licensed practical nurses (LPNs) or registered nurses (RNs) that provide home telehealth services must use Place of Service (POS) code 10 for codes T1030 and T1031 on all claims.

SOURCE: KS Department of Health and Environment, KMAP Bulletin 23033, Adding Place of Service Code 10 to Home Telehealth Nursing Services, Feb. 2023, (Accessed Nov. 2024).

See remote patient monitoring section for more information on home telehealth services from the Home Health Agency Manual.

Intensive Individual Support (IIS) Providers

Intensive Individual Support (IIS) providers may now bill under the following POS codes:…

02 – Telehealth Provided Other Than in Patients Home
10 – Telehealth Provided in Patients Home

See bulletin for other POS codes.

SOURCE: KS KMAP General Medicaid Bulletin 23211, Aug. 2023, (Accessed Nov. 2024).

CCBHC

The allowable Place of Service (POS) codes for HCPCS code H0040 are defined to provide clarity on coverage:

02 – Telehealth Provided Other Than in Patients Home
10 – Telehealth Provided in Patients Home

SOURCE: KS KMAP General Medicaid Bulletin 24005, Jan. 2024, (Accessed Nov. 2024).

GEOGRAPHIC LIMITS

No Reference Found

FACILITY/TRANSMISSION FEE

Certified Community Behavioral Health Clinic (CCBHC) Services

The originating site, with the member present, may bill code Q3014 with the appropriate POS code. No payment will be made for Q3014 if the originating telemedicine site is place of service “home” (POS code 12) without the physical presence of a provider.

SOURCE: KS Dept. of Health and Environment, Kansas Medical Assistance Program, FFS Provider Manual, Certified Community Behavioral Health Clinic (CCBHC) Services, (May 2024). (Accessed Nov. 2024).

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Kentucky

Last updated 11/28/2024

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.

Any recipient, upon being offered the option of an asynchronous or audio-only telehealth visit, shall have the opportunity or option to request to be accommodated by that provider in an in-person encounter or synchronous telehealth encounter.

A telehealth care provider that has received a request for an in-person encounter or synchronous telehealth encounter shall provide an alternative in-person or synchronous telehealth encounter for the recipient within:

A reasonable time;
The existing availability constraints of the provider’s schedule; and
No more than three (3) weeks of the recipient’s request, unless the recipient’s condition or described symptoms suggest a need for an earlier synchronous or in-person encounter.

A provider’s failure to accommodate a recipient with a synchronous telehealth or in-person encounter shall be reported to the Office of the Ombudsman and Administrative Review of the Cabinet for Health and Family Services, or its successor organization by a:

Recipient;
Recipient’s guardian or representative;
Another provider; or
Managed care organization.

The Office of the Ombudsman and Administrative Review shall investigate as appropriate and forward reports of a failure to accommodate to the department.

SOURCE: KY Admin. Regs. Title, 907, 3:170. (Accessed Nov. 2024).

A request for reimbursement shall not be denied solely because:

An in-person consultation between a Medicaid-participating practitioner and a patient did not occur; or
A Medicaid-participating provider employed by a rural health clinic, federally qualified health center, or federally qualified health center look-alike was not physically located on the premises of the clinic or health center when the telehealth service or telehealth consultation was provided.

SOURCE: KY Revised Statute Sec. 205.559. (Accessed Nov. 2024).

In accordance with KRS 211.336, 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 Nov. 2024).

As appropriate for the service, provider, and recipient, utilize the following modalities of communication delivered over a secure communications connection that complies with the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Live or real-time audio and video synchronous telehealth technology;
Asynchronous store-and-forward telehealth technology;
Remote patient monitoring using wireless devices, wearable sensors, or implanted health monitors;
Audio-only telecommunications systems; or
Clinical text chat technology if:
- 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 Nov. 2024).

ELIGIBLE SERVICES/SPECIALTIES

The Cabinet for Health and Family Services and any managed care organization with whom the Department for Medicaid Services contracts for the delivery of Medicaid services shall provide Medicaid reimbursement for covered telehealth services and telehealth consultations, if the telehealth service or telehealth consultation:

Is provided by a Medicaid-participating practitioner, including those employed by a home health agency licensed pursuant to KRS Chapter 216, to a Medicaid recipient or another Medicaid-participating practitioner at a different physical location; and
Meets all clinical, technology, and medical coding guidelines for recipient safety and appropriate delivery of services established by the Department for Medicaid Services or the provider’s professional licensure board.

SOURCE: KY Revised Statute Sec. 205.559. (Accessed Nov. 2024).

Telehealth service means any service that is provided by telehealth that is one of the following:

Event
Encounter
Consultation, including a telehealth consultation
Visit
Store-and-forward transfer, as limited by Section 6
Remote patient monitoring
Referral
Treatment

A telehealth service shall not be reimbursed by the department if:

It is not medically necessary;
The equivalent service is not covered by the department if provided in an in-person setting; or
The telehealth care provider of the telehealth service is:
- Not currently enrolled in the Medicaid Program pursuant to 907 KAR 1:672;
- Not currently participating in the Medicaid Program pursuant to 907 KAR 1:671;
- Not in good standing with the Medicaid Program;
- Currently listed on the Kentucky DMS Provider Terminated and Excluded Provider List, which is available at https://chfs.ky.gov/agencies/dms/dpi/pe/Pages/terminated.aspx;
- Currently listed on the United States Department of Health and Human Services, Office of Inspector General List of Excluded Individuals and Entities, which is available at https://oig.hhs.gov/exclusions/;
- Otherwise prohibited from participating in the Medicaid program in accordance with 42 C.F.R. Part 455; or
- Not physically located within the United States or a United States territory at the time of service.

A telehealth service shall be subject to utilization review for:

Medical necessity;
Compliance with this administrative regulation; and
Compliance with applicable state and federal law.

The department shall not reimburse for a telehealth service if the department determines that a telehealth service is not:

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

The department shall recover the paid amount of a reimbursement for a previously reimbursed telehealth service if the department determines that a telehealth service was not:

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

SOURCE: KY Admin. Regs. Title, 907, 3:170. (Accessed Nov. 2024).

If, after reviewing the allegations contained in the petition and examining the petitioner under oath, it appears to the court that there is probable cause to believe the respondent should be ordered to undergo treatment, then the court shall: …

Cause the respondent to be examined no later than twenty-four (24) hours before the hearing date by two (2) qualified health professionals, at least one (1) of whom is a physician. The qualified health professionals: …
- May conduct the examination required by this paragraph via telehealth as defined in KRS 211.332.

SOURCE: KY Statute Sec. 222.433, (Accessed Nov. 2024).

Dental

“Direct practitioner interaction” means the billing dentist or oral surgeon is physically present with and evaluates, examines, treats, or diagnoses the recipient, unless the service can be appropriately performed via telehealth pursuant to 907 KAR 3:170.

SOURCE: KY Admin Regs. Title 907 KAR 1:126, (Accessed Nov. 2024).

Specialized Children’s Services Clinics

Certain services, such as crisis intervention, intensive outpatient program services, behavioral health therapeutic intervention, group outpatient therapy, family outpatient therapy, and peer support services consist of a one-on-one encounter between the provider and recipient conducted in-person or via telehealth as appropriate pursuant to 907 KAR 3:170.

SOURCE: KY Admin Regs. Title 907 KAR 3:160, (Accessed Nov. 2024).

Rural Health Clinic

Psychological testing, crisis intervention, service planning, individual outpatient therapy, family outpatient therapy, group outpatient therapy, collateral outpatient therapy, screening, brief intervention and refers to treatment for a substance use disorder, partial hospitalization, withdrawal management services, shall:…

Be in-person or via telehealth as appropriate pursuant to 907 KAR 3:170

Medication assisted treatment supporting behavioral health services shall Be colocated within the same practicing site as the practitioner who maintains a current waiver, as necessary, under 21 U.S.C. 823(g)(2) to prescribe buprenorphine products or via telehealth as appropriate pursuant to 907 KAR 3:170.

SOURCE: KY Admin Regs. Title 907 KAR 1:082, (Accessed Nov. 2024).

Treatment of Stuttering (Effective Jan. 1, 2025)

The coverage required under subsection (2) of this section shall … Include coverage for speech therapy provided in person and via telehealth.

The telehealth coverage required under this paragraph shall:

Not be less than the coverage required for health benefit plans under KRS 304.17A-138; and
Include the use of any communication technology, application, or platform to deliver telehealth services, except coverage may be restricted to technology, applications, or platforms that are compliant with any applicable privacy provisions of the federal Health Insurance Portability and Accountability Act of 1996, 42 U.S.C. sec. 1320d et seq., as amended.

SOURCE: KRS Title XXV, Sec. 305.17A-129, & Senate Bill 111 (2024 Session), (Accessed Jul. 2024).

“In-home program” means a program offered by a health care facility or health care professional for the treatment of substance use disorder which the insured accesses through telehealth or digital health service;

The Department for Medicaid Services and any managed care organization with which the department contracts for the delivery of Medicaid services shall provide coverage: …

For telehealth or digital health services that are related to maternity care associated with pregnancy, childbirth, and postpartum care.

The coverage required by this section shall: … For lactation consultation, include: …

The delivery of consultation via telehealth, as defined in KRS 205.510, if the beneficiary requests telehealth consultation in lieu of in-person, one-on-one consultation

SOURCE: KY Revised Statute 205.556, (Accessed Nov. 2024).

Participants in the HANDS program shall participate in the home visitation program through in-person face-to-face methods or through tele-service delivery methods. For the purposes of this subsection, “teleservice” means a home visitation service provided through video communication with the HANDS provider, parent, and child present in real time.

SOURCE: KY Revised Statute 211.690, (Accessed Nov. 2024).

ELIGIBLE PROVIDERS

For rural health clinics, federally qualified health centers, and federally qualified health center look-alikes, reimbursement for covered telehealth services and telehealth consultations shall:

To the extent permitted under federal law, include an originating site fee in an amount equal to that which is permitted under 42 U.S.C. sec. 1395m for Medicare-participating providers if the Medicaid beneficiary who received the telehealth service or telehealth consultation was physically located at the rural health clinic, federally qualified health center, or federally qualified health center look-alike at the time of service or consultation delivery and the provider of the telehealth service or telehealth consultation is not employed by the rural health clinic, federally qualified health center, or federally qualified health center look-alike; or
If the telehealth service or telehealth consultation provider is employed by the rural health clinic, federally qualified health center, or federally qualified health center look-alike, include a supplemental reimbursement paid by the Department for Medicaid Services in an amount equal to the difference between the actual reimbursement amount paid by a Medicaid managed care organization and the amount that would have been paid if reimbursement had been made directly by the department.

SOURCE: KY Revised Statute Sec. 205.559. (Accessed Nov. 2024).

A “telehealth care provider” is a Medicaid provider who is:

Currently enrolled as a Medicaid provider;
Currently participating as a Medicaid provider;
Operating within the scope of the provider’s professional licensure; and
Operating within the provider’s scope of practice; or

A community mental health center (CMHC) that is participating in the Medicaid program in compliance with 907 KAR 1:045, or 907 KAR 1:047.

SOURCE: KY Admin. Regs. Title, 907, 3:170. (Accessed Nov. 2024).

ELIGIBLE SITES

“Place of service” means anywhere the patient is located at the time a telehealth service is provided, and includes telehealth services provided to a patient located at the patient’s home or office, or a clinic, school, or workplace.

SOURCE: KY Admin. Regs. Title, 907, 3:170. (Accessed Nov. 2024).

See Provider Billing Instructions by Provider Type for Place of Service Codes information, including use of 02 for telehealth services and 10 for telehealth provided in a patient’s home. The Physician Services Provider Billing Instructions also include modifiers to be used by physicians with a specialty of teleradiology, including U2 for teleradiology in-state and U3 teleradiology out-of-state.

SOURCE: KY Medicaid Management Information System. Provider Billing Instructions. (Accessed Nov. 2024).

For rural health clinics, federally qualified health centers, and federally qualified health center look-alikes, reimbursement for covered telehealth services and telehealth consultations shall:

To the extent permitted under federal law, include an originating site fee in an amount equal to that which is permitted under 42 U.S.C. sec. 1395m for Medicare-participating providers if the Medicaid beneficiary who received the telehealth service or telehealth consultation was physically located at the rural health clinic, federally qualified health center, or federally qualified health center look-alike at the time of service or consultation delivery and the provider of the telehealth service or telehealth consultation is not employed by the rural health clinic, federally qualified health center, or federally qualified health center look-alike; or
If the telehealth service or telehealth consultation provider is employed by the rural health clinic, federally qualified health center, or federally qualified health center look-alike, include a supplemental reimbursement paid by the Department for Medicaid Services in an amount equal to the difference between the actual reimbursement amount paid by a Medicaid managed care organization and the amount that would have been paid if reimbursement had been made directly by the department.

Notwithstanding any provision of law to the contrary, neither the Department for Medicaid Services nor a Medicaid managed care organization with whom the department has contracted for the delivery of Medicaid services shall require that a health professional, as defined in KRS 205.510, or medical group maintain a physical location or address in this state to be eligible for enrollment as a Medicaid provider if the provider or group exclusively offers services via telehealth as defined in KRS 211.332.

SOURCE: KY Revised Statute Sec. 205.559. (Accessed Nov. 2024).

GEOGRAPHIC LIMITS

No Reference Found

FACILITY/TRANSMISSION FEE

For rural health clinics, federally qualified health centers, and federally qualified health center look-alikes, reimbursement for covered telehealth services and telehealth consultations shall:

To the extent permitted under federal law, include an originating site fee in an amount equal to that which is permitted under 42 U.S.C. sec.
1395m for Medicare-participating providers if the Medicaid beneficiary who received the telehealth service or telehealth consultation was physically located at the rural health clinic, federally qualified health center, or federally qualified health center look-alike at the time of service or consultation delivery and the provider of the telehealth service or telehealth consultation is not employed by the rural health clinic, federally qualified health center, or federally qualified health center look-alike; 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 Nov. 2024).

READ LESS

Louisiana

Last updated 11/06/2024

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.

Medicaid covered services provided using telemedicine must be identified on claim submissions by appending the modifier “95” to the applicable procedure code and indicating the correct place of service, either POS 02 (other than home) or 10 (home). Both the correct POS and the -95 modifier must be present on the claim to receive reimbursement

SOURCE: LA Dept. of Health, Professional Svcs. Provider Manual, Chapter Five of the Medicaid Svcs. Manual, Section 5.1, p. 165-166 (as issued 6/27/22). (Accessed Nov. 2024).

Telemedicine/telehealth is the use of an interactive audio and video telecommunications system to permit real time communication between a distant site health care practitioner and the beneficiary. There is no restriction on the originating site (i.e., where the beneficiary is located) and it can include, but is not limited to, a healthcare facility, school, or the beneficiary’s home.

Medicaid covered services provided via telehealth/telemedicine shall be identified on claim submissions by appending the Health Insurance Portability and Accountability Act (HIPAA) of 1996 compliant place of service (POS) or modifier to the appropriate procedure code, in line with current policy

SOURCE: LA Admin. Code 50: Sec. 501 & 503, p. 36 (Accessed Nov. 2024).

The MCO shall reimburse the distant site provider for services provided via telemedicine/telehealth. Reimbursement for services provided by telemedicine/telehealth is at the same level as services provided in person.

The MCO shall require the provider to include in the enrollee’s clinical record documentation that the service was provided through the use of telemedicine/telehealth.

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

SOURCE: MCO Manual (updated 8/15/24), pg. 178, (Accessed Nov. 2024).

ELIGIBLE SERVICES/SPECIALTIES

The department shall periodically review policies regarding Medicaid reimbursement for telehealth services to identify variations between permissible reimbursement under that program and reimbursement available to healthcare providers under the Medicare program.

To the extent practicable, notwithstanding any other law to the contrary, after conducting a review provided for in Subsection A of this Section, 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 Nov. 2024).

When otherwise covered, services located in the Telemedicine appendix of the CPT manual, or its successor, may be reimbursed when provided by telemedicine/telehealth. In addition, other specified services may be reimbursed when provided by telemedicine/telehealth and these services are explicitly noted in this manual.

SOURCE: LA Dept. of Health, Professional Svcs. Provider Manual, Chapter Five of the Medicaid Svcs. Manual, Section 5.1, p. 165. (as issued 6/27/22). (Accessed Nov. 2024).

In the event that the federal or state government declares an emergency or disaster, the Medicaid Program may temporarily cover services provided through the use of an interactive audio telecommunications system, without the requirement of video, if such action is deemed necessary to ensure sufficient services are available to meet beneficiaries’ needs.

SOURCE: LA Admin Code, Sec. 50:I.505, (Accessed Nov. 2024).

When otherwise covered, the MCO shall cover services located in the Telemedicine appendix of the CPT manual, or its successor, when provided by telemedicine/telehealth. In addition, the MCO shall cover other services provided by telemedicine/telehealth when indicated as covered via telemedicine/telehealth in Medicaid program policy. The MCO shall ensure adequate availability of telemedicine/telehealth during declared emergencies, disasters, and pandemics. Physicians and other licensed practitioners must continue to adhere to all existing clinical policy for all services rendered. Providing services through telemedicine/telehealth does not remove or add any medical necessity requirements.

SOURCE: MCO Manual (revised 8/15/24), pg. 178, (Accessed Nov. 2024).

Treatment-in-place ambulance services

Effective for dates of service on or after May 12, 2023, the Louisiana Medicaid Program provides coverage for initiation and facilitation of telehealth services by qualified Louisiana Medicaid enrolled ambulance providers.

SOURCE: LA Admin Code, Title 50, Part IX, Subpart 1, Ch. 13, Sec. 1301, p. 306 (Accessed Nov. 2024).

A physician directed treatment-in-place service is the facilitation of a telehealth visit by an ambulance provider.

Each paid treatment-in-place ambulance claim must have a separate and corresponding paid treatment-in-place telehealth claim, and each paid treatment-in-place telehealth claim must have a separate and corresponding paid treatment-in-place ambulance claim or a separate and corresponding paid ambulance transportation claim. Reimbursement for both an emergency transport to a hospital and an ambulance treatment-in-place service for the same incident is not permitted.

SOURCE: LA Dept. of Health, Medical Transportation, Sec. 10.8, (As issued on 2/16/24), (Accessed Nov. 2024).

Payment of treatment-in-place ambulance services is restricted to those identified on the Physician Directed Ambulance Treatment-in-Place Fee Schedule and edit claims for non-payable procedure codes as follows:

If a treatment-in-place ambulance claim is billed with mileage, the entire claim document shall be denied;
If an unpayable procedure code, that is not mileage, is billed on a treatment-in-place ambulance claim, only the line with the unpayable code will be denied;
Claims for allowable telehealth procedure codes must be billed with procedure code G2021. The G2021 code shall be accepted, paid at $0.00, and used by the transportation provider to identify treatment-in-place telehealth services; and
As with all telehealth claims, providers must include POS identifier “02” or “10” and modifier “95” with their claim to identify the claim as a telehealth service. Providers must follow CPT guidance relative to the definition of a new patient versus an established patient.

See valid treatment in place ambulance claim modifier list.

If the beneficiary being treated-in-place has a real-time deterioration in their clinical condition necessitating immediate transport to an emergency department, as determined by the ambulance provider (i.e., EMT or paramedic), telehealth provider, or beneficiary, the ambulance provider cannot bill for both the treatment-in-place ambulance service and the transport to the emergency department. In this situation, the ambulance provider shall bill for the transport to the emergency department only. The transportation broker shall require ambulance providers to submit pre-hospital care summary reports when ambulance treatment-in-place and ambulance transportation claims are billed for the same beneficiary with the same date of service.

If a beneficiary is offered treatment-in-place services declines the services, ambulance providers should include procedure code G2022 on claims for ambulance transportation to an emergency department. Use of this informational procedure code is optional and does not affect the establishment of medical necessity of the service or reimbursement of the ambulance transportation claim. The G2022 code shall be accepted, paid at $0.00, and used by the transportation provider to identify beneficiary refusal of treatment-in-place services

Payment of the treatment-in-place services is restricted to those identified on the Treatment-in-Place Telehealth Services Fee Schedule.

SOURCE: MCO Manual (revised 8/15/24), pg. 88-89, & LA Dept. of Health, Medical Transportation, Sec. 10.8, (As issued on 2/16/24), (Accessed Nov. 2024).

Behavioral Health Services

Assessments, evaluations, individual psychotherapy, family psychotherapy, and medication management services [CPST allowed in Rehabilitation Services section and services allowed within intensive outpatient or outpatient treatment may be provided in Addiction Services section] may be reimbursed when provided via telecommunication technology when the following criteria is met:

The telecommunication system used by physicians and LMHPs must be secure, ensure member confidentiality, and be compliant with the requirements of the Health Insurance Portability and Accountability Act (HIPAA);
The services provided are within the practitioner’s telehealth scope of practice as dictated by the respective professional licensing board and accepted standards of clinical practice;
The member’s record includes informed consent for services provided through the use of telehealth;
Services provided using telehealth must be identified on claims submission using by appending the modifier “95” to the applicable procedure code and indicating the correct place of service, either POS 02 (other than home) or 10 (home). Both the correct POS and the 95 modifier must be present on the claim to receive reimbursement;
Assessments and evaluations conducted by an LMHP through telehealth should include synchronous, interactive, real-time electronic communication comprising both audio and visual elements unless clinically appropriate and based on member consent; and
Providers must deliver in-person services when telehealth is not clinically appropriate or when the member requests in-person services.
Group psychotherapy is only allowed via telehealth when utilized for Dialectical Behavioral Therapy (DBT) and must include synchronous, interactive, real-time electronic communication comprising of both audio and visual elements. [in Outpatient Services, Outpatient Therapy by Licensed Practitioners section only, not Addiction section)

Exclusions: Methadone admission visits conducted by the admitting physician within Opioid Treatment Programs are not allowed via telecommunication technology. [in Addiction section only].

LMHP’s providing assessments, evaluations, individual psychotherapy, family psychotherapy, and medication management services offered within Opioid treatment programs may be reimbursed when conducted via telecommunication technology. The LMHP is responsible for acting within the telehealth scope of practice as decided by the respective licensing board. The provider must bill the procedure code (CPT codes) with modifier “95”, as well as the correct place of service, either POS 02 (other than home) or 10 (home). Reimbursement will be at the same rate as a face-to-face service. Exclusions: Methadone admission visits conducted by the admitting physician within OTPs are not allowed via telecommunication technology.

SOURCE: LA Dept. of Health and Hospitals, Behavioral Health Services, Chapter Two of the Medicaid Svcs. Manual, Section 2.3, p. 115, 201 & 272 (As issued 10/1/24). (Accessed Nov. 2024).

Parent-Child Interaction Therapy

Fidelity is then directly assessed via the following requirement: Applicants must have their treatment sessions observed by a certified PCIT Trainer. Observations may be conducted in real time (e.g., live or online/telehealth) or through video recording.

Dialectical Behavioral Therapy

As an outpatient therapy service delivered by licensed practitioners, allowed modes of delivery include individual, family, group, on-site, off-site, and tele-video. Telehealth delivery is allowed if it includes synchronous, interactive, real-time electronic communication comprising both audio and visual elements.

A comprehensive DBT program is typically provided in an outpatient setting. Telehealth is an allowed modality, and use of telehealth for DBT skills training groups in particular may support continued and consistent client engagement, especially when travel or transportation is a barrier to client engagement.

Components of DBT may be delivered, with some adaptation, in a residential or inpatient setting; however, this would not be billed as a separate service, instead would be part of the active treatment plan reimbursed as part of the comprehensive inpatient or psychiatric residential treatment facility (PRTF) rate

Only direct staff face-to-face time with the individual or family may be billed. DBT is a face-to-face intervention with the individual present. Telehealth delivery is allowed if it includes synchronous, interactive, real-time electronic communication comprising both audio and visual elements. Services provided using telehealth must be identified on claims submission by appending the modifier “95” to the applicable procedure code and indicating the correct place of service, either POS 02 (other than home) or 10 (home). Both the correct POS and the 95 modifier must be present on the claim to receive reimbursement;

SOURCE: LA Dept. of Health and Hospitals, Behavioral Health Services, Chapter Two of the Medicaid Svcs. Manual, Section 2.3, 417, 464, 473 (As issued 10/1/24). (Accessed Jun. 2024).

Ambulance Providers – Managed Care Organizations

Physician directed treatment-in-place service is the facilitation of a telehealth visit by an ambulance provider.

MCO Manual: The MCO may not reimburse for both an emergency transport to a hospital and an ambulance treatment-in-place service for the same incident.

Medical Transportation Manual: Reimbursement for both an emergency transport to a hospital and an ambulance treatment-in-place service for the same incident is not permitted.

SOURCE: LA Medicaid Managed Care Organization (MCO) Manual, p. 88 (Updated 8/15/24), & LA Dept. of Health, Medical Transportation, Sec. 10.8, (As issued on 2/16/24), (Accessed Nov. 2024).

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

Louisiana Medicaid allows for the telemedicine/telehealth mode of delivery for many common healthcare services.

Permissible Telecommunications Systems:

All services eligible for telemedicine/telehealth may be delivered via an interactive audio/video telecommunications system;
A secure, HIPAA-compliant platform is preferred, if available. However, for the duration of the COVID-19 event, if a HIPAA-compliant system is not immediately available at the time it is needed, providers may use everyday communications technologies such as cellular phones with widely available audio/video communication platforms;
Providers should follow guidance from the Office for Civil Rights at the Department of Health and Human Services for software deemed appropriate for use during this event;
For the duration of the COVID-19 event, in cases where an interactive audio/video system is not immediately available at the time it is needed, an interactive audio-only system (e.g., telephone) without the requirement of video may be employed, unless noted otherwise;
For use of an audio-only system, the same standard of care must be met, and the need and rationale for employing an audio-only system must be documented in the clinical record; and
Please note, some telemedicine/telehealth services described below require delivery through an audio/video system due to the clinical nature of these services. Where applicable, this requirement is noted explicitly.

As always, providers must maintain the usual medical documentation to support reimbursement of the visit. In addition, providers must adhere to all telemedicine/telehealth-related requirements of their respective professional licensing boards.

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

Providers must indicate place of service 02 and must append modifier -95.

SOURCE: LA Dept. of Health, Provider Manual, Chapter Twenty of the Medicaid Svcs. Manual, Section 20.1, p. 19-20 (As issued 3/14/24). (Accessed Nov. 2024).

Consultations are to be face-to-face contact in one-on-one sessions. These are services for which a parent would otherwise seek medical attention at a physician or health care provider’s office. Telemedicine/telehealth is not a covered service, but is an applicable service delivery method. When otherwise covered by Louisiana Medicaid, telemedicine/telehealth is allowed for all CPT codes located in Appendix P of the CPT manual. This service is available to all Medicaid individuals eligible for EPSDT.

SOURCE: LA Admin Code, Title 50, Part XV, Subpart 5, Ch. 95, Sec. 9503, p. 363 (Accessed Nov. 2024).

The department shall include in its Medicaid policies and procedures all of the following information relating to telehealth:

An exhaustive listing of the covered healthcare services which may be furnished through telehealth.
Processes by which providers may submit claims for reimbursement for healthcare services furnished through telehealth.
The conditions under which a managed care organization may reimburse a provider or facility that is not physically located in this state for healthcare services furnished to an enrollee through telehealth.

SOURCE: LA Revised Statute, Ch. 46, Sec. 460.54, (Accessed Nov. 2024).

For services rendered in the natural environment (home and community). “Community”: environment where children of same age with no disabilities or special needs participate such as childcare centers, agencies, libraries, and other community settings. Services can be provided via “teletherapy” specific POS/modifier combinations.

POS/modifier combination must be one of these two choices:

POS 12 (Home) and Procedure Modifier U8; or
POS 99 (Other Place of Service) and Procedure Modifier U8.
POS 02 (Teletherapy) and Procedure Modifiers 95 and U8.

SOURCE: LA Dept. of Health, Professional Svcs. Provider Manual, EPSDT Health and IDEA, Part C- Early Steps, Section 47.5.1, p. 21 (As issued on 2/27/23), (Accessed Nov. 2024).

Supports Waiver

Virtual delivery of onsite day habilitation should be used during times that do not allow the beneficiary to attend in person (i.e. medical issues/surgery, an emergency where a provider agency may be closed) or when the beneficiary chooses not attend in person. Virtual delivery is not the typical delivery method. In order to participate in virtual delivery of the service, the beneficiary should be independent or have natural supports, as this service cannot be billed at the same time as another service. The beneficiary should also have the technology necessary to participate in the virtual service (i.e., internet connection, laptop, smartphone, and/or tablet).

See manual for virtual delivery guidelines.

SOURCE: LA Dept. of Health, Support Services, Ch. 43.4, (As issued on 10/7/24), (Accessed Nov. 2024).

Applied Behavior Analysis

Louisiana Medicaid will reimburse the use of telehealth, when appropriate, for rendering certain ABA services for the care of patients or to support the caregivers of beneficiaries.

Telehealth requires prior authorization for services. Subsequent assessments and behavior treatment plans can be performed remotely via telehealth only if the same standard of care can be met.

Previously approved prior authorizations can be amended to increase units of care and/or to reflect re-assessment goals.

The codes listed below can be performed via telehealth; however, requirements for reimbursement are otherwise unchanged from Section 4.5 – Reimbursement of this manual chapter. See manual for relevant CPT codes and guidance

SOURCE: LA Dept of Health, Applied Behavior Analysis, pg. 12, (As issued on 4/22/24), & Healthy Louisiana Informational Bulletin 24-13, May 6, 2024, (Accessed Nov. 2024).

RHCs/FQHCs

If a covered service is provided via an interactive audio and video telecommunications system (telemedicine), providers must refer to Chapter 5 of the Professional Services Provider Manual on www.lamedicaid.com for specific billing instructions.

SOURCE: LA Dept. of Health, FQHCs, Ch. 22, (as issued 6/30/22), & RHCs, Ch. 40, (as issued 6/30/22), pg. 33, (Accessed Nov. 2024).

ELIGIBLE PROVIDERS

Distant site means the site at which the physician or other licensed practitioner is located at the time the services are provided.

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

SOURCE: LA Dept. of Health, Professional Svcs. Provider Manual, Chapter Five of the Medicaid Svcs. Manual, Section 5.1, p. 165 (As issued on 6/27/22) (Accessed Nov. 2024).

Distant site means the site at which the physician or other licensed practitioner is located at the time the telehealth services are provided.

SOURCE: Behavioral Health Services, Chapter Two of the Medicaid Svcs. Manual, Section 2.3, p. 115, 174, & 201 (As issued 10/1/24). (Accessed Nov. 2024).

Rural health clinics (RHC) and federally qualified health clinics (FQHC): Reimbursement for these services will be at the all-inclusive prospective payment rate on file for the date of service (DOS).

SOURCE: LA Dept. of Health, Informational Bulletin 20-1. (May 20, 2022). (Accessed Nov. 2024).

FQHC manual refers to provider manual for billing instructions for telemedicine services.

SOURCE: LA Dept. of Health, Federally Qualified Health Centers Provider Manual, Chapter 22, Sec. 22.4, pg. 33, (As issued on Jun. 30, 2022) & Rural Health Clinic Manual, Chapter 40, Sec. 40.4, pg. 33 (As issued on Jun. 30, 2022). (Accessed Nov. 2024).

Distant Site: The distant site refers to where the provider is located. The preferred location of a distant site provider is in a healthcare facility. However, if there is disruption to a healthcare facility or a risk to the personal health and safety of a provider, there is no formal limitation as to where the distant site provider can be located, as long as the same standard of care can be met.

SOURCE: LA Dept. of Health, EPSDT Health and IDEA Related Services, Ch. 20, Sec. 20.1, (As issued on 3/14/24), (Accessed Nov. 2024).

Treatment-in-place ambulance services

Ambulance providers interested in offering physician directed treatment-in-place telehealth services must complete the following:

enroll as a CMS ET3 model participant;
enter into a partnership with a qualified, Louisiana Medicaid enrolled healthcare provider to furnish treatment-in-place telehealth services to Louisiana Medicaid beneficiaries; and
notify the Department of Health of its partnerships with each telehealth provider.
Reimbursement for initiation and facilitation of telehealth services shall be made according to the established physician directed treatment-in-place telehealth service fee schedule or billed charges, whichever is the lesser amount.

Initiation and facilitation of physician directed treatment-in-place telehealth services are performed by Louisiana Medicaid enrolled ambulance providers on site, with no transport, using audio and video telecommunications systems that permit real-time communication between a qualified, Medicaid enrolled, licensed medical practitioner and the beneficiary.

All services provided by ambulance providers during the initiation and facilitation of the physician directed treatment-in-place intervention are covered by the associated BLS-E, emergency base rate, or the ALS1-E, Level 1 emergency base rate.

Ambulance providers are not eligible to submit a claim for reimbursement or receive payment for other services (except for supplies) at the scene.

If a beneficiary must be transported to an emergency department (ED) due to poor internet connection, which resulted in a failed physician directed treatment-in-place encounter, or the beneficiary’s condition deteriorates, the ambulance provider may submit a claim for reimbursement and receive compensation for the transport to the ED, but not for initiation and facilitation of the telehealth service.

The entity seeking reimbursement for the corresponding physician directed treatment-in-place telehealth service must be an enrolled Louisiana Medicaid provider.

Reimbursement to the ambulance providers for initiation and facilitation of the physician directed treatment-in-place telehealth service requires a corresponding treatment-in-place telehealth service. The corresponding treatment-in-place telehealth service is demonstrated via a Louisiana Medicaid paid treatment-in-place telehealth service claim.

SOURCE: LA Admin Code, Title 50, Part IX, Subpart 1, Ch. 13, Sec. 1301-1305, p. 306 (Accessed Nov. 2024).

Valid rendering providers are licensed physicians, advanced practice registered nurses, and physician assistants.

SOURCE: MCO Manual (revised 8/15/24), pg. 89, & LA Dept. of Health and Hospitals, Medical Transportation, Sec. 10.8, (As issued on 2/16/24), (Accessed Nov. 2024).

School Based Health Centers provide convenient access to preventive and acute care services for students who might otherwise have limited or no access to health care. This care may be provided onsite or through telehealth.

SOURCE: LA Admin Code, Title 50, Park XV, Subpart 5, Ch. 91, Sec. 9101, pg. 358 (Accessed Nov. 2024).

ELIGIBLE SITES

Originating site means the location of the Medicaid beneficiary [enrollee, member] at the time the services are provided. There is no restriction on the originating site and it can include, but is not limited to, a healthcare facility, school, or the beneficiary’s [enrollee’s] home.

SOURCE: LA Dept. of Health, Professional Svcs. Provider Manual, Chapter Five of the Medicaid Svcs. Manual, Section 5.1, p. 165. (As issued 6/27/22), & MCO Manual (revised 8/15/24), pg. 177, & Behavioral Health Services, Chapter Two of the Medicaid Svcs. Manual, Section 2.3, p. 115, 174, 201 (As issued 10/1/24). (Accessed Jun. 2024).

The Centers for Medicare and Medicaid Services (CMS) added a new place of service (POS) for telehealth services provided in the patient’s home effective for dates of service on and after January 1, 2022. Providers are required to use the appropriate POS, either 02 (other than home) or 10 (home) with modifier 95 for the billing of telemedicine/telehealth services based on the beneficiary’s location at the time of service.

SOURCE: LA Dept. of Health, Informational Bulletin 19-11. (May 18, 2022). (Accessed Nov. 2024).

Rural health clinics (RHC) and federally qualified health clinics (FQHC) are required to indicate the appropriate place of service, either 02 (other than home) or 10 (home), based on the beneficiary’s location at the time of and append modifier 95 for the billing of telemedicine/telehealth services. Services delivered via an audio/video system and via an audio-only system are to be coded the same way.

SOURCE: LA Dept. of Health, Informational Bulletin 20-1. (May 20, 2022). (Accessed Nov. 2024).

Originating Site: The originating site refers to where the patient is located. There is currently no formal limitation on the originating site and this can include, but is not limited to, the patient’s home.

SOURCE: LA Dept. of Health, EPSDT Health and IDEA Related Services, Ch. 20, Sec. 20.1, (As issued on 3/14/24), (Accessed Nov. 2024).

GEOGRAPHIC LIMITS

A BHS provider that is not a licensed mental health professional or a provisionally licensed mental health professional acting within his/her scope of practice may not provide telehealth services outside of its geographic service area.

SOURCE: LA Admin Code 48:I Sec. 5605, (Accessed Nov. 2024).

FACILITY/TRANSMISSION FEE

Louisiana Medicaid only reimburses the distant site provider for services provided via telemedicine/telehealth.

SOURCE: LA Dept. of Health, Professional Svcs. Provider Manual, Chapter Five of the Medicaid Svcs. Manual, Section 5.1, p. 166 (As issued on 6/27/22). (Accessed Nov. 2024).

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Maine

Last updated 10/23/2024

POLICY

If a Member is eligible for the underlying Covered …

POLICY

If a Member is eligible for the underlying Covered Service to be delivered, and if delivery of the Covered Service via Telehealth Services is medically appropriate, as determined by the Health Care Provider, the Member is eligible for Telehealth Services.

Except as set forth herein, reimbursement will not be provided for communications between Health Care Providers when the Member is not participating.

Except as set forth herein, reimbursement will not be provided for communications solely between Health Care Providers and Members when such communications would not otherwise be billable.

Reimbursement

Services are to be billed in accordance with applicable Sections of the MBM. Providers must submit claims in accordance with Department billing instructions.

Telehealth Services are subject to all conditions and restrictions described in Chapter I, Section 1, of the MBM.

Telehealth Services are subject to co-payment requirements for the underlying Covered Service, if applicable, as established in Chapter I, Section 1, of the MBM. However, there shall be no separate co-payment for telehealth services.

Specific reimbursement rates for other telehealth services can be found in the appropriate Sections of the MBM or the MaineCare Provider fee schedules on the MaineCare Health PAS Portal.

SOURCE: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4., (Nov. 6, 2023). (Accessed Oct. 2024).

“Synchronous encounters” means a real-time interaction conducted with interactive audio or video connection between a patient and the patient’s provider or between health professionals regarding the patient.

SOURCE: ME Statute Sec. 22:855.3173-H, Sub. Sec. 1 (Accessed Oct. 2024).

ELIGIBLE SERVICES/SPECIALTIES

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

The Member is otherwise eligible for the Covered Service, as described in the appropriate Section of the MBM; and
The Covered Service delivered by Telehealth Services is of comparable quality to what it would be were it delivered in person.

Prior authorization is required for Telehealth Services only if prior authorization is required for the underlying Covered Service. In these cases, the prior authorization is the usual prior authorization for the underlying Covered Service, rather than a prior authorization for the mode of delivery. Unless otherwise required by law, a face-to-face encounter is not required prior to delivering Telehealth Services.

Non-Covered Services and Limitations

Except as set forth herein, services not otherwise covered by MaineCare are not covered when delivered via Telehealth Services.

Services covered under other MaineCare Sections but specifically excluded from Telehealth coverage include, but are not limited to the following:

Services that require direct physical contact with a Member by a Health Care Provider and that cannot be delegated to another Health Care Provider at the site where the Member is located are not covered;
Any service medically inappropriate for delivery through Telehealth Services – e.g. services that include providing medical procedures or administration of medications that must be conducted in person.

Except as set forth herein, reimbursement will not be provided for communications between Health Care Providers when the Member is not participating.

Except as set forth herein, reimbursement will not be provided for communications solely between Health Care Providers and Members when such communications would not otherwise be billable.

The Originating Site Fee may be paid only to a Health Care Provider.

Virtual Check-In

Virtual Check-in is a brief communication where an established patient checks in with a Health Care Provider using a telephone or other telecommunications device for 5-10 minutes to determine the status of a chronic clinical condition(s) and to determine whether an office visit is needed. Modalities permitted for Virtual Check-Ins include Telephonic Services or Interactive Services to deliver clinical services at a distance for the purpose of diagnosis, disease monitoring, or treatment.

Communications exclusively by email, text, or voicemail are not reimbursable.

The Health Care Provider must document a Virtual Check-In in the Member’s record, including the length of the Virtual Check-In, an overview and outcome of the conversation, and the modality of the interaction.

If the Virtual Check-In takes place within seven (7) days after an in-person visit or triggers an in-person office visit within 24 hours (or the soonest available appointment), the Virtual Check-In is not billable under this Section.

SOURCE: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4., (Nov. 6, 2023). (Accessed Oct. 2024).

Rules adopted by the department:

May not include any requirement that a patient have a certain number of emergency room visits or hospitalizations related to the patient’s diagnosis in the criteria for a patient’s eligibility for telemonitoring services;
Except as provided in paragraph E, must include qualifying criteria for a patient’s eligibility for telemonitoring services that include documentation in a patient’s medical record that the patient is at risk of hospitalization or admission to an emergency room;
Must provide that group therapy for behavioral health or addiction services covered by the MaineCare program may be delivered through telehealth;
Must include requirements for providers providing telehealth and telemonitoring services; and
Must allow at least some portion of case management services covered by the MaineCare program to be delivered through telehealth, without requiring qualifying criteria regarding a patient’s risk of hospitalization or admission to an emergency room.

SOURCE: ME Revised Statute Sec. 3173,-H, (Accessed Oct. 2024)

A multitude of services are listed as being allowed either face-to-face or through telehealth in the behavioral health services manual.

SOURCE: MaineCare Benefits Manual, Behavioral Health Services, 10-44 Ch. II, Sec. 65, (Nov. 9, 2022). (Accessed Oct. 2024).

Rehabilitative and Community Support Services for Children with Cognitive Impairments and Functional Limitations

Telemedicine may be utilized as clinically appropriate, according to the standards described in Chapter I, Section 4 of the MaineCare Benefits Manual.

SOURCE: MaineCare Benefits Manual, Rehabilitative and Community Support Services for Children with Cognitive Impairments and Functional Limitations, 28.08, Ch. 101, Ch. II, Sec. 28, p. 12, (9/23/19), (Accessed Oct. 2024).

Durable Medical Equipment

A face-to-face encounter is a mandatory encounter (including encounters through telehealth (as described in Chapter I, Section 4) and other than encounters incidental to services involved) between the member and a Qualified Provider that takes place within the six (6) months prior to the date of a written order for DME. The written order may be, but does not have to be, prescribed by the provider who performed the face-to-face encounter.

SOURCE: MaineCare Benefits Manual, Durable Medical Equipment, 60.06, Ch. 101, Ch. II, Sec. 60, p. 4, (10/31/23), (Accessed Oct. 2024).

Children’s Residential Care Facilities (CRCFs)

The nurse may provide in-person, telehealth, and/or telephonic support outside of normal business hours as needed. The nurse must be either a psychiatric mental health nurse practitioner (APRN-PMH-NP), or a registered nurse (RN) with experience in the treatment of children with serious behavioral health conditions or requisite training to treat children with serious behavioral health conditions.

SOURCE: MaineCare Benefits Manual, Private Non-Medical Institution, 97.07, Ch. 101, Ch. II, Sec. 97, (11/1/21), (Accessed Oct. 2024).

Teledentistry

Providers may deliver diagnostic services via telehealth in accordance with Chapter I, Section 4, of the MaineCare Benefits Manual (MBM) and current Board rules and guidance. When delivering services via telehealth, providers shall bill for the underlying service and include, for tracking purposes only, the appropriate teledentistry CDT code that indicates a synchronous real-time encounter or an asynchronous encounter in which information is stored and forwarded to the dentist for subsequent review.

SOURCE: ME Benefits Manual, Dental Services and Reimbursement Methodology, 10-144, Ch. II, Sec. 25, pg. 4, (Sept. 25, 2024), (Accessed Oct. 2024).

Primary Care Plus (PCP)

In PCP Tier II Services, providers must offer telehealth as an alternative to traditional office visits in accordance with MBM, Ch. I, Sec. 4, Telehealth Services, and/or for non-office visit supports and outreach to increase access to the care team and clinicians in a way that best meets the needs of Members.

SOURCE: MaineCare Benefits Manual, Primary Care Plus, 10-144, Ch. VI, Sec. 3.03, pg. 6, June 21, 2022, (Accessed Oct. 2024).

Home Health Services

Face to Face Encounter means an encounter between the member and the certifying physician, or a nurse practitioner or clinical nurse specialist who is working in collaboration with the physician, or a certified nurse midwife as authorized by State law or physician assistant under the supervision of the physician. The encounter may be through telehealth, consistent with Section 1834(m) of the Social Security Act and 42 CFR 424.22. The face-to-face encounter must be related to the primary reason the patient requires Home Health Services.

SOURCE: Main Care Benefits Home Health Services, 10-144, Chapter II, Section 40 (Aug. 11, 2019), p. 1. (Accessed Oct. 2024).

Community Care Teams

A comprehensive biopsychosocial assessment, conducted face-to-face or via telehealth. See manual for necessary components.

SOURCE: Maine Care Benefits Manual Home Health Services – Community Care Teams, 10-144, Chapter II, Section 91 (June 21, 2022), p. 15, (Accessed Oct. 2024).

Support Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder

AT-Assessment: Evaluation of the assistive technology needs of a member, including a functional evaluation of the impact of the provision of appropriate assistive technology and appropriate services to the member in the customary environment of the member.

Evaluation of the assistive technology needs of a Member may be delivered via telehealth when the provider ensures that the assessment via telehealth meets the requirements of the scope of the service.

SOURCE: Maine Care Benefits Manual Support Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder, 10-144, Chapter II, Section 29 (Jan. 24, 2024), p. 15, Adopted Rule: 10-144 C.M.R. Chapter 101, MaineCare Benefits Manual, Chapter II, Section 29, Support Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder (Jan. 12, 2024). (Accessed Oct. 2024).

Diabetes Prevention Program

Providers shall bill 0403T for each in-person session and bill 0403T with the GT modifier for sessions delivered through telehealth, e.g. online and distance learning sessions, as defined in the DPRP Standards.

SOURCE: Maine Care Benefits Manual National Diabetes Prevention Program Services, 10-144, Chapter II, Section 71 (Nov. 8, 2023), p. 5, Adopted Rule: 10-144 C.M.R. Chapter 101, Chapter II, Section 71, National Diabetes Prevention Program Services (Nov. 8, 2023). (Accessed Oct. 2024).

MaineMOM Services and Reimbursement

The MaineMOM provider shall offer telehealth as an alternative to traditional office visits in accordance with the MBM, Chapter I, Section 4, and/or for non-office visit supports and outreach to increase access to the care team and clinicians in a way that best meets the needs of members.

SOURCE: MaineCare Benefits Manual, MaineMOM Services and Reimbursement, 10-44 Ch. II, Sec. 89, p. 22 (Dec. 6, 2023). (Accessed Oct. 2024).

Newly Adopted Rule:

MaineCare will reimburse providers for one health assessment visit per member for each age shown on the Bright Futures Periodicity Schedule. The Department covers one additional health assessment visit per member within a year following an initial assessment via telehealth for each age shown on the Bright Futures Periodicity Schedule.

SOURCE: MaineCare Benefits Manual, Early and Periodic Screening, Diagnosis and Treatment Services, 10-44 Ch. II, Sec. 94, p. 10 (Apr. 22, 2024) Adopted Rule: 10-144 C.M.R., Chapter 101, MaineCare Benefits Manual, Chapter II Section 94, Early and Periodic Screening, Diagnosis and Treatment Services (EPSDT) (Apr. 22, 2024). (Accessed Oct. 2024).

Note: MaineCare issued a notice indicating they plan to submit a waiver renewal for the MaineCare Benefits Manual, Section 18, Home and Community Based Services for Members with Brain Injury which will include updates to assistive technology services by allowing qualified providers to conduct Assistive Technology Assessments via telehealth when the provider ensures that the assessment via telehealth meets the requirements of the scope of the service. The manual does not yet indicate this change.

SOURCE: MaineCare Benefits Manual, Notice of Agency Waiver Renewal: Section 18, Home and Community Based Services for Members with Brain Injury, Mar. 22, 2024, (Accessed Oct 2024).

ELIGIBLE PROVIDERS

A health care provider is an individual or entity licensed or certified to provide medical, behavioral health, and related services to MaineCare Members. Health Care Providers must be enrolled as MaineCare Providers to receive reimbursement for services.

In order to be eligible for reimbursement for Telehealth Services, a Health Care Provider must

Act within the scope of their license;
Be enrolled as a MaineCare provider;
Be otherwise eligible to deliver the underlying Covered Service according to the requirements of the applicable Section of the MBM; and
Be appropriately licensed, accredited, certified, and/or registered in the State where the Member is located during the provision of the Telehealth Service.

Reimbursement – Receiving (Provider) Site

Except as described below, only the Health Care Provider at the Receiving (Provider) Site may receive payment for Telehealth Services.
When billing for Telehealth Services, Health Care Providers at the Receiving (Provider) Site must bill for the underlying Covered Service using the same claims they would if it were delivered face-to-face and must add the GT modifier for Interactive Telehealth Services and the 93 modifier for Telephonic Services.
When billing for Telephone Evaluation and Management Services, Health Care Providers at the Receiving (Provider) Site must use the appropriate E&M code. The GT and 93 modifier should not be used.
No separate transmission fees will be paid for Telehealth Services. The only services that may be billed by the Health Care Provider at the Receiving (Provider) Site are the fees for the underlying Covered Service delivered with the GT or 93 modifier.

The Health Care Providers at the Receiving and Originating Sites may be part of the same organization. A Health Care Provider at the Originating (Member) Site may bill MaineCare and receive payment for Telehealth Services if the service is provided by a Treating Provider who is under a contractual arrangement with the Originating (Member) Site.

SOURCE: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4.03., (Nov. 6, 2023). (Accessed Oct. 2024).

Telehealth Services may be included in a Federally Qualified Health Center (FQHC), Rural Health Clinic (RHC), or Indian Health Center (IHC) scope of practice, as approved by the State. If approved, these facilities may serve as the provider site and bill under the encounter rate. When an FQHC or RHC serves as the Originating (Member) Site, the Originating Facility Fee is paid separately from the center or clinic all-inclusive rate.

SOURCE: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4., p. 12. (Nov. 6, 2023). (Accessed Oct. 2024).

Interprofessional Codes for Medication Management Providers

Medication management providers and other treating providers of Section 65 of the MaineCare Benefits Manual (MBM) may deliver and bill MaineCare for interprofessional consultations in alignment with MBM Chapter 1, Section 4.04-2(B). As described in CMS state health official letter #23-001, interprofessional consultations are assessments and management services in which a patient’s treating provider requests the opinion and/or treatment advice of a consultant with specific specialty expertise to assist the treating provider in the diagnosis and/or management of the patient’s condition without the need for the patient’s face-to-face contact with the consultant.

The consulting provider and the provider requesting the consultation must be able to independently bill for evaluation and management services. Examples of these provider types include physicians, nurse practitioners, clinical nurse specialists, physician assistants, and licensed clinical social workers. A registered nurse, for example, is not an eligible provider type.

The following examples illustrate when medication management providers may deliver and bill for interprofessional consultations:

A medication management provider provides consultation to a primary care provider (PCP) on cross-tapering a patient from one antidepressant to another due to concerning side-effects.
A medication management provider provides consultation to a PCP regarding antipsychotic medications because the PCP has a symptomatic patient who has been off of medications, and the PCP has never prescribed antipsychotic medication before.
The PCP has been treating a behavioral health patient who was previously stabilized and who is now reporting increased symptoms with active substance use. The PCP is not sure of what to do about medications in the context of active substance use and consults a medication management provider.

Providers must bill for interprofessional consultations using common procedural terminology (CPT) codes 99446-99449, 99451, and 99452. However, CPT code 99452 is different. Interprofessional consultation code 99452 applies when the patient’s PCP or other qualified health professional interacts with a consultant via telephone, the Internet, or an electronic health record to provide the consultant with the patient’s clinical data so that the consultant can form an opinion regarding further management of the patient’s condition. For example, a PCP would bill CPT code 99452 if they send a patient to a medication management provider and the PCP provided background information.

SOURCE: State of Maine Department of Health and Human Services, Bulletin: Interprofessional Codes for Medication Management Providers, Nov. 13, 2023, (Accessed Oct. 2024).

Electronic Visit Verification (EVV) Place of Service Providers

Telehealth Personal Care Services (PCS) claims are excluded from Electronic Visit Verification (EVV) record requirements. When billing telehealth claims on the CMS 1500 Claim Form, you must use the POS code 02 or 10 and include the GT modifier, as this indicates you are providing services via telehealth and not in-person.

See the table below for affected codes. UB04 claim lines submitted with telemedicine revenue code 078x are exempt from EVV editing.

SOURCE: ME Department of Health and Human Services, Office of MaineCare Services, Electronic Visit Verification (EVV) Place of Service Reminders, Sept. 26. 2022. (Accessed Oct. 2024).

ELIGIBLE SITES

Originating (Member) Site: The site at which the Member is located at the time of Telehealth Service delivery. The site must be physically located in the United States.

When an FQHC or RHC serves as the Originating (Member) Site, the Originating Facility Fee is paid separately from the center or clinic all-inclusive rate.

Reimbursement – Originating (Member Site)

If the Health Care Provider at the Originating (Member) Site supports the Member’s access to Telehealth Services the Health Care Provider at the Originating (Member) Site may bill MaineCare for an Originating Facility Fee using code Q3014 for the service of supporting access to the Telehealth Service. Supporting access to telehealth services means providing a room and/or telecommunications equipment and/or helping a Member use audio or video conferencing software or equipment to enable the Member to utilize telehealth.
The Health Care Provider at the Originating (Member) Site may not bill for assisting the Health Care Provider at the Receiving (Provider) Site with an examination.
No separate transmission fees will be paid for Telehealth Services.
The Health Care Provider at the Originating (Member) Site may bill for any clinical services provided on-site on the same day that a Telehealth Service claim is made, except as specifically excluded elsewhere in this Section.
Telehealth Services may be included in a Federally Qualified Health Center (FQHC), Rural Health Clinic (RHC), or Indian Health Center (IHC) scope of practice, as approved by the State. If approved, these facilities may serve as the provider site and bill under the encounter rate. When an FQHC or RHC serves as the Originating (Member) Site, the Originating Facility Fee is paid separately from the center or clinic all-inclusive rate.
In the event an interpreter is required, the Health Care Provider at either the Originating (Member) Site or the Receiving (Provider) site must provide and may bill for interpreter services in accordance with the provisions of Chapter I, Section 1, of the MBM. Members may not bill or be reimbursed by the Department for interpreter services utilized during a telehealth encounter.
If the technical component of an X-ray, ultrasound, or electrocardiogram is performed at the Originating (Member) Site during a Telehealth Service, the technical component and the Originating Facility Fee are billed by the Health Care Provider at the Originating (Member) Site. The professional component of the procedure and the appropriate visit code are billed by the Receiving (Provider) Site. The professional component of the procedure and the appropriate visit code are billed by the Receiving (Provider) Site.

SOURCE: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4. (Nov. 6, 2023). Adopted 10-144 C.M.R. Chapter 101, Chapter I, Section 4, Telehealth Services. (Nov. 6, 2023). (Accessed Oct. 2024).

Electronic Visit Verification (EVV) Place of Service Reminders

Personal Care Services (PCS) claims are included or excluded from EVV record requirements based on the POS code and EVV service codes that are submitted on the CMS 1500 claim form.

Claims for services delivered in the following locations are not subject to EVV and do not require a verified EVV visit record:

POS 02: Telehealth provided other than in a patient’s home
- Use this POS for Home Support-Remote Support: Monitor Only and Interactive services (including MaineCare policy Sections 18, 19, 20, 21, and 29).
- Please refer to our additional telehealth billing guidance for PCS.
POS 10: Telehealth provided in patient’s home

SOURCE: ME Department of Health and Human Services, Office of MaineCare Services, Electronic Visit Verification (EVV) Place of Service Reminders, Sept. 26. 2022. (Accessed Oct. 2024).

GEOGRAPHIC LIMITS

No Reference Found

FACILITY/TRANSMISSION FEE

Originating Facility Fee: Fee paid to the Health Care Provider at the Originating (Member) Site for the service of coordinating Telehealth Services.

If the Health Care Provider at the Originating (Member) Site supports the Member’s access to Telehealth Services the Health Care Provider at the Originating (Member) Site may bill MaineCare for an Originating Facility Fee using code Q3014 for the service of supporting access to the Telehealth Service. Supporting access to telehealth services means providing a room and/or telecommunications equipment and/or helping a Member use audio or video conferencing software or equipment to enable the Member to utilize telehealth.

The Health Care Provider at the Originating (Member) Site may not bill for assisting the Health Care Provider at the Receiving (Provider) Site with an examination.

No separate transmission fees will be paid for Telehealth Services.

When an FQHC or RHC serves as the Originating (Member) Site, the Originating Facility Fee is paid separately from the center or clinic all-inclusive rate.

If the technical component of an X-ray, ultrasound, or electrocardiogram is performed at the Originating (Member) Site during a Telehealth Service, the technical component and the Originating Facility Fee are billed by the Health Care Provider at the Originating (Member) Site.

The professional component of the procedure and the appropriate visit code are billed by the Receiving (Provider) Site.

The Department will not separately reimburse Health Care Providers for any charge related to the purchase, installation, or maintenance of telehealth equipment or technology, nor any transmission fees. Health Care Providers shall not bill Members for such costs or fees.

The rate for Telehealth Originating Facility Fee, per visit, code Q3014, is listed on the MaineCare Provider fee schedule, which is posted on the Department’s website in accordance with 22 MRSA Section 3173-J(7) at https://mainecare.maine.gov/Provider%20Fee%20Schedules/Forms/Publication.aspx.

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Maryland

Last updated 11/15/2024

POLICY

In accordance with SB 534, Preserve Telehealth Access Act …

POLICY

In accordance with SB 534, Preserve Telehealth Access Act of 2023 (Ch. 382 of the Acts of 2023), telehealth flexibilities, including coverage of audio-only phone conversations, will continue through at least June 30, 2025.

The use of non-HIPAA compliant technology products previously authorized through the end of the federal PHE at the discretion of the federal Office of Civil Rights (OCR) and subsequent 90-calendar day transition period for covered health care providers to come into compliance with the HIPAA Rules expired as of August 9, 2023. Regular policies are in effect at this time. For more information, visit HHS’s HIPAA and Telehealth webpage.

Guidance previously issued in PT 56-23 as it relates to telehealth including dental services delivered via telehealth (teledentistry), SBHC services, and well-child visits delivered via telehealth is still in effect. Please refer to PT 56-23 for this guidance.

SOURCE: MD Medicaid Provider Transmittal 43-25, Post-PHE and COVID-19 Guidance, Oct. 29, 2024. (Accessed Nov. 2024).

Reimbursement for telehealth is required for services appropriately delivered through telehealth regardless of the location of the patient and may not exclude from coverage a health care service or behavioral health service solely because it is through telehealth.

SOURCE: MD Health General Code 15-141.2 (Accessed Nov. 2024).

Maryland Medicaid reimburses providers for services delivered via synchronous telehealth. Synchronous telehealth is defined as real-time interactive communication between the originating and distant sites via a secure, two-way audiovisual telecommunication system, and for some services audio-only, depending on the program.

The “distant site,” is the location of the provider who will perform the services. The “distant site provider” is the rendering practitioner that is not physically present at the originating site.

The “originating site” is where the participant/patient is located.

SOURCE: MD Medicaid Synchronous Telehealth Policy Guide, p. 1. Updated Aug. 2023. (Accessed Nov. 2024).

Mental Health

The Department shall grant approval to a telemental health provider to be eligible to receive State or federal funds for providing interactive telemental health services if the provider meets requirements of this chapter and for outpatient mental health centers; or if the telemental heath provider is an individual psychiatrist.

SOURCE: Code of Maryland Admin. Regs. Sec. 10.21.30.03. (Accessed Nov. 2024).

Managed Care

MCOs shall provide coverage for medically necessary telemedicine services.

SOURCE: Code of Maryland Admin. Regs. Sec. 10.67.06.31. (Accessed Nov. 2024).

ELIGIBLE SERVICES/SPECIALTIES

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

A provider may receive reimbursement for services delivered via telehealth if the participant:

Consents to service rendered via telehealth (unless there is an emergency that prevents obtaining consent, which shall be documented in the participant’s medical record); and,
Is authorized to receive services, except for services provided in a hospital emergency department

Providers must include the “GT” modifier with the billed procedure code to identify services rendered via audio-video telehealth.

Providers should use the place of service code that would be appropriate as if it were a non-telehealth claim. The billing provider should use the location of the rendering practitioner. If a distant site provider is rendering services at an off-site office, use the place of service office (11). Do not use place of service codes 02 (Telehealth-Other than home) and 10 (Telehealth-Home) for Medicaid-only FFS claims. Medicare Crossover Claims: For Medicare crossover claims, billing providers should use the same Place of Service Code as on the Medicare claim submission: 02 (Telehealth-Other than home) and 10 (Telehealth-Home) are permitted for use on crossover claims only.

For services delivered via audio-visual telehealth, a provider may not bill:

When technical difficulties prevent the delivery of all or part of the telehealth session;
Services that require in-person evaluation or cannot be reasonably delivered via telehealth;
Telecommunication between providers without the participant present

SOURCE: MD Medicaid Synchronous Telehealth Policy Guide, p. 1-3. Updated Aug. 2023. (Accessed Nov. 2024).

Mental Health Eligible Services:

Diagnostic interview;
Individual therapy
Family therapy
Group therapy, up to 8 individuals
Outpatient evaluation and management
Outpatient office consultation
Initial inpatient consultation
Emergency department services

SOURCE: Code of Maryland Admin. Regs. Sec. 10.21.30.09. (Accessed Nov. 2024).

Services required to be provided shall include counseling and treatment for substance use disorders and mental health conditions. The Program may not exclude from coverage a behavioral health care service provided to a Program recipient in person solely because the service may also be provided through telehealth.

The Program may undertake utilization review, including preauthorization, to determine the appropriateness of any health care service whether the service is delivered through an in–person consultation or through telehealth if the appropriateness of the health care service is determined in the same manner.

For the purpose of reimbursement and any fidelity standards established by the Department, a health care service provided through telehealth is equivalent to the same health care service when provided through an in–person consultation.

SOURCE: MD General Health Code 15-141.2(c-e, h). (Accessed Nov. 2024).

Maryland Public Behavioral Health System – Deaf or Hard of Hearing

Maryland Medicaid will reimburse services delivered via telehealth to a patient that is deaf or hard of hearing by any enrolled provider that is fluent in ASL. Unlike telehealth for patients who are not deaf or hard of hearing, the patient may be located in their home. The originating site must meet the technological requirements listed in COMAR 10.09.49. If the ASL fluent provider is enrolled in Maryland Medicaid, actively licensed, and permitted within scope of practice to use telehealth, the provider may act as a distant site provider. The provider may bill for services rendered via telehealth to the patient that is deaf or hard of hearing, using the GT modifier. As with all specialty behavioral health services, the distant site provider is required to have authorizations for all services delivered via telehealth. More information, including the “Telehealth Program Manual,” can be found on the Maryland Medicaid Telehealth Program webpage.

SOURCE: Maryland PBHS Provider Manual (Sept. 2022), p. 35. (Accessed Nov. 2024).

Doula Services

Prenatal and postpartum services may be delivered in the home, at the provider’s office or doctor’s office and other community-based settings. Doula services for prenatal and postpartum visits may be delivered in-person or as a telehealth service. The labor and delivery service must be provided in-person and can only be delivered at a hospital or freestanding birthing center.

The Maryland Medical Assistance Program will not cover Doula services rendered during labor and delivery as a telehealth visit.

See MD Medicaid Coverage of Doula Services Provider Transmittal 17-25 for additional billing information regarding providing doula services via telehealth.

SOURCE: MD Medicaid Doula Services Program Manual. Updated Oct. 4, 2024. (Accessed Nov. 2024).

Effective January 1, 2022, the Program covers doula services as defined in Regulation .01 of this chapter when the services:

Are medically necessary;
Are rendered during a birthing parent’s prenatal period, labor and delivery, and postpartum period; and
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:

Eight prenatal or postpartum visits; and
One labor and delivery service.

SOURCE: Code of Maryland Admin Regs. 10.09.39.04. (Accessed Nov. 2024).

Individualized Education Program (IEP) and Individualized Family Service Plan (IFSP) Services

MDH Will reimburse IEP and IFSP providers for certain procedure codes via telehealth. Providers must identify telehealth services on the child’s IEP/IFSP and bill using the appropriate modifier (GT or UB). Service coordination procedures (T1023, T1023-TG, T2022, W9322, W9323, and W9324) and individual psychotherapy services (90791, 90832 and 90834) may continue with an audio-only component. In addition to IEP/IFSP services, MDH will continue to reimburse Autism Waiver service coordination when provided via telehealth. See Provider Transmittal for approved Maryland Medicaid Fee-for-Service approved IEP/IFSP Telehealth Services.

SOURCE: MD Medical Assistance Program. Early Intervention and School Health Service Providers Transmittal No. 3. Sept. 23, 2021. (Accessed Nov. 2024).

GT Modifier required for telehealth delivered services.

SOURCE: MD Dept of Health, Medicaid Policy & Procedure Manual For Services Delivered through the IEP/IFSP (Sept. 2024). p. 26. (Accessed Nov. 2024).

Therapy Services (Physical Therapists, Occupational Therapists, Speech Therapists, Therapy Groups, EPSDT Providers, Managed Care Organizations)

MDH will reimburse providers for certain procedure codes when provided via audio-visual telehealth. Services must be identified and billed using the GT modifier to indicate a telehealth delivery model. MDH will not reimburse for services provided via an audio-only delivery model or for codes not included on the Provider Transmittal regarding approved therapy telehealth services when provided via any method of telehealth.

SOURCE: MD Medical Assistance Program. Guidance on the Continuation of Telehealth for Therapy Services. PT 09-22. Oct. 7, 2021. MD Dept of Health, Audiology, Physical Therapy, and Early Periodic, Screening, Diagnosis, and Treatment (EPSDT) Provider Manual (Sept. 2024). (Accessed Nov. 2024).

Applied Behavior Analysis (ABA) Services

Maryland Medicaid reimburses for certain procedure codes via audio-visual telehealth for ABA providers. ABA providers may continue to render up to 100% of supervision services (97155) via telehealth. When billing for services that are rendered via two-way HIPAA compliant audio-visual telehealth, providers must bill using the GT modifier and Place of Service 11 to indicate a telehealth delivery model.

SOURCE: MD Medical Assistance Program. Guidance on the Continuation of Telehealth for ABA Services. PT 11-22. Oct. 26 2021. (Accessed Nov. 2024).

Effective October 16, 2023, the Telehealth Readiness Checklist will be a required element to be added to treatment plans when requesting telehealth services for 97155, 97156 and 97157. Please ensure that all areas of the Telehealth Readiness Checklist are assessed and that the checklist is being utilized to determine if telehealth services are appropriate for the participant and the family

The following services may be rendered via a two-way audio-visual telehealth delivery model:

Direct supervision of a BCaBA, RBT, or BT;
Parent training; and
Group parent training.

ABA services must be delivered in a home or community setting, including a clinic, when medically necessary. The ABA provider may not bill the Program for services rendered by mail or telephone or telehealth services that don’t meet the requirements in COMAR 10.09.49.

SOURCE: MD Department of Health, Maryland Medical Assistance Program Applied Behavior Analysis (ABA) Provider Manual (Sept. 2024), p. 9-11. (Accessed Nov. 2024).

Dental Services

Coverage for teledentistry as described in previous guidance will continue to be permitted after the end of the PHE. See list of procedure codes in PT 56-23 PHE Unwinding for teledentistry. Services delivered via telehealth using two way audio- visual technology assisted communication should be billed using the Place of Service “02” to indicate use of telecommunication technology. For these services, audio-only or telephonic services are not reimbursable. This code does not require prior authorization from Maryland Medicaid.

SBHC Services

When billing for services rendered via audio-video or audio-only modalities, SBHC sponsoring agencies must adhere to the following:

Federal Rules (Clinic Services): SBHCs must adhere to federal Medicaid regulations governing clinics (42 CFR § 440.90 – Clinic Services). Medicaid may not reimburse SBHCs or other clinics if neither the practitioner nor patient is physically located within the clinic. This requirement applies to all freestanding clinics participating in the Maryland Medicaid program, regardless of whether they are community-based clinics or SBHCs.
1. During the PHE, CMS granted MDH an 1135 waiver permitting services provided via telehealth from clinic practitioners’ homes (or another location) to be considered to be provided at the clinic for purposes of 42 C.F.R. § 440.90(a). Under this authority, SBHCs were permitted to receive Medicaid reimbursement for services rendered if both the practitioner and the patient are in their homes for the duration of the federal government’s declared public health emergency. The waiver has a retroactive effective date of March 1, 2020, and will terminate when the federal public health emergency ends on May 11, 2023
Modifiers: When billing Medicaid or a HealthChoice MCO for an audio-video telehealth visit or an audio-only visit, sponsoring agencies should bill using the usual procedure code with the appropriate modifier.
1. To bill for services delivered via two-way audio-visual telehealth technology assisted communication, providers must bill for the appropriate service code and use the “-GT” modifier.
2. 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.
Place of Service (POS): SBHC sponsoring agencies should bill using the same POS code that would be appropriate for a non-telehealth claim.
1. If conducting a telehealth visit with a student enrolled with a SBHC (or family member who is also enrolled) who would normally be eligible to receive in-person care at the SBHC, sponsoring agencies should use POS code 03 (School). Sponsoring agencies should use POS code 03 for such visits regardless of the physical location of the student.
2. If a SBHC location adds or maintains telehealth services and wishes to use their telehealth service model to see patients they would not normally see (i.e., patients that are not associated with the student population), the sponsoring agency should not bill for the services as a SBHC. For such visits, sponsoring agencies should use POS code 11 (Office). Services to these recipients are not considered to be self-referred under COMAR 10.67.06.28. SBHCs should not use the 03 (School) POS when billing for services rendered to patients who would otherwise not be able to receive in-person care at the SBHC. MCOs also are not required to reimburse for such services if the sponsoring agency has not contracted with the MCO.
3. SBHCs may NOT bill using the 02 (Telehealth) code in the POS field.

Well-Child Visits

Coverage for well-child visits delivered via telehealth as described in previous guidance will continue to be permitted after the end of the PHE. This guidance does not apply to sick visits or chronic care appointments. See PT 56-23 PHE Unwinding for additional information and eligible codes.

SOURCE: MD Medicaid Provider Transmittal 56-23 PHE Unwinding, May 30, 2023. (Accessed Nov. 2024).

Long Term Services and Supports

On December 22, 2021, via Provider Transmittal 27-22, the Maryland Department of Health (MDH), Medicaid Office of Long Term Services and Supports, authorized the continuation of reimbursement to providers for services determined to be clinically appropriate for delivery via telehealth. Effective July 1, 2023, the following services, which were previously authorized to be completed via telehealth, may no longer be provided in this manner and the MDH will not reimburse providers for these services delivered via telehealth:

Registered Nurse Supervisory Visits (Staff training and supervision)
Initial and significant change assessments (Private duty nursing)
Personal Assistance Services
Certain case management services

As previously discussed, effective July 1, 2023, the following services may continue to be provided via telehealth, MDH will reimburse providers for services delivered via telehealth below:

Model Waiver Case Management (when authorized by the Division of Nursing Services (DONS))
Psychological and psychiatric evaluations
Participant and family consultation
Certain case managment services and nurse monitoring

See PT 11-24 and 58-23 for additional details.

SOURCE: MD Medicaid Provider Transmittal 11-24 Discontinuation of Telehealth for Certain Services, Jul. 10, 2023 & MD Medicaid Provider Transmittal 58-23 Discontinuation of Telehealth for Certain Services, Jun. 7, 2023. (Accessed Nov. 2024).

Behavioral Health Mobile Crisis Services

Mobile crisis team services are covered and shall include mobile crisis follow-up services by means of telephone, telehealth, or in-person contact with the individual served, family members, caregivers, or referred providers. A mobile crisis team program shall include at least one licensed mental health professional available at all times, either via telehealth or face-to-face.

SOURCE: COMAR 10.09.16 as proposed to be added by Final Regulation; COMAR 10.63.03.20 as proposed to be added by Final Regulation . (Accessed Nov. 2024).

Effective June 1, 2024, Maryland Medicaid will reimburse mobile crisis team (MCT) services. MCT services include mobile crisis follow-up outreach service which is a short-term care coordination and follow-up service. This service may be rendered via telehealth in accordance with the requirements in COMAR 10.09.49. To be eligible for MCT reimbursement, all teams must include a licensed mental health professional – as defined in 10.09.16.01 – either as part of the two-person team or operating via telehealth as a third team member in accordance with COMAR 10.63.03.20 and 10.09.16.05. See transmittal for additional details on eligibility criteria, reimbursement, and enrollment procedures for MCT providers.

SOURCE: MD Medicaid Provider Transmittal No. 78-24, Medicaid Coverage of MCT Services, Jun. 6, 2024. (Accessed Nov. 2024).

Collaborative Care Model (CoCM) Services: HealthChoice and Fee-for-Service

See chart on page 3 of guidance for CoCM Service reimbursement methodology for minimum payment for visits rendered in-person or via telehealth.

SOURCE: MD Medicaid Provider Transmittal No. 71-24, Superseding Guidance – Medicaid Coverage of Collaborative Care Model Services: HealthChoice and Fee-for-Service, Apr. 19, 2024, (Accessed Nov. 2024).

ELIGIBLE PROVIDERS

“Health care provider” means:

A person who is licensed, certified, or otherwise authorized under the Health Occupations Article to provide health care in the ordinary course of business or practice of a profession or in an approved education or training program;
A mental health and substance use disorder program licensed in accordance with § 7.5–401 of this article;
A person licensed under Title 7, Subtitle 9 of this article to provide services to an individual with developmental disability or a recipient of individual support services; or
A provider as defined under § 16–201.4 of this article to provide services to an individual receiving long–term care services.

SOURCE: MD General Health Code 15-141.2(a)(4). (Accessed Nov. 2024).

The Program shall reimburse a health care provider for the diagnosis, consultation, and treatment of a Program recipient for a health care service covered by the Program that can be appropriately provided through telehealth. This subsection does not require the Program to reimburse a health care provider for a health care service delivered in person or through telehealth that is:

Not a covered health care service under the Program; or
Delivered by an out–of–network provider unless the health care service is a self–referred service authorized under the Program.

From July 1, 2021, to June 30, 2025, both inclusive, when appropriately provided through telehealth, the Program shall provide reimbursement on the same basis and the same rate as if the health care service were delivered by the health care provider in person. Reimbursement does not include:

Clinic facility fees unless the health care service is provided by a health care provider not authorized to bill a professional fee separately for the health care service; or
Any room and board fees.

The Department may specify in regulation the types of health care providers eligible to receive reimbursement for health care services provided to Program recipients under this section. If the Department specifies by regulation the types of health care providers eligible to receive reimbursement for health care services provided to Program recipients under this subsection, the regulations shall include all types of health care providers that appropriately provide telehealth services.

The Program or a managed care organization that participates in the Program may not impose as a condition of reimbursement of a covered health care service delivered through telehealth that the health care service be provided by a third–party vendor designated by the Program.

The Department may adopt regulations to carry out this section. The Department shall obtain any federal authority necessary to implement the requirements of this section, including applying to the Centers for Medicare and Medicaid Services for an amendment to any of the State’s § 1115 waivers or the State plan. This section may not be construed to supersede the authority of the Health Services Cost Review Commission to set the appropriate rates for hospitals, including setting the hospital facility fee for hospital–provided telehealth.

SOURCE: MD General Health Code 15-141.2(g-l). (Accessed Nov. 2024).

All distant site providers enrolled in Maryland Medicaid may provide services via telehealth if telehealth is a permitted delivery model within the rendering provider’s scope of practice.

For participants physically located in Maryland, Maryland Health Professional Licensing Boards set licensure requirements. Providers should consult licensing boards (in both originating and distant site states, if applicable) prior to rendering services via telehealth to verify governing authority over licensure, as well as for information about the permitted use of telehealth as a service modality.

Providers delivering services via telehealth must use technology that supports the standard level of care required to deliver the service rendered.

Providers delivering services via telehealth submit claims in the same manner the provider uses for in-person services.

For audio-visual telehealth, services rendered must be performed via technology that is HIPAA compliant and meets Technical Requirements of COMAR 10.09.49.05.

SOURCE: MD Medicaid Synchronous Telehealth Policy Guide, p. 2-3. Updated Aug. 2023. (Accessed Nov. 2024).

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

SOURCE: MD Medical Assistance Program. Professional Services Provider Manual, p. 82. Updated Oct. 2024. (Accessed Nov. 2024).

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

SOURCE: Code of Maryland Admin. Regs. Sec. 10.09.49.04(E). (Accessed Nov. 2024).

Mental Health

Eligible Providers:

Outpatient mental health centers
Telemental health providers who are individual psychiatrists.

Telemental health providers may be private practice, part of a hospital, academic, health or mental health care system. Public Mental Health System (PMHS) approved community-based providers or individual practitioners may engage in agreements with TMH providers for services. Fee-for-service reimbursement shall be at an enhanced rate, as stipulated by the Department, provided all applicable provisions of this chapter are met and funds are available.

SOURCE: Code of Maryland Admin. Regs. Sec. 10.21.30.03 & Sec. 10.21.30.04. (Accessed Nov. 2024).

ELIGIBLE SITES

The Program shall provide health care services appropriately delivered through telehealth to Program recipients regardless of the location of the Program recipient at the time telehealth services are provided and allow a distant site provider to provide health care services to a Program recipient from any location at which the health care services may be appropriately delivered through telehealth.

SOURCE: MD General Health Code 15-141.2(b). (Accessed Nov. 2024).

The originating site may be any secure location, approved by the participant and the provider, for the delivery of services. All distant site providers enrolled in Maryland Medicaid may provide services via telehealth if telehealth is a permitted delivery model within the rendering provider’s scope of practice.

SOURCE: MD Medicaid Synchronous Telehealth Policy Guide, p. 2. Updated Aug. 2023. (Accessed Nov. 2024).

Providers should use the place of service code that would be appropriate as if it were a non-telehealth claim. The distant site should use the location of the doctor. If a distant site provider is rendering services at an off-site office, use place of service office (11). Place of Service Code 02 (Telehealth) is not recognized for Maryland Medicaid participants except for use on Medicare crossover claims to specify services rendered through a telecommunication system for dual eligible participants. Allowable place of service codes should remain unchanged for Medicaid-only claims.

The Program recognizes specific modifiers for certain services rendered via synchronous 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 audio-video telehealth. To bill for audio-only telephonic services, providers must bill for the appropriate service code and use the “-UB” modifier to identify the claim as a telephonically delivered service. Billing with these modifiers will not affect Medicaid reimbursement rates.

SOURCE: MD Medical Assistance Program. Professional Services Provider Manual, p. 25-26, 82. Updated Jan. 2024. (Accessed Nov. 2024).

Maryland Public Behavioral Health System – Deaf or Hard of Hearing

SOURCE: Maryland PBHS Provider Manual (Sept. 2022), p. 35. (Accessed Nov. 2024).

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 Nov. 2024).

Freestanding Clinics

On July 15th, 2024, MDH released clarifying guidance about services rendered via telehealth at freestanding clinics since the end of the COVID-19 public health emergency. The Federal four walls rule does not allow Medicaid to reimburse a freestanding clinic if neither the practitioner nor patient is physically onsite at the clinic. This includes provider types:

Clinic, Local Health Department – PT 35
Clinic, General, PT 38
Clinic, Family Planning – PT 33
Outpatient Mental Health Clinic – PT MC

This does not apply to FQHCs or FQHC-sponsored School-Based Health Centers.

MDH submitted an §1115 waiver amendment for an exemption to the four walls requirement. Pending approval, it would allow clinics to bill telehealth services regardless of whether practitioner or patient is physically onsite at the clinic.

SOURCE: MD Medicaid Telehealth Page; MD Medicaid Provider Transmittal 21-25, Policy Clarification – Four Walls Requirement Termination, Jul. 15, 2024. (Accessed Nov. 2024).

GEOGRAPHIC LIMITS

The Program may not distinguish between Program recipients in rural or urban locations in providing coverage under the Program for health care services delivered through telehealth.

SOURCE: MD General Health Code 15-141.2(f). (Accessed Nov. 2024).

The telehealth care delivery model serves Medicaid participants regardless of geographic location.

SOURCE: MD Medicaid Synchronous Telehealth Policy Guide, p. 1. Updated Aug. 2023. (Accessed Nov. 2024).

Mental Health

To be eligible a beneficiary must reside in one of the designated rural geographic areas or whose situation makes person-to-person psychiatric services unavailable.

SOURCE: Code of Maryland Admin. Regs. Sec. 10.21.30.05(A)(3). (Accessed Nov. 2024).

FACILITY/TRANSMISSION FEE

From July 1, 2021, to June 30, 2025, when appropriately provided through telehealth, the Program shall provide reimbursement in accordance on the same basis and the same rate as if the health care service were delivered by the health care provider in person. Reimbursement does not include:

Clinic facility fees unless the health care service is provided by a health care provider not authorized to bill a professional fee separately for the health care service; or
Any room and board fees.

The Department may adopt regulations to carry out this section.

SOURCE: MD Health General Code 15-141.2 (g)(3),(h). (Accessed Nov. 2024).

A provider eligible to bill a professional fee for a health care service shall bill a professional fee for the health care service instead of a clinic facility fee.

SOURCE: Code of Maryland Admin. 10.09.49.07 (Accessed Nov. 2024).

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. MDH cannot reimburse facility, room, or board charges for telehealth visits unless a professional fee cannot be billed separately.

SOURCE: Maryland Dept. of Health Medical Assistance, UB04 Hospital Billing Instructions, 2/2024, p. 102. (Accessed Nov. 2024).

READ LESS

Massachusetts

Last updated 12/21/2024

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.

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 service delivered via in-person methods; provided, that this subsection shall apply to providers of behavioral health services covered as required under subclause (i) of clause (4) of the second sentence of subsection (a) of section 6 of chapter 176O.

Coverage that reimburses a provider with a global payment, as defined in section 1 of chapter 6D, 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 Dec. 2024).

Telehealth is a modality of treatment, not a separate covered service. Providers are not required to deliver services via telehealth.

The bulletin does not apply to services under the Children’s Behavioral Health Initiative (CBHI) program, which may continue to be delivered via all modalities currently authorized in applicable program specifications.

SOURCE: MassHealth All Provider Bulletin 281, p. 1, Jan. 2019. (Accessed Dec. 2024).

Under this policy, MassHealth will continue to allow MassHealth-enrolled providers to deliver a broad range of MassHealth-covered services via telehealth. MassHealth will reimburse for such services at parity with their in-person counterparts, including services provided through live-video, audio-only, or asynchronous visits that otherwise meet billing criteria, including use of required modifiers. All providers delivering services via telehealth must comply with the policy detailed in this bulletin.

This bulletin applies to members enrolled in MassHealth fee-for-service, the Primary Care Clinician (PCC) Plan, a Managed Care Organization (MCO), an Accountable Care Partnership Plan (ACPP), or a Primary Care Accountable Care Organization (PCACO). Information about coverage through MassHealth Managed Care Entities (MCEs) and the Program for All-inclusive Care for the Elderly (PACE) will be issued in a forthcoming MCE bulletin.

SOURCE: MassHealth All Provider Bulletin 379, Oct. 2023. (Accessed Dec. 2024).

Managed Care Entities:

This bulletin, which supersedes Managed Care Entity Bulletin 95 and will remain in effect until superseding guidance is issued, requires managed care entities to maintain a telehealth policy consistent with All Provider Bulletin 379, including but not limited to maintaining policies for coverage of telehealth services no more restrictive than those described in All Provider Bulletin 379.

SOURCE: MassHealth Managed Care Entity Bulletin 115 [replaced Bulletin 95], Apr. 2024, (Accessed Dec. 2024).

Home Health Agency

Rates of payment for home health services delivered via telehealth will be the same as rates of payment for home health services delivered via traditional (e.g., in-person) methods set forth in 101 CMR 350:00: Rates for Home Health Services.

Home health agencies must include modifier “GT” when submitting claims for services delivered via telehealth.

Failure to include modifier “GT” when submitting claims for services delivered via telehealth may result in sanctions pursuant to 130 CMR 450.238-450.240.

Important note: Although MassHealth allows reimbursement for the delivery of certain home health services via telehealth as described in this bulletin, MassHealth does not require providers to deliver services via telehealth.

SOURCE: MassHealth Home Health Agencies, Bulletin 87, Jul. 2023, (Accessed Dec. 2024).

Therapy

Rehabilitation Center providers must include modifier “GT” when submitting claims for services delivered via telehealth. Rates of payment for therapist services delivered via telehealth will be the same as rates of payment for therapist services delivered via traditional (e.g., in-person) methods set forth in 101 CMR 339.00: Rates for Restorative Services.

Failure to include modifier “GT” when submitting claims for Rehabilitation Center services delivered via telehealth may result in the imposition of sanctions pursuant to 130 CMR 450.238- 450.240. [excluded in Therapist Bulletin 18]

Important note: Although MassHealth allows reimbursement for delivering certain services through telehealth, MassHealth does not require providers to deliver services via telehealth.

STATUS: MassHealth Rehabilitation Center Bulletin 16, Apr. 2023; Therapist Bulletin 18, Apr. 2023; Speech and Hearing Center Bulletin 16, Apr. 2023, (Accessed Dec. 2024).

ELIGIBLE SERVICES/SPECIALTIES

Health Care Services

SOURCE: Massachusetts General Laws, Part I, Title XVII, Ch. 118E, Sec. 79. (Accessed Dec. 2024).

Behavioral Health Services

SOURCE: Massachusetts General Laws, Part I, Title XVII, Ch. 118E, Sec. 79. (Accessed Dec. 2024).

The commission shall ensure that the rate of payment for in-network providers of behavioral health services delivered via interactive audio-video technology and audio-only telephone shall be no less than the rate of payment for the same behavioral health service delivered via in-person methods, provided certain conditions. See statute.

Source: Massachusetts General Laws, Ch. 32A Sec. 30, Ch. 118E Sec. 79, Ch. 175 47MM, Ch. 176A Sec. 38, Ch. 176B Sec. 25, Ch. 176G Sec. 33, Ch. 176I Sec. 13. (Accessed Dec. 2024).

Unlicensed or Not Independently Licensed Staff. All professionals who are unlicensed, who are in a profession without licensure, or who are not independently licensed or certified as a peer supervisor must receive direct and continuous supervision. Direct and continuous supervision may be provided using telehealth technology

Independently Licensed and Certified Peer Supervisor Staff. All independently licensed professionals and certified peer supervisors must receive supervision in accordance with the relevant licensing requirements and program policy. Supervision may be provided using telehealth technology

The MassHealth agency will pay a provider only for a case consultation that involves a personal meeting with a professional of another agency. Personal meetings may be conducted via audio-only telephonic, audio-video, or in person meetings.

SOURCE: MA Regulations 130 CMR Sec. 418.410 and 412, (Accessed Dec. 2024).

Community Health Centers, Community Mental Health Centers, and Outpatient Substance Use Disorder providers (provider types 20, 26 and 28) may deliver the following covered services via telehealth:

All services specified in 101 CMR 306.00 et seq.; and
The outpatient services specified in the following categories:
Opioid Treatment Services: Counseling;
Ambulatory Services: Outpatient Counseling; Clinical Case Management; and
Services for Pregnant/Postpartum Clients: Outpatient Services

SOURCE: MassHealth All Provider Bulletin 281, p. 1, Jan. 2019. (Accessed Dec. 2024).

Mental Health Centers

Satellite Clinics: All clinic locations must meet, independently of its parent clinic, all requirements set forth in 130 CMR 429. Satellite locations must be able offer in person services for up to 20 hours per week; use of telehealth is acceptable when agreed upon by the member.

Case Consultation: intervention, including scheduled audio-only telephonic, audio-video, or in person meetings, for behavioral and medical management purposes on a member’s behalf with agencies, employers, or institutions which may include the preparation of reports of the member’s psychiatric status, history, treatment, or progress (other than for legal purposes) for other physicians, agencies, or insurance carriers.

The MassHealth agency pays only for a case consultation that involves a personal meeting with a professional of another agency. Personal meetings may be conducted via audio-only telephonic, audio-video, or in person meetings.

Staff Supervision:

Unlicensed or Not Independently Licensed Staff: All professionals who are unlicensed, who are in a profession without licensure, or who are not independently licensed or certified as a peer supervisor must receive Direct and Continuous Supervision. Direct and Continuous Supervision may be provided using telehealth technology.
Independently Licensed and Certified Peer Supervisor Staff. All independently licensed professionals and certified peer supervisors must receive supervision in accordance with center policy. Supervision may be provided using telehealth technology.

SOURCE: MassHealth Mental Health Center Manual, Ch. 4, 1/1/23, (Accessed Dec. 2024).

Crisis Intervention: The MassHealth agency pays for crisis intervention as defined in 130 CMR 429.402 … This service is limited to face-to-face contacts, which includes Telehealth, with the member

Group behavioral health, group medical visit, individual behavioral health visits, individual dental visit, individual medical visit, individual mental health visit, nurse-midwife medical visit, can be conducted via a clinically appropriate telehealth modality. See manual for codes.

SOURCE: MassHealth Rates for Community Health Centers, 101 CMR Sec. 304.02 (Accessed Dec. 2024).

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

SOURCE: MassHealth Community Health Center Manual, Ch. 6, 1/1/23, (Accessed Dec. 2024).

CARES Team

The care manager must provide regular contact with the member and their parent/guardian (either face-to-face or by telehealth, in accordance with the preferences of the member and their parent/guardian);

In order to qualify for payment of the monthly fee, the CARES program provider must provide at least two of the CARES program services described in the regulation to that member during that calendar month, with at least one of those services including live interaction between the provider and the member and their parent/guardian, whether in person or via telehealth.

SOURCE: MassHealth Community Health Center Manual, Ch. 6, (7/7/23), (Accessed Dec. 2024).

CARES program providers may deliver services via telehealth.

SOURCE: MassHealth Rates for Community Health Centers, 130 CMR Sec. 405.477 and Sec. 433.485, & Physician Manual, 7/7/23, (Accessed Dec. 2024).

The Community Support Program (CSP) provider delivers CSP services on a mobile basis to members in any setting that is safe for the member and staff. Services may be provided via telehealth, as appropriate.

SOURCE: Massachusetts Regulations, Sec. 130 CMR 461.410, & Community Support Service Manual, 4/28/23, (Accessed Dec. 2024).

Important Note: Although MassHealth allows reimbursement for the delivery of certain services through telehealth for certain billing providers as described in this bulletin, MassHealth does not require providers to deliver services via telehealth.

As under All Provider Bulletin 355, Section B of this bulletin identifies specific categories of service that MassHealth has deemed inappropriate for delivery via any telehealth modality. Except for those services identified in Section B in this bulletin, and notwithstanding any regulation to the contrary, including the physical-presence requirement at 130 CMR 433.403(A)(2), a MassHealth enrolled provider may deliver medically necessary MassHealth-covered services on an outpatient basis to a MassHealth member via the telehealth modalities of audio-only, live video, and asynchronous visits, if:

the provider has determined that it is clinically appropriate to deliver such service via telehealth, including the telehealth modality and technology employed, including obtaining member consent;
such service is payable under that provider type;
the provider satisfies all requirements set forth in this bulletin, including in Appendix A, and any applicable program-specific bulletin;
the provider delivers those services in accordance with all applicable laws and regulations (including M.G.L. c. 118E, § 79 and MassHealth program regulations); and
the provider is appropriately licensed or credentialed to deliver those services.

MassHealth will continue to monitor telehealth’s impacts on quality of care, cost of care, patient and provider experience, and health equity to inform the continued monitoring and iteration of its telehealth policy. Based on the results of this monitoring, and its analysis of relevant data and information, MassHealth may adjust its coverage policy, including by imposing limitations on the use of certain telehealth modalities for various covered services or provider types.

As under All Provider Bulletin 355, MassHealth has deemed these following categories of service ineligible for delivery via any telehealth modality.

Ambulance Services
Ambulatory Surgery Services
Anesthesia Services
Certified Registered Nurse
Anesthetist Services
Chiropractic Services
Hearing Aid Services
Inpatient Hospital Services1
Laboratory Services
Nursing Facility Services
Orthotic Services
Personal Care Services
Prosthetic Services
Renal Dialysis Clinic Services
Surgery Services
Transportation Services
X-Ray/Radiology Services

Telehealth and Children’s Behavioral Health Initiative (CBHI) Services

As under All Provider Bulletin 355, existing performance specifications for Children’s Behavioral Health Initiative (CBHI) services allow for the telephonic delivery of services, other than for initial assessments. Notwithstanding any requirements that initial assessments be conducted in person, where appropriate, services for new clients may be initiated by telephone or other telehealth modality. CBHI providers must use the regular CBHI codes, as well as the POS code and modifiers described above, as appropriate, when billing for CBHI services delivered via approved telehealth modalities.

SOURCE: MassHealth All Provider Bulletin 379, Oct. 2023. (Accessed Dec. 2024).

Continuous Skilled Nursing Agency

Following the end of the FPHE, MassHealth continues to allow telehealth services for face-to-face visits through December 31, 2024.

SOURCE: MassHealth Continuous Skilled Nursing Agencies, Bulletin 12, Jul. 2023, (Accessed Dec. 2024).

Home Health Agency

Effective May 12, 2023, per the Consolidated Appropriations Act of 2023, MassHealth will continue to allow telehealth services for a face-to-face visit through December 31, 2024. The face-to-face visit may only be conducted via two-way audio-video telecommunications technology that allows for real-time interaction.

MassHealth is not imposing specific requirements for technologies used to deliver services via telehealth and will allow reimbursement for MassHealth home health services delivered through telehealth, as long as such services are medically necessary and clinically appropriate and comply with the guidelines established in this bulletin. Providers are encouraged to use appropriate technologies to communicate with individuals and should, to the extent feasible, ensure the same rights to confidentiality and security as provided in face-to-face services. Providers must inform members of any relevant privacy considerations.

Home health telehealth visits may be used for home health services that

the member has provided consent for;
are follow-up visits that do not require any hands-on care;
pertain to any ongoing review of the member’s assessment, including the member’s 60-day recertification for home health services; or
pertain to the discharge visit.

Follow-up visits do not include initial evaluations or certifications for home health services and may be conducted by telephone if appropriate, but live video is preferred.
Home health telehealth visits may not be used for

any service that requires hands-on care;
any start of care (SOC) assessment visit; or
any resumption of care visit.

SOURCE: MassHealth Home Health Agencies, Bulletin 87, Jul. 2023, (Accessed Dec. 2024).

Hospice Agencies

Effective May 12, 2023, consistent with the federal Consolidated Appropriations Act of 2023, MassHealth continued to cover the face-to-face visit required for members entering their third hospice benefit period when appropriately provided via telehealth through December 31, 2024. Under the Consolidated Appropriations Act, the face-to-face visit may only be conducted via two-way audio-video telecommunications technology that allows for real-time interaction. See 130 CMR 437.411(C) for MassHealth’s face-to-face requirement.

SOURCE: MassHealth Hospice Agencies, Bulletin 29, Jul. 2023, (Accessed Dec. 2024).

Adult Foster Care

The Executive Office of Health and Human Services (EOHHS) is not imposing specific requirements for technologies used to deliver services via telehealth and will allow reimbursement for MassHealth-covered AFC/GAFC services delivered via telehealth, as long as such services are medically necessary and clinically appropriate and delivered in accordance with this bulletin. Providers are encouraged to use appropriate technologies to communicate with individuals and should, to the extent feasible, ensure the same rights to confidentiality and security as provided in in-person services. Providers must inform members of any relevant privacy considerations.

EOHHS does not require providers to deliver AFC/GAFC services via telehealth and may continue to provide services in-person as necessary or appropriate. AFC/GAFC providers must clearly document in the member record if the member refuses an in-person visit.

AFC and GAFC providers may use telehealth for

Level I AFC home visit structure – telehealth may be used for up to three nonconsecutive visits in a 12-month period;
Level II AFC home visit structure – telehealth may be used for up to six nonconsecutive visits in a 12-month period;
GAFC home visit structure – telehealth may be used for up to three nonconsecutive visits in a 12-month period;
Level I AFC admission visit – may be done in person/on-site or via telehealth;
Level II AFC admission visits – for the first month of service, the first and last admission visits must be done in person/on-site, the two weekly visits in between may be conducted via telehealth;
GAFC admission visits –for the first month of service, the first and last admission visits must be done in person/on-site, the two weekly visits in between may be conducted via telehealth; and
Extraordinary circumstances resulting from unusual and unavoidable circumstances that substantially impede the ability of the provider to conduct a visit or other AFC/GAFC program requirement in person that can be directly addressed by use of telehealth. This may include, but is not necessarily limited to, staffing shortages due to illness and/or medical leave (such as Family Medical Leave Act absences). In these limited instances, the AFC/GAFC program director must document the approved temporary telehealth use. Further, for each use of telehealth for extraordinary circumstances, the AFC/GAFC provider must document the description of the extraordinary circumstance, the timeframe during which the extraordinary circumstances necessitated the telehealth visits, which types of visits are permitted to be conducted by telehealth, and how the use of telehealth is narrowly tailored to address this extraordinary circumstance. Such documentation must be made available upon request by EOHHS or other appropriate auditor. The AFC/GAFC provider must also document in the relevant member record each visit that occurred via telehealth in accordance with this bulletin. If telehealth use extends past three months, the AFC/GAFC provider must contact MassHealth for approval and must provide a deadline by which the use of telehealth for extraordinary circumstances will conclude. Such use of telehealth to address extraordinary circumstances cannot be used for caregiver or direct care aide assistance with activities of daily living or instrumental activities of daily living, including cueing and supervision of such activities.

Adult foster care and group adult foster care providers may not use telehealth for

Caregiver or direct care aide assistance with activities of daily living or instrumental activities of daily living, including cueing and supervising such activities; and
Initial evaluations and reassessments, including reassessments based on significant change.

AFC/GAFC providers must conduct both initial and annual member home inspections in person/on-site.

STATUS: MassHealth Adult Foster Care, Bulletin 29, Apr. 2023, (Accessed Dec. 2024).

Durable Medical Equipment

Federal regulations require that, for certain DME services, physicians or certain authorized nonphysician practitioners must document a face-to-face meetingwith the Medicaid-eligible beneficiary. See 42 CFR 440.70. Through the end of the FPHE, and as described in 42 CFR 440.70 (f) (6), any required face-to-face meeting may be delivered via telehealth (including telephone and live video)according to the standards in All Provider Bulletin 314.

This is consistent with Centers for Medicare & Medicaid Services (CMS) Interim Final Rules with Comment Period (CMS-1744-IFC (April 6, 2020) and CMS-5531-IFC (May 8, 2020) which provide that the face-to-face meeting requirement does not apply for DME for the duration of the COVID-19 emergency, except for power mobility devices (PMDs) with a statutory requirement for a face-to-face meeting. For those PMDs, a telehealth face-to-face meeting may satisfy the requirement. See CMS COVID-19 Frequently Asked Questions on Medicare Fee-for-Service Billing Question AA.

On May 12, 2023, consistent with 42 CFR 440.70, providers may use telehealth for face-to-face meetings. Providers must follow the federal DME Face-to-Face Requirements identified in 42 CFR 440.70 and maintain the required documentation in the member’s record. See 130 CMR 409.430(C) and DME Bulletin 26. All documentation, recordkeeping, and other applicable provisions of 130 CMR 450.000 and 130 CMR 409.000 apply.

STATUS: MassHealth Durable Medical Equipment, Bulletin 32, Apr. 2023, (Accessed Dec. 2024).

Oxygen and Respiratory Therapy

Federal regulations require that, for certain oxygen services, physicians or certain authorized nonphysician practitioners, must document a face-to-face meeting with the Medicaid-eligible beneficiary. See 42 CFR 440.70. Through the end of the FPHE, and as described in 42 CFR 440.70(f)(6), any required face-to-face meetings may be delivered via telehealth (including telephone and live video) according to the standards in All Provider Bulletin 314.

This is consistent with Centers for Medicare & Medicaid Services (CMS) Interim Final Rules with Comment Period (CMS-1744-IFC (April 6, 2020) and CMS-5531-IFC (May 8, 2020), which provide that the face-to-face meeting requirement does not apply for oxygen and respiratory equipment for the duration of the COVID-19 emergency, except for power mobility devices (PMDs) with a statutory requirement for a face-to-face meeting. For those PMDs, a telehealth face-to-face meeting may satisfy the requirement. See the CMS COVID-19 Frequently Asked Questions on Medicare Fee-for-Service Billing.

On May 12, 2023, consistent with 42 CFR 440.70, providers may use telehealth for face-to-face meetings. Providers must follow the federal oxygen Face-to-Face Requirements identified in 42 CFR 440.70. Providers must also maintain the required documentation in the member’s record. See Oxygen and Respiratory Therapy Equipment Provider Bulletin 17. All documentation, recordkeeping, and other applicable provisions of 130 CMR 450.000 and 130 CMR 427.000 apply.

STATUS: MassHealth Oxygen and Respiratory Therapy, Bulletin 26, Apr. 2023, (Accessed Dec. 2024).

Therapy

After the FPHE ends, consistent with the federal Consolidated Appropriations Act of 2023, MassHealth will continue to cover therapy appropriately provided by telehealth services until December 31, 2024, or when specified by MassHealth via regulation or Congress. See Consolidated Appropriations Act, 2023, H.R.2617, Sec. 4113, 117th Cong. (2022).

Services must meet all requirements under the MassHealth Guidelines for Medical Necessity Determination for Speech and Language Therapy, Physical Therapy, and Occupational Therapy [MassHealth Guidelines for Medical Necessity Determination for Speech and Language Therapy].

MassHealth is not imposing specific requirements for technologies used to deliver services via telehealth and will allow reimbursement for MassHealth therapist services delivered through telehealth, as long as such services

are medically necessary;
are clinically appropriate;
meet requirements within 130 CMR 430.000 [432.00 and 413.000] 130 CMR 450.000; and
meet all additional requirements of the therapy telehealth guidance in this bulletin.

Providers are encouraged to use appropriate technologies to communicate with individuals and should, to the extent possible, ensure the same rights to confidentiality and security as provided in face-to-face services. Providers must inform members of any relevant privacy considerations.

Therapy telehealth visits may be used for therapist services that

require the member’s consent, documented as described below; and
are follow-up visits that do not require any hands-on care.

Follow-up visits do not include evaluations or re-evaluations and may be conducted by telephone if appropriate, but live video is preferred

STATUS: MassHealth Rehabilitation Center Bulletin 16, Apr. 2023; Therapist Bulletin 18, Apr. 2023; Speech and Hearing Center Bulletin 16, Apr. 2023, (Accessed Dec. 2024).

Therapy telehealth visits may not be used for any therapy specifically requiring hands-on care.

STATUS: MassHealth Therapist Bulletin 18, Apr. 2023; (Accessed Dec. 2024).

Community Behavioral Health Center

Several services listed as allowed to be provided via telehealth. Supervision, in some cases, can also be provided using telehealth technology. See manual.

SOURCE: MassHealth Commonwealth of Massachusetts MassHealth Provider Manual Series, Community Behavioral Health Center Manual, 1/1/23, (Accessed Dec. 2024).

Mobile Crisis Intervention: Services may be provided via telehealth.

SOURCE: MA Admin Code Sec. 352.02, (AccessedDec. 2024).

Managed Care Entity and PACE Organizations

Some specialized community support program services are appropriate to deliver via telehealth. See bulletin.

SOURCE: MassHealth Managed Care Entity Bulletin 99, Mar. 2023, (Accessed Dec. 2024).

Community Support Provider

The CSP provider delivers CSP services on a mobile basis to members in any setting that is safe for the member and staff. Services may be provided via telehealth, as appropriate.

SOURCE: MassHealth Commonwealth of Massachusetts MassHealth Provider Manual Series, Community Support Program Services Manual, 4/28/23, (Accessed Dec. 2024).

Continuous Skilled Nursing Agencies

If clinically appropriate, the 14-day RN supervisory visit may be performed using two-way audio-video telecommunications technology that allows for real-time interaction between the RN and the patient, and representative as needed. If a CSN agency determines that a member’s clinical needs require in-person supervision, the RN supervisor must perform the supervisory visit in person and in the member’s home. MassHealth will update the CSN agency provider regulations to reflect this clarification. The 60-day supervisory visits under 130 CMR 438.415(C)(5)(c) cannot be performed using telecommunications technology.

SOURCE: MassHealth Continuous Skilled Nursing Agencies Bulletin 15, Aug. 2023, (Accessed Dec. 2024).

The MassHealth agency pays for medically necessary doula services including perinatal visits and labor and delivery support provided in-person or via telehealth.

SOURCE: MA Admin Code Sec. 463.407, & Doula Services Manual, 12/8/23, (Accessed Dec. 2024).

Psychologists – Case Consultation

The MassHealth agency pays for case consultation delivered in person or via telephonic or audio-visual methods only when written communication alone, and other non-reimbursable forms of communication, clearly will not suffice. Such circumstances must be documented in the member’s record. Such circumstances are limited to situations in which both the provider and the other party are actively involved in treatment or management programs with the member (or family members) and where a lack of direct communication would impede a coordinated treatment program.

The MassHealth agency does not pay the provider for court testimony.

SOURCE: MassHealth Psychologist Manual, Sec. 411.405, (1/1/23), (Accessed Dec. 2024).

Substance Use Disorder Treatment

Telehealth: Telehealth. Services including the prescribing of controlled substances must be in accordance with state and federal regulations.

Case Consultation: intervention, including scheduled audio-only telephonic, audio-video, or in-person meetings, for behavioral and medical management purposes on a member’s behalf with agencies, employers, or institutions which may include the preparation of reports of the member’s psychiatric status, history, treatment, or progress (other than for legal purposes) for other physicians, agencies, or insurance carriers.

The MassHealth agency will pay for case consultation only when written communication, and other non-reimbursable forms of communication clearly, will not suffice. Such circumstances must be documented in the member’s record. Such circumstances are limited to situations in which the program and the other party are actively involved in the treatment or management programs with the member (or family members) and where a lack of face-to-face communication would impede a coordinated treatment program.

Staff Supervision Requirements.

Unlicensed or Not Independently Licensed Staff. All professionals who are unlicensed, who are in a profession without licensure, or who are not independently licensed or certified as a peer supervisor must receive direct and continuous supervision. Direct and continuous supervision may be provided using telehealth technology.
Independently Licensed and Certified Peer Supervisor Staff. All independently licensed professionals and certified peer supervisors must receive supervision in accordance with the relevant licensing requirements and program policy. Supervision may be provided using telehealth technology.

SOURCE: MassHealth Substance Use Disorder Treatment Manual, 418.412, (1/1/23), (Accessed Dec. 2024).

ELIGIBLE PROVIDERS

Coverage shall not be limited to services delivered by third-party providers.

SOURCE: Massachusetts General Laws, Part I, Title XVII, Ch. 118E, Sec. 79. (Accessed Dec. 2024).

Distant site is the site where the practitioner providing the service is located at the time the service is provided via a telehealth system. All applicable licensure and programmatic requirements apply to the delivery of the service. While the distant site must be located in the United States or its territories, there are no additional geographic or facility restrictions on distant sites for services delivered via telehealth in this bulletin.

Consistent with All Provider Bulletin 355 and its predecessor bulletins, MassHealth will reimburse providers delivering any telehealth-eligible covered service via any telehealth modality at parity with its in-person counterpart as above. Likewise, an eligible distant-site provider delivering covered services via telehealth in accordance with this bulletin may bill MassHealth a facility claim if such a fee is allowed under the provider’s governing regulations or contracts.

Providers must include the place of service (POS) code 02 when submitting a professional claim for telehealth provided in a setting other than in the patient’s home. They must include POS code 10 when submitting a professional claim for telehealth provided in the patient’s home. Additionally, for any such professional claim, providers must include:

modifier 95 to indicate counseling and therapy services rendered via audio-video telecommunications;
modifier 93 to indicate services rendered via audio-only telehealth;
modifier FQ to indicate counseling and therapy services provided using audio-only telecommunications;
modifier FR to indicate a supervising practitioner was present through a real-time two-way, audio and video communication technology; and/or
modifier GQ to indicate services rendered via asynchronous telehealth.

Additionally, for any institutional claim, providers are allowed to use the following modifiers:

modifier 95 to indicate counseling and therapy services rendered via audio-video telecommunications;
modifier 93 to indicate services rendered via audio-only telehealth;
modifier GT to indicate services rendered via interactive audio and video telecommunications systems;
modifier FQ to indicate counseling and therapy services provided using audio-only telecommunications;
modifier FR to indicate that a supervising practitioner was present through a real-time two-way, audio and video communication technology; and/or
modifier GQ to indicate services rendered via asynchronous telehealth.

Modifier GT is required on the institutional claim, for the distant-site provider, when there is an accompanying professional claim containing POS 02 or 10.

Effective August 31, 2023, modifier V3, which was previously used to indicate services rendered via audio-only telehealth, will no longer be available. Providers must use modifier 93 in its place.

Billing and Payment Rates for Services

Providers billing under an 837I/UB-04 form must include the modifier GT when submitting claims for services delivered via telehealth. Providers billing under an 837P/1500 form must include the place of service (POS) code 02 or 10 when submitting claims for services delivered via telehealth.

Additionally, for any such professional claim, providers must include:

modifier 95 to indicate counseling and therapy services rendered via audio-video telehealth;
modifier 93 to indicate services rendered via audio-only telehealth;
modifier GQ to indicate services rendered via asynchronous telehealth;
modifier FQ to indicate counseling and therapy services provided using audio-only telecommunications; and/or
modifier FR to indicate a supervising practitioner was present through a real-time two-way, audio and video communication technology.

Rates of payment for services delivered via telehealth will be the same as the rates of payment for services delivered via traditional (i.e., in-person) methods as set forth in the applicable regulations.

Providers may not bill MassHealth a facility claim for originating sites.

SOURCE: MassHealth All Provider Bulletin 379, Oct. 2023. (Accessed Dec. 2024).

Managed Care Entities:

SOURCE: MassHealth Managed Care Entity Bulletin 115, Apr. 2024, (Accessed Dec. 2024).

Synchronous teledentistry code is listed in rule.

SOURCE: MA 101 CMR 314. 05. (Accessed Dec. 2024).

Home Health Agency

MassHealth home health agencies may deliver clinically appropriate, medically necessary MassHealth-covered home health services to MassHealth members via telehealth (including telephone and live video), in accordance with the standards in this bulletin and notwithstanding any regulation to the contrary, including physical presence requirements in 130 CMR 403.000: Home Health Agency. Home health agencies must follow all PA requirements under 130 CMR 403.410: Prior Authorization Requirements and must meet all requirements under the MassHealth Home Health Medical Necessity Guidelines.

SOURCE: MassHealth Home Health Agencies, Bulletin 87, Jul. 2023, (Accessed Dec. 2024).

Adult Foster Care

MassHealth AFC providers and GAFC providers may deliver clinically appropriate, medically necessary MassHealth-covered AFC/GAFC services to eligible MassHealth members via telehealth (including telephone or live video), in accordance with the standards in this bulletin and notwithstanding any regulation to the contrary, including physical presence requirements in regulation at 130 CMR 408.000.

STATUS: MassHealth Adult Foster Care, Bulletin 29, Apr. 2023, (Accessed Dec. 2024).

Clinical Social Worker

The licensed independent clinical social worker may provide therapy in any suitable location, such as an office, the member’s place of residence, other facility, or by telehealth.

SOURCE: Commonwealth of Massachusetts MassHealth Provider Manual Series, Licensed Independent Clinical Social Worker Manual, 1/1/23, p. 4, (Accessed Dec. 2024).

ELIGIBLE SITES

Originating site is the location of the member at the time the service is being provided. While the originating site must be located in the United States or its territories, there are no additional geographic or facility restrictions on originating sites in this bulletin. A member may receive telehealth services while located within their own home, or any other appropriate site, provided that the provider complies with all applicable laws and regulations, including those related to privacy and data security.

modifier 95 to indicate counseling and therapy services rendered via audio-video telecommunications;
modifier 93 to indicate services rendered via audio-only telehealth;
modifier FQ to indicate counseling and therapy services provided using audio-only telecommunications;
modifier FR to indicate a supervising practitioner was present through a real-time two-way, audio and video communication technology; and/or
modifier GQ to indicate services rendered via asynchronous telehealth.

Additionally, for any institutional claim, providers are allowed to use the following modifiers:

modifier 95 to indicate counseling and therapy services rendered via audio-video telecommunications;
modifier 93 to indicate services rendered via audio-only telehealth;
modifier GT to indicate services rendered via interactive audio and video telecommunications systems;
modifier FQ to indicate counseling and therapy services provided using audio-only telecommunications;
modifier FR to indicate that a supervising practitioner was present through a real-time two-way, audio and video communication technology; and/or
modifier GQ to indicate services rendered via asynchronous telehealth.

Modifier GT is required on the institutional claim, for the distant-site provider, when there is an accompanying professional claim containing POS 02 or 10.

Effective August 31, 2023, modifier V3, which was previously used to indicate services rendered via audio-only telehealth, will no longer be available. Providers must use modifier 93 in its place.

SOURCE: MassHealth All Provider Bulletin 379, Oct. 2023. (Accessed Dec. 2024).

A health care provider shall not be required to document a barrier to an in-person visit nor shall the type of setting where telehealth services are provided be limited for health care services provided via telehealth; provided, however, that a patient may decline receiving services via telehealth in order to receive in-person services.

SOURCE: Massachusetts General Laws, Part I, Title XVII, Ch. 118E, Sec. 79. (Accessed Dec. 2024).

Psychologists

The MassHealth agency pays for medically necessary services provided in any suitable location, such as the psychologist’s office, the member’s place of residence, other facility, or by telehealth.

SOURCE: MassHealth Psychologist Manual, Sec. 411.405, (1/1/23), (Accessed Dec. 2024).

GEOGRAPHIC LIMITS

SOURCE: MassHealth All Provider Bulletin 379, Oct. 2023. (Accessed Dec. 2024).

SOURCE: Massachusetts General Laws, Part I, Title XVII, Ch. 118E, Sec. 79. (Accessed Dec. 2024).

FACILITY/TRANSMISSION FEE

Providers may not bill MassHealth a facility claim for originating sites.

SOURCE: MassHealth All Provider Bulletin 379, Oct. 2023. (Accessed Dec. 2024).

READ LESS

Michigan

Last updated 12/22/2024

POLICY

Beginning October 1, 2020, telemedicine services are covered under …

POLICY

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. Beginning the effective date of the amendatory act that added subsection (7), telemedicine services are also covered under the medical assistance program and Healthy Michigan program if those services are provided at, or contracted through, a distant site allowed in the Medicaid provider manual.

Telemedicine services are covered both when a distant provider’s synchronous interactions occur using an audio and video electronic media or when using an audio-only electronic media.

The medical assistance program and Healthy Michigan program shall not do any of the following:

Impose quantity or dollar amount maximums or limitations for services delivered using telemedicine that are more restrictive than those imposed on comparable in-person services.
Reimburse distant providers for telemedicine services at a lower rate than comparable services rendered in person, except when reimbursing a provider who exclusively provides telemedicine services.
Impose specific requirements or limitations on the technologies used to deliver telemedicine services, unless necessary to ensure the safety of a recipient, and the technology is compliant with requirements of the health insurance portability and accountability act of 1996, Public Law 104-191.
Impose additional certification, location, or training requirements on health care professionals who are distant providers as a condition of reimbursing the distant provider for telemedicine services.
Require a recipient to use telemedicine services in lieu of in-person consultation or contact.

Reimbursement for telemedicine services authorized under this section is contingent upon the availability of federal financial participation for those services in the medical assistance program and the Healthy Michigan program.

The department must seek any necessary waiver or state plan amendment from the United States Department of Health and Human Services to implement the provisions of this section.

Telemedicine services authorized under this section must be incorporated in rate development for any managed care program that is implemented in the medical assistance program and the Healthy Michigan program subject to federal actuarial soundness requirements.

SOURCE: MI Compiled Laws Sec. 400.105h as amended by HB 4213 and HB 4580. (Accessed Dec. 2024).

The Michigan Department of Health and Human Services (MDHHS) covers both synchronous (real-time interactions) and asynchronous (over separate periods of time) telemedicine services. MDHHS requires that all telemedicine policy provisions within this policy and other current policy are established and maintained within all telemedicine services.

Recognizing that telemedicine can never fully replace in-person care, MDHHS has established the following principles to be used by MDHHS-enrolled providers during the provision of telemedicine services:

Effectual services – a service provided via telemedicine should be as effective as its in-person equivalent, ensuring convenient and high-quality care.
Improved and appropriate access – the right visit, for the right beneficiary, at the right time by minimizing the impact of barriers to care, such as transportation needs or availability of specialty providers in rural areas.
Appropriate beneficiary choice – the beneficiary is an active participant in the decision for telemedicine as a means for service delivery as appropriate (e.g., Does the beneficiary prefer telemedicine to an in-person visit? What is the optimal combination of ongoing service delivery for the individual? etc.).
Appropriate utilization – ensure providers are utilizing telemedicine appropriately and that items listed above are taken into consideration when offering these services.
Value considerations – telemedicine visits should yield the desired outcomes and quality measures; health outcomes should be improving and remain consistent with in-person care at a minimum.
Privacy and security measures – providers must ensure the privacy of the beneficiary and the security of any information shared via telemedicine in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and other privacy/security regulations as applicable.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2146-2147, Oct. 1, 2024 & MI Dept. of Health and Human Services., Bulletin 23-10, Telemedicine Policy Post-COVID PHE, Mar. 2, 2023. (Accessed Dec. 2024).

The reimbursement rate for allowable telemedicine services will be the same (also known as “at parity”) as in-person services. This means that all providers will be paid the equivalent amount, no matter the physical location of the beneficiary during the visit. To effectuate this policy, the provider must report the place of service as they would if they were providing the service in-person. See the “Telemedicine Billing Requirements” section of this policy for further details.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2152 Oct. 1, 2024 & MI Dept. of Health and Human Services., Bulletin 23-10, Telemedicine Policy Post-COVID PHE, Mar. 2, 2023, (Accessed Dec. 2024).

ELIGIBLE SERVICES/SPECIALTIES

The medical assistance program and Healthy Michigan program must include an extensive set of the programs’ services and benefits as covered telemedicine services including, at a minimum, medical, dental, behavioral, and substance use disorder services.

The department must seek any necessary waiver or state plan amendment from the United States Department of Health and Human Services to implement the provisions of this section.

SOURCE: MI Compiled Laws Sec. 400.105h as amended by HB 4213 and HB 4580. (Accessed Dec. 2024).

Telemedicine must only be utilized when there is a clinical benefit to the beneficiary. Examples of clinical benefit include:

Ability to diagnose a medical condition in a beneficiary population without access to clinically appropriate in-person diagnostic services.
Treatment option for a beneficiary population without access to clinically appropriate in-person treatment options.
Decreased rate of subsequent diagnostic or therapeutic interventions (for example, due to reduced rate of recurrence of the disease process).
Decreased number of future hospitalizations or physician visits.
More rapid beneficial resolution of the disease process treatment.
Decreased pain, bleeding, or another quantifiable symptom.

Furthermore, telemedicine must only be utilized when the beneficiary’s goals for the visit can be adequately accomplished, there exists reasonable certainty of the beneficiary’s ability to effectively utilize the technology, and the beneficiary’s comfort with the nature of the visit is ensured. Telemedicine must be used as appropriate regarding the best interests/preferences of the beneficiary and not merely for provider ease. Appropriate guidance must be provided to the beneficiary to ensure they are prepared and understand all steps to effectively utilize the technology prior to the first visit. Beneficiary consent must be obtained prior to service provision (see policy for “Consent for Telemedicine Services” for further information).

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2147 Oct. 1, 2024 & MI Dept. of Health and Human Services., Bulletin 23-10, Telemedicine Policy Post-COVID PHE, Mar. 2, 2023 (Accessed Dec. 2024).

In-person visits remain the preferred method of service delivery for most healthcare services; however, in cases where this option is not available or in-person services are not ideal or are challenging for the beneficiary, telemedicine may be used as a complement to in-person services. Applicable beneficiary records must contain documentation regarding the reason for the use of telemedicine and the steps taken to ensure the beneficiary was provided utilization guidance in an appropriate manner.

In special situations, depending upon the needs of the beneficiary, providers may opt to deliver the majority of or all services for a specific condition via telemedicine. If this situation occurs, it must be documented in the beneficiary’s record or in their individual plan of service (IPOS). This situation should be the exception, not the norm. (Refer to the program-specific subsections of this policy for specific guidance regarding this benefit.)

All services provided via telemedicine must meet all the quality and specifications as would be if performed in-person. Furthermore, if while participating in the visit the desired goals of the beneficiary and/or the provider are not being accomplished, either party must be provided the opportunity to stop the visit and schedule an in-person visit instead (refer to “Contingency Planning” for such instances). This follow-up visit must be provided within a reasonable time and be as easy as possible to schedule.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2147-2148 Oct. 1, 2024, & MI Medicaid Policy Bulletin MMP 24-06, Apr. 1, 2024, (Accessed Dec. 2024).

When referenced within MDHHS Telemedicine Policy, face-to-face refers to either an in-person visit or a visit performed via simultaneous audio/visual technology.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2149 Oct. 1, 2024, (Accessed Dec. 2024).

All telemedicine visits are required to ascribe to correct coding requirements equivalent to in-person services, including ensuring that all aspects of the code billed are performed during the visit.

Allowable telemedicine services for synchronous telemedicine are listed on the telemedicine fee schedules which can be accessed on the MDHHS website.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2152 Oct. 1, 2024, (Accessed Dec. 2024).

For End Stage Renal Disease (ESRD), MDHHS aligns with Medicare policy regarding the delivery of telemedicine and frequency of in-person services.

For PIHP/CMHSP service providers where in-person visits are required, the telemedicine service may be used in addition to the required in-person visit but cannot be used as a substitute. Refer to the MDHHS Bureau of Specialty Behavioral Health Services Telemedicine Database for services allowed via telemedicine. (Refer to the Directory Appendix for website information.)

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2153 Oct. 1, 2024 & MI Dept. of Health and Human Services., Bulletin 23-10, Telemedicine Policy Post-COVID PHE, Mar. 2, 2023 (Accessed Dec. 2024).

Listed 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 Dec. 2024).

For behavioral and physical health services provided through managed care or the fee-for-service program, the department shall require, for the nonfacility component of the reimbursement rate, at least the same reimbursement for that service, if that service is provided through telemedicine, as if the service involved face-to-face contact between the health care professional and the patient.

SOURCE: Senate Bill 747, (Accessed Dec. 2024).

Professional Providers

Procedure code and modifier information for all telemedicine services is contained in the MDHHS Telemedicine Services Databases available on the MDHHS website. (Refer to the Directory Appendix for website information.)

Appropriate telemedicine modifiers must be used in conjunction with the appropriate CPT/HCPCS procedure code to identify the professional telemedicine services provided by the distant site provider.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 274, Oct. 1, 2024 (Accessed Dec. 2024).

Child Therapy

Telemedicine is approved for Individual Therapy or Family Therapy using approved children’s evidence based practices (i.e., Trauma Focused Cognitive Behavioral Therapy, Parent Management TrainingOregon, Parenting Through Change) and utilizes the GT modifier when reporting the service. Qualified providers of children’s evidence-based practices have completed their training in the model, its implementation via telehealth, and are able to provide the practice with fidelity.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 353 Oct. 1, 2024 (Accessed Dec. 2024).

Behavioral Health

Behavioral health services may be delivered via telemedicine in accordance with current Medicaid policy. In compliance with the Michigan Insurance Code of 1956 (Act 218 of 1956), telemedicine services must be provided by a health care professional who is licensed, registered, or otherwise authorized to engage in his or her health care profession in the state where the patient is located.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 559 Oct. 1, 2024 (Accessed Dec. 2024).

Brain Injury – Referral and Admission Process

When appropriate, the evaluation may occur through telecommunication technology (telemedicine). MDHHS requires a real-time interactive system at both the originating and distant sites, allowing instantaneous interaction between the patient and the health care professional via the telecommunication system. Telemedicine should be used primarily when travel is prohibitive for the beneficiary. Providers must ensure the privacy of the beneficiary and the security of any information shared via telemedicine.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 566 Oct. 1, 2024 (Accessed Dec. 2024).

Children’s Special Health Care Services

The primary CSHCS benefits may include: …

Telemedicine

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 602 Oct. 1, 2024 (Accessed Dec. 2024).

Doula Services

It is the expectation that doula services be provided face-to-face with the beneficiary. Prenatal and postpartum services may be delivered via telehealth. Doula providers will be expected to adhere to current MDHHS telemedicine policy.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 707 Oct. 1, 2024 (Accessed Dec. 2024).

Home and Community Based Services

The HCBS Final Rule includes the following: …

Provides requirements for independent assessment. This is a face-to-face assessment, conducted by a conflict-free individual or agency. The assessment is based on the individual’s needs and strengths and is part of the person-centered planning process. Telemedicine is an acceptable method of assessment.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 862, Oct. 1, 2024, (Accessed Dec. 2024).

Laboratory – Provider Evaluation

The consultation must be documented in the beneficiary’s medical record and, if performed via telemedicine, should follow all the requirements specified in Medicaid’s telemedicine policy.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 1116 Oct. 1, 2024 (Accessed Dec. 2024).

Maternal Infant Health Program

MIHP agencies may conduct initial assessment visits and professional visits via telehealth. Agencies will be allowed to provide a maximum of up to 40 percent of their total caseload of visits as telehealth, while 60 percent of visits must remain as in-person visits. This percentage is applied to the agency and not per beneficiary to allow for telehealth visit flexibility dependent on beneficiary needs.

Telehealth visits must include a dual audio/visual platform. Providers must ensure the privacy of the beneficiary and the security of any information shared via telehealth. MDHHS requires either direct or indirect beneficiary consent for all services provided via telehealth. This consent must be properly documented in the beneficiary’s chart in accordance with applicable standards of practice. Telehealth visits must follow policy guidelines and program requirements for typical MIHP initial assessment and professional visits.

Appropriate use of telehealth will be determined by a combination of beneficiary preference and MIHP provider judgement. Examples of when telehealth is an appropriate option may include, but are not limited to, circumstances such as when a beneficiary:

Refuses an in-person visit and would benefit from receiving MIHP services,
Has an illness in their household, or
Needs to share sensitive information that cannot be discussed in the home environment and a transportation barrier exists for an office visit.

Inappropriate use of telehealth may include, but is not limited to, circumstances such as when a beneficiary has no barrier for an in-person visit and does not request a telehealth visit.

Telehealth visits that occur via telephone-only are allowable only when a beneficiary barrier exists for use of an audio/visual platform (e.g., lack of smart phone or internet access). Documentation in the beneficiary’s chart must include the reason for a telephone-only visit.

MIHP providers are required to follow current Medicaid telemedicine policy requirements as applicable.

SOURCE: MI Medicaid Policy Bulletin, MMP 23-17, Apr. 10, 2023, & MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 1148-1149 Oct. 1, 2024 (Accessed Dec. 2024).

All audio-visual MIHP telehealth services must be reported with:

Modifier 95 for audio-visual services.
Report the place of service (POS) code that would be reported as if the beneficiary were in person for the visit (e.g., home or office)

See bulletin for recently added covered services and services that may be billed via telemedicine.

SOURCE: MI Medicaid Policy Bulletin, MMP 24-36, Sept. 9, 2024 – effective Oct. 1, 2024. (Accessed Dec. 2024).

Medical Supplier – Face-to-Face (F2F) Visit Requirement

Prior to the initial written order and delivery of selected durable medical equipment and medical supplies (some accessories), the beneficiary must have a face-to-face visit with a physician or NPP within six months prior to the initial written order. The visit must be related to the primary condition that supports the medical need for the equipment or supply. Telemedicine visits (refer to the Telemedicine Chapter) qualify as face-to-face visits.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 1190 Oct. 1, 2024, (Accessed Dec. 2024).

Practitioner – CoCM Services

CoCM services must include:

Initial assessment: Visit occurring either in-person or via audio-visual telemedicine in which the beneficiary sets goals and is screened by a diagnosis-appropriate and consistent validated clinical rating scale, such as the PHQ-9 or GAD-7, which also must be done prior to subsequent CoCM services.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 1924 Oct. 1, 2024, (Accessed Dec. 2024).

PIHP/CMHSP

The MDHHS Bureau of Specialty Behavioral Health Services requires all the requirements of Telemedicine policy are attained and maintained during all beneficiary visits. In addition to the Determination of Appropriateness/Documentation section of this policy, the Bureau of Specialty Behavioral Health Services would like to reiterate that services delivered to the beneficiary via telemedicine be done at the convenience of the beneficiary, not the convenience of the provider. In addition, these services must be a part of the person-centered plan of service and available as a choice, not a requirement, to the beneficiary.

If the individual (beneficiary) is not able to communicate effectively or independently, they must be provided appropriate on-site support from natural supports or staff. This includes the appropriate support necessary to participate in assessments, services, and treatment.

The PIHP/CMHSP must guarantee the individual is not being influenced or prompted by others when utilizing telemedicine.

Use of telemedicine should ensure and promote community integration and prevent isolation of the beneficiary. Evidence-based practice policies must be followed as appropriate for all services. For services within the community, in-person interactions must be prioritized.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2155 Oct. 1, 2024 & MI Dept. of Health and Human Services., Bulletin 23-10, Telemedicine Policy Post-COVID PHE, Mar. 2, 2023, (Accessed Dec. 2024).

PIHP Telemedicine

The following requirements apply to the child/youth and their parents/primary caregivers. Professional and natural supports may join Child and Family Team meetings either in-person or via simultaneous audio/visual telemedicine during all phases, according to the preference of the child/youth and their parents/primary caregivers.

All Child and Family Team meetings are to be provided in-person during the Hello and Help phases.

Child and Family Team meetings may be provided either in-person or via simultaneous audio/visual telemedicine during the Heal and Hope phases, according to the preference of the child/youth and their parents/primary caregivers, with the following exceptions:

Development of the transition plan (Hope phase) is to be completed in-person.
Graduation activities (Hope phase) are to be completed in-person.
Child and Family Team meetings are to be provided in-person for the first 60 days upon a child/youth transitioning back to their home and community from out-of-home placement.
In-person Child and Family Team meetings are to be provided once per month, at minimum, for children/youth served under the SEDW during both the Heal and Hope phases.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 373 Oct. 1, 2024, (Accessed Dec. 2024).

Physical Therapy, Occupational Therapy and Speech Therapy Services

MDHHS will allow select therapy services to be provided via telemedicine when performed by Medicaid enrolled private practice and outpatient hospital physical therapy (PT), occupational therapy (OT) and speech therapy (ST) providers. PT, OT and ST services allowed via telemedicine will be represented by applicable CPT/HCPCS codes on the telemedicine fee schedule. Therapy services provided via telemedicine are intended to be an additional treatment tool and complement in-person services where clinically appropriate for the individual beneficiary.

Documentation re-evaluation, performance, and treatment elements that typically require hands-on contact for measurement or assessment must include a thorough description of how the assessment or performance findings were established via telemedicine. This includes, but is not limited to, such elements as standardized tests, strength, range of motion, and muscle tone.

Initial PT and OT evaluations and oral motor/swallowing services are not allowed via telemedicine and should be provided in-person.

Services that require utilization of equipment during treatment and/or physical hands-on interaction with the beneficiary cannot be provided via telemedicine.

Therapy re-evaluations performed via telemedicine must be provided by a therapist whose facility/clinic has previously evaluated and/or treated the beneficiary in-person.

Durable Medical Equipment (DME) re-assessments performed via telemedicine must be provided by a therapist who has previously evaluated and/or treated the beneficiary in-person, otherwise an in-person visit is required.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2156 Oct. 1, 2024 & MI Dept. of Health and Human Services., Bulletin 23-10, Telemedicine Policy Post-COVID PHE, Mar. 2, 2023, (Accessed Dec.. 2024).

Audiology Services

MDHHS will allow speech therapy, auditory rehabilitation, select hearing device adjustments, programming, device performance evaluations, and education or counseling to be performed via telemedicine (simultaneous audio/visual). Remote device programming must be provided in compliance with current U.S. Food and Drug Administration (FDA) guidelines. Auditory brainstem response (ABR) and auditory evoked potential (AEP) testing may also be conducted via telemedicine when performed using remote technology located at a coordinating clinical site with appropriately trained staff (i.e., mobile unit, office/clinic, or hospital).

Reimbursable procedure codes are limited to the specific set of audiology codes listed in the telemedicine fee schedule. Audiology services provided via telemedicine are intended to be an additional treatment tool and complement in-person services where clinically appropriate.

Audiological diagnostic tests (other than those mentioned above), hearing aid examinations, surgical device candidacy evaluations, and other audiology and hearing aid services conducted via telemedicine are not reimbursable by Michigan Medicaid and should be provided in-person.

This policy supplements the existing audiology, hearing aid dealer and speech therapy services policies. All current referral, PA, documentation requirements, standards of care, and limitations remain in effect regardless of whether the service is provided through telemedicine. Providers should refer to the Hearing Services chapter of this Manual for complete information.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2157 Oct. 1, 2024 & MI Dept. of Health and Human Services., Bulletin 23-10, Telemedicine Policy Post-COVID PHE, Mar. 2, 2023, (Accessed Dec. 2024).

Dentistry

Services delivered to the beneficiary via telemedicine must be done for the convenience of the beneficiary, not the convenience of the provider. Services must be performed using simultaneous audio/visual capabilities. All services using telemedicine must be documented in the beneficiary’s record, including the date, time, and duration of the encounter, and any pertinent clinical documentation required per CDT code description. The provider is responsible for ensuring the safety and quality of services provided with telemedicine technologies.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2157-2158 Oct. 1, 2024 & MI Dept. of Health and Human Services., Bulletin 23-10, Telemedicine Policy Post-COVID PHE, Mar. 2, 2023, (Accessed Dec. 2024).

School Services Program (SSP)

Billing and reimbursement for telemedicine services are accomplished using the same methodology as other services; however, the service must be billed using POS 03—school and modifier 95 or modifier 93. Telemedicine claims for SSP are paid according to the Centers for Medicare & Medicaid Services (CMS) approved cost-based methodology used for other services provided within the program and not the information provided previously in this policy. SSP providers are not eligible for the facility fee as the facility is an integral part of the service provided and is covered under the service claim. A database of allowable telemedicine services for SSP can be found on the MDHHS website. (Refer to the Directory Appendix for website information.)

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2158 Oct. 1, 2024, & MI Dept. of Health and Human Services., Bulletin 23-10, Telemedicine Policy Post-COVID PHE, Mar. 2, 2023, (Accessed Dec. 2024).

School Services Program (SSP) PT and OT services, as outlined in this policy, will also be allowed via telemedicine. These services must meet all other telemedicine policies as outlined.

SOURCE: MI Dept. of Health and Human Services., Bulletin 23-10, Telemedicine Policy Post-COVID PHE, Mar. 2, 2023, & MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2157 Oct. 1, 2024 (Accessed Dec. 2024).

FQHCs and RHCs

Claims for telemedicine services must be submitted using the ASC X 12N 837 5010 form using the appropriate telemedicine HCPCS or CPT code. All telemedicine claims must include the corresponding modifier 95- “Synchronous Telemedicine Service rendered via a real-time interactive audio and video telecommunications system” or 93 – “Synchronous Telemedicine Service rendered via telephone or other real-time interactive audio-only telecommunications system” and the appropriate revenue code.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2159 Oct. 1, 2024 (Accessed Dec. 2024).

Clinics are also permitted to submit for reimbursement telemedicine services (using simultaneous audio/visual technologies) per bulletin MSA 20-09 if all other provisions of telemedicine policy are maintained. Simultaneous audio/visual telemedicine services, as indicated by CPT/HCPCS codes listed on the telemedicine fee schedule and considered qualifying visits, will also be considered face-to-face and will trigger the PPS/AIR if the service billed is listed as a qualifying visit.

Center (THC)/ Tribal Federally Qualified Health Centers (Tribal FQHC) Considerations – PT, OT and ST, when provided in accordance with this policy using both audio/visual modalities, will be considered face-to-face and will trigger the PPS AIR if the service billed is listed as a qualifying visit.

For FQHCs, RHCs, THCs and Tribal FQHCs, the appropriate CPT/HCPCS code, PPS/AIR payment code (if the service generates a Qualifying Visit), and modifier 95 – synchronous telemedicine must be used. Refer to www.michigan.gov/medicaidproviders >> Provider Specific Information for additional information.

SOURCE: MI Dept. of Health and Human Services., Bulletin 23-10, Telemedicine Policy Post-COVID PHE, Mar. 2, 2023, (Accessed Dec. 2024).

Healthy Michigan Plan – Diabetes Prevention Program (MiDPP)

Sessions may take place in the following modalities and make-up sessions are encouraged:

In-person
Distance Learning (synchronous audio-visual or audio-only telemedicine): Lifestyle coaches deliver sessions where the coach is present in one location and participants are participating from another location. Claims for an audio-only session must include the appropriate procedure code, place of service code and modifier 93 and claims for an audio-visual session must include the appropriate
procedure code, place of service code and modifier 95.
Online: An asynchronous mode of delivery where participants log into course sessions via a computer, tablet, or smart phone. Per CDC requirements, MiDPP lifestyle coach interaction (in person or via synchronous telemedicine) is required and must be no less than once per week during the first six months and once per month during the second six months.

When billing for a telemedicine session, synchronous or asynchronous, MiDPP providers are expected to adhere to current MDHHS telemedicine policy and modifiers. Refer to the Michigan Medicaid Telemedicine Fee schedule for the list of current codes acceptable for MiDPP telemedicine claims. Claims for an asynchronous session must include the appropriate procedure code and the following remark: “Service provided via an asynchronous telemedicine platform”.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2123 Oct. 1, 2024 & MI Bulletin MMP 23-33, Michigan Diabetes Prevention Program (MiDPP), July 1, 2023, (Accessed Dec. 2024).

Psychiatric Residential Treatment Facilities (PRTF)

The Prepaid Inpatient Health Plan (PIHP) is responsible for managing Medicaid mental health services for all Medicaid beneficiaries residing within the service area covered by the PIHP. This includes the responsibility for timely screening, referral and certification of requests for admission to, PRTF services, defined as follows:

Screening means the PIHP has been notified of the youth and has been provided enough information to support a referral to a PRTF based on the admission criteria established below. The screening may be provided on-site, face-to-face by PIHP personnel, the telephone or via a video conference platform.
Certification means the PIHP has screened the youth and has documented that the services requested seem appropriate. Telephone screening must be followed by the written certification.

SOURCE: MI Bulletin MMP 23-39, Psychiatric Residential Treatment Facilities (PRTF), July 1, 2023, (Accessed Dec. 2024).

Dialysis

MDHHS follows the Medicare billing guidelines for hemodialysis and peritoneal dialysis for both in-person and telemedicine visits.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 990 Oct. 1, 2024, (Accessed Dec. 2024).

Targeted Case Management Services for Recently Incarcerated Beneficiaries

Accessing Services Via In-Reach – The in-reach visit is to be provided face-to-face. Face-to-face is defined as either in-person or via telehealth (i.e., simultaneous audio and visual technology).

SOURCE: MI Bulletin MMP 23-37, Targeted Case Management Services for Recently Incarcerated Beneficiaries, Oct 1, 2023, (Accessed Dec. 2024).

Practitioner

Covered Supports and Services:

A face-to-face encounter, provided in-person or via simultaneous audiovisual technology, with the beneficiary lasting a minimum of 30 minutes.

SOURCE: MI Dept. of Health and Human Services., Bulletin 24-57, Medicaid, Healthy Michigan Plan, Children’s Special Health Care Services, Children’s Waiver, Maternity Outpatient Medical Services, MI Choice Waiver, Nov. 27, 2024, (Accessed Dec. 2024).

Intensive Care Coordination with Wraparound (ICCW)

Frequency and scope (face-to-face and telephone) of other ICCW monitoring activities must reflect the intensity of the child, youth or young adult’s health and welfare needs.

The following requirements apply to the child, youth, or young adult and their parents/primary caregivers. Professional and natural supports may join Team Meetings either in-person or via simultaneous audio/visual telemedicine during all phases, according to the preference of the child, youth, or young adult and their parents/primary caregivers.

Team Meetings may be provided either in-person or via simultaneous audio/visual telemedicine during the Heal and Hope phases, according to the preference of the child, youth, or young adult and their parents/primary caregivers (see bulletin for exceptions).

SOURCE: MI Dept. of Health and Human Services., Bulletin 24-41, Establishment of Intensive Care Coordination with Wraparound (ICCW), Aug. 30, 2024, (Accessed Dec. 2024).

ELIGIBLE PROVIDERS

The medical assistance program and Healthy Michigan program must authorize as many types of providers as appropriate per scope of practice to effectively render telemedicine services.

Telemedicine services are covered both when a distant provider’s synchronous interactions occur using an audio and video electronic media or when using an audio-only electronic media.

The distant provider or organization is responsible for verifying a recipient’s identification and program eligibility.

The distant provider or organization must ensure that the information is available to the primary care provider.

The distant provider must encourage the recipient to proceed with the telemedicine service only if the recipient is in a safe and private environment.

The distant provider must follow generally accepted clinical practice guidelines and ensure the clinical appropriateness and effectiveness of services delivered using telemedicine.

A telemedicine service is an allowable encounter for a federally qualified health center, rural health clinic, or tribal health center in the medical assistance program or Healthy Michigan program.

SOURCE: MI Compiled Laws Sec. 400.105h as amended by HB 4213 and HB 4580. (Accessed Dec. 2024).

In alignment with the Michigan Insurance Code of 1956 (Act 218 of 1956), telemedicine services must be provided by a health care professional who is licensed, registered, or otherwise authorized to engage in their health care profession in the state where the beneficiary is located. The provider at the distant site who is licensed under State law to furnish a covered telemedicine service (as described in telemedicine policy) may bill, and receive payment for, the service when it is delivered via a telecommunications system.

Telemedicine providers must be enrolled in Michigan Medicaid and must have the ability to refer the beneficiary to another provider of the same type or specialty who can see the beneficiary in-person when necessary. If rendering services within a managed care plan, providers must refer beneficiaries to resources within the plan for additional services as needed.

See out of state providers section for information on providers licensed out of state or through PSYPACT.

Telemedicine providers who do not have a physical location for treatment, but are Michigan licensed and meet all other Medicaid enrollment requirements, are considered “virtual-only”, and are permitted to render services for Michigan Medicaid-enrolled beneficiaries.

Virtual-only providers not associated to a Michigan billing provider within the Community Health Automated Medicaid Processing System (CHAMPS) will be subject to out-of-state provider PA requirements. Providers should refer to the Out-of-State/Beyond Borderland Providers subsection in the General Information for Providers chapter of the MDHHS Medicaid Provider Manual for situations where PA could be approved.

Virtual-only providers must report Place of Service (POS) 02 or 10 along with the appropriate modifier when submitting claims/encounters for telemedicine.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2145-2146 Oct. 1, 2024 & MI Medicaid Policy Bulletin MMP 24-06, Apr. 1, 2024, (Accessed Dec. 2024).

Distant site is defined as the location of the provider providing the professional service at the time of the telemedicine visit. This definition encompasses the provider’s office, or any established site considered appropriate by the provider, so long as the privacy of the beneficiary and security of the information shared during the telemedicine visit are maintained.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2149, Oct. 1, 2024 (Accessed Dec. 2024).

Assertive Community Treatment Program

Typically, although not exclusively, physician activities may include team meetings, beneficiary appointments during regular office hours, psychiatric evaluations, psychiatric meetings/consultations, medication reviews, home visits, telephone consultations and telemedicine. The physician (MD or DO) must possess a valid license to practice medicine in Michigan, a Michigan Controlled Substance License, and a Drug Enforcement Administration (DEA) registration.

Typically, although not exclusively, physician assistant activities may include team meetings, beneficiary appointments during regular office hours, evaluations, psychiatric meetings/consultations, medication reviews, home visits, telephone consultations and telemedicine.

Typically, although not exclusively, nurse practitioner/clinical nurse specialist activities may include team meetings, beneficiary appointments during regular office hours, evaluations, psychiatric meetings/consultations, medication reviews, home visits, telephone consultations and telemedicine.

The telemedicine modifier must be used in conjunction with the ACT encounter reporting code when telemedicine is used.

All telemedicine interactions shall occur through real-time interactions between the ACT consumer and the physician/nurse practitioner/physician’s assistant/clinical nurse specialist from their respective physical location. Psychiatric services are the only ACT services that are approved to be provided in this manner.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 379 Oct. 1, 2024 (Accessed Dec. 2024).

Behavioral Health

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 559 Oct. 1, 2024 (Accessed Dec. 2024).

Federally Qualified Health Centers

An FQHC can be either an originating or distant site for telemedicine services.

An allowable FQHC encounter means a face-to-face medical visit or an interaction using a qualifying telemedicine modality (audio/visual or audio-only) between a patient and the provider of health care services who exercises independent judgment in the provision of health care services. Encounters may be classified as medical, dental, or behavioral health.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 770 & 772, Oct. 1, 2024 (Accessed Dec. 2024).

Hospital

A hospital can be either an originating or distant site for telemedicine services. Refer to the Billing & Reimbursement for Institutional Providers Chapter for specific billing instructions.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 1013, Oct. 1, 2024 (Accessed Dec. 2024).

Nursing Facility

A nursing facility can be either an originating or distant site for telemedicine. Refer to the Billing & Reimbursement for Institutional Providers Chapter for information regarding billing the originating site facility fee.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 1556, Oct. 1, 2024 (Accessed Dec. 2024).

Rural Health Clinic

An RHC can be either an originating or distant site for telemedicine services. Refer to the Billing & Reimbursement for Institutional Providers Chapter for specific billing instructions.

An encounter is a face-to-face visit or an interaction using a qualifying telemedicine modality (audio/visual or audio-only) between a patient and the provider of health care services who exercises independent judgment in the provision of health care services. For a health service to be defined as an encounter, the provision of the health service must be recorded in the patient’s medical record. Encounters may be classified as medical or behavioral health.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 1992-1993, Oct. 1, 2024 (Accessed Dec. 2024).

PIHP/CMHSP

A CMH/PIHP can be either an originating or distant site for telemedicine services. Practitioners must meet the provider qualifications for the covered service provided via telemedicine.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 368 Oct. 1, 2024 (Accessed Dec. 2024).

Telemedicine providers who are rendering services within the specialty behavioral health system must follow all PIHP/CMHSP enrollment procedures. These PIHP/CMHSP providers are required to be affiliated to the beneficiary’s care team (via a shared medical record or a referral relationship) to ensure that the beneficiary has reasonably frequent and periodic in-person evaluations to personally reassess and update the beneficiary’s medical treatment/history, effectiveness of treatment modalities, and current medical/behavioral condition and/or treatment plan.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2155 Oct. 1, 2024 & MI Medicaid Policy Bulletin MMP 24-06, Apr. 1, 2024, Accessed Dec. 2024).

When the outpatient facility provides administrative support for a telemedicine service, the outpatient hospital facility may bill the hospital outpatient clinic visit on the institutional claim with modifier 95 or modifier 93 and the appropriate revenue code.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2155, Oct. 1, 2024, & MI Dept. of Health and Human Services., Bulletin 23-10, Telemedicine Policy Post-COVID PHE, Mar. 2, 2023, (Accessed Dec. 2024).

PIHP/CMHSP providers must submit encounters for audio/visual telemedicine with POS 02 or 10 (as applicable) and for audio-only POS 02 or 10 (as applicable) and Modifier 93.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2154, Oct. 1, 2024 & Bulletin 23-10, Telemedicine Policy Post-COVID PHE, Mar. 2, 2023, (Accessed Dec. 2024).

Telemedicine is allowed for all services indicated in the Bureau of Specialty Behavioral Health Services Telemedicine Database. The features of what will be counted as a telemedicine visit need to align with the same standards of an in-person visit. Any phone call or web platform used to schedule, obtain basic information or miscellaneous work that would have been billed as a non-face-to-face and therefore non-billable contact, will remain non-billable. Telemedicine visits must include service provision as indicated in the IPOS and should reflect work towards or review of goals and objectives indicated forthwith.

Medicaid beneficiaries whose needs do not render them eligible for specialty services and supports through the PIHPs/CMHSPs may receive outpatient mental health services through Medicaid FFS or MHPs as applicable. These FFS/MHP enrolled non-physician behavioral health services may be provided via telemedicine when performed by Medicaid-enrolled psychologists, social workers, counselors, and marriage and family therapists. Services are covered when performed in a non-facility setting or outpatient hospital clinic. All applicable services are listed in the telemedicine audio/visual and audio-only fee schedules.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2155-2156 Oct. 1, 2024 & MI Dept. of Health and Human Services., Bulletin 23-10, Telemedicine Policy Post-COVID PHE, Mar. 2, 2023, (Accessed Dec. 2024).

Physical Therapy, Occupational Therapy and Speech Therapy Services

This policy supplements existing PT, OT, and ST services policy. All current therapy referral, PA, documentation requirements, standards of care, and limitations remain in effect regardless of whether the service is provided through telemedicine. All telemedicine therapy services will count toward the beneficiary’s therapy service limits. (Refer to the Therapy Services chapter for additional information.)

Modifier 95 should be used in addition to the required modifiers for therapy services as outlined in therapy policy.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2156-2157 Oct. 1, 2024 (Accessed Dec. 2024).

Dentistry

MDHHS will allow dentists to provide the limited oral evaluation (Current Dental Terminology [CDT] code D0140) via telemedicine (simultaneous audio/visual) technology so long as all other telemedicine policy is followed.

All requirements of the general telemedicine policy must be followed when providing the limited oral evaluation via telemedicine, including scope of practice requirements, contingency plan, and the use of both audio/visual service delivery unless otherwise indicated by federal guidance.

Billing instructions depend upon the claim format used:

American Dental Association (ADA) Claim Format: Use POS 02 or POS 10.
Institutional Claim Format: POS 02 and POS 10 are not required; Use modifier 95.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2158 Oct. 1, 2024 (Accessed Dec. 2024).

Vision

Telemedicine vision services can be provided through a Medicaid-enrolled provider who can report E/M services as listed in the telemedicine fee schedules.

An intermediate ophthalmological exam can be provided via telemedicine for an established patient with a known diagnosis. The provider must have a previous in-person encounter with the beneficiary to ensure the provider is knowledgeable of the beneficiary’s current medical history and condition. For cases in which the provider must refer the beneficiary to another provider, a consulting provider is not required to have a pre-existing provider-patient relationship if the referring provider shares medical history, past eye examinations, and any related beneficiary diagnosis with the consulting provider. Intermediate ophthalmological exam codes should not be used to diagnose eye health conditions (an initial diagnosis). When medically necessary, providers must refer beneficiaries for an in-person encounter to receive a diagnosis and/or care. Telemedicine cannot act as a replacement for recommended in-person interactions.

School Services Program (SSP)

Because of the unique circumstances regarding the delivery of services within the School Services Program (SSP), telemedicine may be the primary delivery modality for some beneficiaries; however, the decision to use telemedicine should be based on the needs or convenience of the beneficiary, and not those of the provider.

In cases where the beneficiary is unable to use telemedicine equipment without assistance, an attendant must be provided by the provider. The attendant must be trained in the use of the telemedicine equipment to the point where they can provide adequate assistance. The attendant must also be available for the entire telemedicine session; however, they should also ensure the beneficiary’s privacy to the greatest extent possible. When the originating site for the service is the student’s home, any cost for an attendant is not reimbursable.

School Services Program

The 95 modifier is used with the appropriate procedure codes to identify when a service is provided via telemedicine using audio and video.

NOTE: Telemedicine Services are covered in the Telemedicine Chapter of this manual. (listed at several points throughout document)

SOURCE: MI Dept. of Health and Human Services., Bulletin 24-17, School Services Program (SSP) Providers, SSP Chapter Rewrite and Update, Jul. 1, 2024, (Accessed Dec. 2024).

Durable Medical Equipment (DME) Providers

All DME providers must reference the Medical Supplier chapter of this Manual for specific requirements in the provision of services via telemedicine.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2159 Oct. 1, 2024 (Accessed Dec. 2024).

FQHCs and RHCs

All current Medicaid policy for telemedicine services, including definitions, requirements and parameters of telemedicine, apply to FQHCs and RHCs. FQHCs and RHCs are responsible for ensuring compliance with all telemedicine policy.

Distant site services provided by qualified Medicaid enrolled providers may be covered when the qualified provider is employed by the clinic or working under the terms of a contractual agreement with the clinic. FQHCs and RHCs must maintain all practitioner contracts and provide them to MDHHS upon request.

During the Medicaid provider enrollment process, contracted providers must associate to the FQHC or RHC billing NPI. Refer to the Billing & Reimbursement for Institutional Providers chapter of this Manual for further information.

PPS is reimbursed according to the billing rules described below (See manual).

If both the originating and distant sites submit identical procedure code(s) for a telemedicine visit for the same beneficiary on the same date of service, it is considered duplicate billing. MDHHS will recover payment from the appropriate FQHC, RHC, or contracted provider. Recovery will be based on the terms specified in the contract.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2159-2160 Oct. 1, 2024 (Accessed Dec. 2024).

Tribal FQHC

A Tribal facility may choose to enroll as a Tribal FQHC and be reimbursed for outpatient face-to-face visits within the FQHC scope of services provided to Medicaid beneficiaries, including telemedicine and services provided by contracted employees. Tribal FQHCs are eligible to receive the IHS outpatient AIR for eligible encounters.

A THC can be either an originating or distant site for telemedicine services.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2203 & 2207, Oct. 1, 2024 (Accessed Dec. 2024).

Maternal Infant Health Program

All audio-visual and audio-only MIHP telehealth services must be reported with:

Modifier 93 for audio–only services
Modifier 95 for audio-visual services
Report the place of service (POS) code that would be reported as if the beneficiary were in-person for the visit (e.g., home or office)

ELIGIBLE SITES

“Originating site” means the location of the eligible recipient at the time the service being furnished by a telecommunications system occurs.

“Distant provider” and “distant site” mean the location of the health care professional providing the service at the time the service is being furnished by a telecommunications system and the health care professional providing those services. Distant site may include the health care professional’s office or any established site considered appropriate by the health care professional as long as the privacy of the recipient and security of the information shared during the telemedicine visit are maintained.

SOURCE: MI Compiled Laws Sec. 400.105h as amended by HB 4213 and HB 4580. (Accessed Dec. 2024).

Originating site is defined as the location of the eligible beneficiary at the time of the telemedicine service.

Authorized originating sites include:

County mental health clinic or publicly funded mental health facility
Federally Qualified Health Center (FQHC)
Hospital (inpatient, outpatient, or critical access hospital)
Office of a physician or other provider (including medical clinics)
Hospital-based or Critical Access Hospital (CAH)-based Renal Dialysis Centers (including satellites)
Rural Health Clinic (RHC)
Skilled nursing facility
Tribal Health Center (THC)
Local Health Department (LHD) as defined in Sections 333.2413, 333.2415 and 333.2421 of the Michigan Public Health Code (PA 368 of 1978 as amended)
Home, as defined as a location, other than a hospital or other facility, where the beneficiary receives care in a private residence
Other established site considered appropriate by the provider (in accordance with clinical judgement)

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2149, Oct. 1, 2024, & MI Dept. of Health and Human Services. Bulletin 20-09, General Telemedicine Policy, Mar. 12, 2020, [Provider Bulletin 23-10 indicates policy is permanent] (Accessed Dec. 2024).

MDHHS does not recognize the following place of service codes for reimbursement by the program: …

10 – Telehealth Provided in Patient’s Home (added 7/1/24)

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 255, Oct. 1, 2024, (Accessed Dec. 2024).

Effective March 1, 2020. The distant site is defined as the location of the practitioner, providing the professional service at the time of the telemedicine visit. The definition encompasses the providers office or any established site, considered appropriate by the provider so long as the privacy of the beneficiary and security of the information shared during the telemedicine visit are maintained.

Telemedicine services where “home” or another “establish site, considered appropriate by the provider” are utilized as the originating site or not eligible to receive the telehealth facility fee. Distant site providers in these situations are instructed to bill the appropriate current procedural term analogy HCPCS code for the services provided.

Neither the originating site or the distant side is permitted to bill both the telehealth facility and the code for the professional service for the same beneficiary at the same time.

SOURCE: MI Dept. of Health and Human Services. Bulletin 20-09, General Telemedicine Policy, Mar. 12, 2020, [Provider Bulletin 23-10 indicates policy is permanent] (Accessed Dec. 2024).

All audio/visual telemedicine services, as allowable on the telemedicine fee schedule and submitted on the professional invoice, must be reported with the Place of Service (POS) code that would be reported as if the beneficiary were in-person for the visit along with modifier 95—”Synchronous Telemedicine Service rendered via a real-time interactive audio and video telecommunications system”.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2153, Oct. 1, 2024 & Bulletin 23-10, Telemedicine Policy Post-COVID PHE, Mar. 2, 2023, (Accessed Dec. 2024).

PIHP/CMHSP providers must submit encounters for audio/visual telemedicine with POS 02 or 10 (as applicable) and for audio-only POS 02 or 10 (as applicable) and Modifier 93.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2154, Oct. 1, 2024 & Bulletin 23-10, Telemedicine Policy Post-COVID PHE, Mar. 2, 2023, (Accessed Dec. 2024).

For PIHP/CMHSP service providers, refer to the MDHHS Bureau of Specialty Behavioral Health Services Telemedicine Database and the Audio-Only Telemedicine Database on the MDHHS website for services allowed via both audio/visual and audio-only telemedicine.

This information should be used in conjunction with the Billing & Reimbursement for Professionals and the Billing & Reimbursement for Institutional Providers Chapters as well as the Medicaid Code and Rate Reference tool and other related procedure databases/fee schedules located on the MDHHS website.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2154, Oct. 1, 2024, (Accessed Dec. 2024).

For services submitted on the institutional invoice, the appropriate National Uniform Billing Committee (NUBC) revenue code, along with the appropriate telemedicine CPT/HCPCS procedure code and modifier 95 or modifier 93, must be used.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2153, Oct. 1, 2024, (Accessed Dec. 2024).

An FQHC can be either an originating or distant site for telemedicine services.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 770 Oct. 1, 2024 (Accessed Dec. 2024).

Hospital

A hospital can be either an originating or distant site for telemedicine services. Refer to the Billing & Reimbursement for Institutional Providers Chapter for specific billing instructions.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 1013, Oct. 1, 2024. (Accessed Dec. 2024).

Nursing Facility

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 1556, Oct. 1, 2024. (Accessed Dec. 2024).

Pharmacy

In the event that the beneficiary is unable to physically access an in-person (revised per bulletin MMP 23-20) care setting, an eligible pharmacist may provide MTM services via telemedicine. Telemedicine is the use of telecommunications and information technologies for the exchange of encrypted patient data for the provision of services. Telemedicine must be obtained through real-time interactions between the beneficiary’s physical location (originating site) and the pharmacist provider’s physical location (distant site). MTM telemedicine audio/visual services are provided to beneficiaries through hardwire or internet connection. It is the expectation that providers and facilitators involved in telemedicine are trained in the use of equipment and software prior to servicing beneficiaries. The arrangements for telemedicine will be made by the pharmacist. The administration of telemedicine services is subject to the same provision of services that are provided to a beneficiary in person. Providers must ensure the privacy of the beneficiary and secure any information shared via telemedicine. Refer to the Telemedicine chapter for additional information regarding telemedicine service provision.

For services provided through telemedicine, each procedure code must include the modifier 95.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 1839, Oct. 1, 2024. (Accessed Dec. 2024).

Rural Health Clinic

An RHC can be either an originating or distant site for telemedicine services. Refer to the Billing & Reimbursement for Institutional Providers Chapter for specific billing instructions.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 1992, Oct. 1, 2024. (Accessed Dec. 2024).

Dentistry

Billing instructions depend upon the claim format used:

American Dental Association (ADA) Claim Format: Use POS 02 or POS 10.
Institutional Claim Format: POS 02 and POS 10 are not required; Use modifier 95.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2158 Oct. 1, 2024. (Accessed Dec. 2024).

FQHC/RHC

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2160 Oct. 1, 2024. (Accessed Dec. 2024).

Tribal Health Centers

A THC can be either an originating or distant site for telemedicine services.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2207, Oct. 1, 2024 (Accessed Dec. 2024).

Tribal FQHCs are eligible to receive all-inclusive rate (AIR) reimbursement for clinic services provided outside of the four walls of the facility, including telemedicine and services provided by contracted employees.

SOURCE: MI Medical Services Administration Bulletin MSA 20-60, Sept. 1, 2020. (Accessed Dec. 2024).

Speech Hearing and Language

A CMH/PIHP can be either an originating or distant site for telemedicine services.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 368 Oct. 1, 2024 (Accessed Dec. 2024).

Maternal Infant Health Program

All audio-visual and audio-only MIHP telehealth services must be reported with:

Modifier 93 for audio–only services
Modifier 95 for audio-visual services
Report the place of service (POS) code that would be reported as if the beneficiary were in-person for the visit (e.g., home or office)

GEOGRAPHIC LIMITS

No Reference Found

FACILITY/TRANSMISSION FEE

Allowable originating sites are permitted to submit claims for the telehealth facility fee. This fee is intended to reimburse the provider for the expense of hosting the beneficiary at their location. To submit this code, the originating site must ensure the technology is functioning, the privacy of the beneficiary is secured, and that the information is shared confidentially.

Telemedicine services where “home” or another “established site considered appropriate by the provider” are utilized as the originating site are not eligible to receive the telehealth facility fee. Distant site providers in these situations are instructed to bill the appropriate Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) code (as represented by the Telemedicine database) for the service(s) provided.

Neither the originating site nor the distant site is permitted to bill both the telehealth facility fee and the code for the professional service for the same beneficiary at the same time.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2153 Oct. 1, 2024, & MI Dept. of Health and Human Services. Bulletin 20-09, General Telemedicine Policy, Mar. 12, 2020, [Provider Bulletin 23-10 indicates policy is permanent] (Accessed Dec. 2024).

Institutional Providers

To be reimbursed for the originating site facility fee, the hospital must bill the appropriate telemedicine NUBC revenue code with the appropriate telemedicine facility fee code and modifier.

To be reimbursed for the originating site facility fee, the hospital must bill the telemedicine facility fee code and modifier. Refer to the Telemedicine Chapter for additional information.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 191 & 204 Oct. 1, 2024. (Accessed Dec. 2024).

Professional Providers

To be reimbursed for the originating site facility fee, the originating site provider must bill the telehealth facility fee. MDHHS will reimburse the originating site provider the current Medicaid fee screen. Additional services provided at the originating site on the same date as the telemedicine service may be billed and reimbursed separately according to published policy.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 274 Oct. 1, 2024. (Accessed Dec. 2024).

Nursing Facility

To be reimbursed for the originating site facility fee, the NF must bill the appropriate telemedicine NUBC revenue code with the appropriate telemedicine facility fee and modifier.

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 217 Oct. 1, 2024. (Accessed Dec. 2024).

FQHCs and RHCs

The telehealth facility fee does not qualify as a face-to-face visit and does not generate the PPS payment. Telemedicine service(s) provided at the distant site that qualify as a face-to-face visit may generate the PPS payment. All current PPS rules and encounter criteria apply to telemedicine visits. Refer to the Federally Qualified Health Centers and the Rural Health Clinics chapters of this Manual and the FQHC and RHC reimbursement lists on the MDHHS website for further information. (Refer to the Directory Appendix for website information.)

SOURCE: MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2159 Oct. 1, 2024. (Accessed Dec. 2024).

READ LESS

Minnesota

Last updated 11/22/2024

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

SOURCE: MN Statute Sec. 256B.0625, Subdivision 3b(a). (Accessed Nov. 2024).

MHCP programs will cover telehealth services in the same manner as any other benefits covered through the programs. Coverage will not be limited on the basis of geography or location. Out-of-state coverage policy applies to services provided via telehealth.

SOURCE: MN Dept. of Human Services, Provider Manual, Telehealth Services, As revised Jun. 2, 2023. (Accessed Nov. 2024).

Minnesota’s Medical Assistance program reimburses live video for fee-for-service programs.

Providers must self-attest that they meet all of the conditions of the MHCP telehealth policy by completing and submitting the Telehealth Provider Assurance Statement (DHS-6806) (PDF) to be eligible for reimbursement.

SOURCE: MN Dept. of Human Services, Provider Manual, Physician and Professional Services (Telehealth), As revised Apr. 4, 2024. (Accessed Nov. 2024).

ELIGIBLE SERVICES/SPECIALTIES

SOURCE: MN Dept. of Human Services, Provider Manual, Telehealth Services, As revised Jun. 2, 2023. (Accessed Nov. 2024).

The CPT and HCPC codes that describe a telehealth service are generally the same codes that describe an encounter when the health care provider and patient are at the same site. Examples of eligible services:

Consultations
Telehealth consults: emergency department or initial inpatient care
Subsequent hospital care services with the limitation of one telehealth visit every 30 days per eligible provider
Subsequent nursing facility care services with the limitation of one telehealth visit every 30 days
End-stage renal disease services
Individual and group medical nutrition therapy
Individual and group diabetes self-management training with a minimum of one hour of in-person instruction to be furnished in the initial year training period to ensure effective injection training
Smoking cessation [in telehealth services manual only]
Alcohol and substance abuse (other than tobacco) structured assessment and intervention services

SOURCE: MN Dept. of Human Services, Provider Manual, Physician and Professional Services (Telehealth), As revised Apr. 4, 2024 & Telehealth Services, As revised Jun. 2, 2023. (Accessed Nov. 2024).

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. 2, 2023. (Accessed Nov. 2024).

Non-covered services:

See list above from Telehealth Services manual page.

SOURCE: MN Dept. of Human Services, Provider Manual, Physician and Professional Services (Telehealth), As revised Apr. 4, 2023, (Accessed Nov. 2024).

Two-way interactive video consultation in an emergency department (ED)

Two-way interactive video consultation may be billed when no physician is in the ED and the nursing staff is caring for the patient at the originating site. The ED physician at the distant site bills the ED CPT codes with place of service 02. Nursing services at the originating site would be included in the ED facility code. If the ED physician requests the opinion or advice of a specialty physician at a “hub” site, the ED physician bills the ED CPT codes and the consulting physician bills the consultation E/M code with place of service 02.

SOURCE: MN Dept of Human Services, Telehealth Services Manual, Jun. 2, 2023. (Accessed Nov. 2024).

Mental Health Services

Subject to federal approval, mental health services that are otherwise covered by medical assistance as direct face-to-face services may be provided via telehealth in accordance with subdivision 3b.

SOURCE: MN Statute Sec. 256B.0625, Subd. 46. (Accessed Nov. 2024).

MHCP members eligible for mental health services can receive mental health services delivered through telehealth.

Mental health services covered by medical assistance as direct face-to-face services may be provided via telehealth and are covered by MHCP. For mental health services or assessments delivered through telehealth that are based on an individual treatment plan, the provider may document the client’s verbal approval or electronic written approval of the treatment plan or change in the treatment plan in lieu of the client’s signature.

Authorization is required for mental health services delivered through telehealth if authorization is required for the same service through in-person contact.

SOURCE: MN Dept. of Human Services, Provider Manual, Telehealth Delivery of Mental Health Services, Revised Oct. 17, 2022, (Accessed Nov. 2024).

Assertive Community Treatment and Intensive Residential Treatment Services

Physician services that are not separately billed may be included in the rate to the extent that a psychiatrist, or other health care professional providing physician services within their scope of practice, is a member of the intensive residential treatment services treatment team. Physician services, whether billed separately or included in the rate, may be delivered by telehealth.

SOURCE: MN Statute Sec 256B.0622, subdivision 8(e), (Accessed Nov. 2024).

Individualized Education Program (IEP)

Telehealth coverage applies to a child or youth who is MA eligible, has an IEP and the service provided is identified in the IEP.

To be eligible for reimbursement, the school or school district must self-attest by completing the Provider Assurance Statement for Telehealth (DHS-6806) (PDF) that the telehealth services are provided by a qualified professional provider, either employed by or contracted by the school, who meets all of the conditions of the MHCP telehealth policy.

MHCP covers these services for telehealth:

Physical therapy
Occupational therapy
Speech language therapy services

Schools that provide mental health service through the Children’s Therapeutic Services and Suports program (CTSS) should follow CTSS telehealth policies. For more information, review the IEP Mental Health Services manual section and the Children’s Therapeutic Services and Supports webpage.

Non-Covered Services:

IEP nursing services
Special transportation
Assistive technology
Personal care assistance (PCA) services

MHCP telehealth coverage will not pay the following:

Electronic connections that are conducted over a website that is not secure and encrypted as specified by the Health Insurance Portability and Accountability Act of 1996 privacy and security rules (for example, Skype)
IEP evaluations assessments and services that are less effective if provided in person, or require hands on, face-to-face contact
Prescription renewals, refills, obtaining orders from a primary care provider
Scheduling a test or appointment
Non-clinical communication
Communication via telephone, email or fax

Use the same HCPC codes and modifiers that describe the IEP services being performed via telehealth as you would if the service was being provided in person with the child at the same site.

IEP Telehealth Place of Service Codes:

Originating site

Use place of service 10 on claims to indicate when the child receives the health-related service via telecommunication technology in the child’s home. This is a location other than a hospital or other facility where the child receives care in a private residence.

Distant site

Use place of service 02 on claims to indicate when the child receives the health-related service via telecommunication technology when the child is in a location other than a child’s home.

SOURCE: MN Dept. of Human Svcs., Provider Manual, IEP Services, Revised May 19, 2022, (Accessed Nov. 2024).

Providers may deliver some SUD services via telehealth. Review the Telehealth Delivery of Substance Use Disorder Services section of the MHCP Provider Manual for more information.

SOURCE: MN Dept. of Human Services, Provider Manual, Substance Use Disorder (SUD) Services, Sept. 2024, (Accessed Nov. 2024).

The following medically necessary substance use disorder (SUD) services provided by eligible SUD providers via telehealth are covered:

Comprehensive assessments
Individual and group treatment services
Peer recovery support services

See the Telehealth Services section of the MHCP Provider Manual for noncovered telehealth services.

SOURCE: Substance Use Disorder Telehealth, May 23, 2023, (Accessed Nov. 2024).

Child Welfare Targeted Case Management (CW-TCM)

Case management activities are those that help the eligible member gain access to needed medical, social, educational and other services as identified in an individual service plan. Only services delivered on a face-to-face or interactive video basis are claimable as CW-TCM unless the client is in placement more than 60 miles beyond county or reservation boundaries. If a client is in placement more than 60 miles beyond county or reservation boundaries, a provider may deliver services using telephone or interactive video contact for two consecutive months. There must be a face-to-face contact in the month before the eligible telephone or ITV contacts when children have been and continue to be in placement.

See manual for examples.

Interactive video means the delivery of targeted case management services in real time through the use of two-way interactive audio and visual communication, or accessible video-based platforms.

CW-TCM services may be provided through ITV according to Minnesota Statutes, 256B.0625, subdivision 20b and reimbursed according to Minnesota Statutes, 256B.094, subdivision 6. ITV or face-to-face contact meets the minimum face-to-face contact requirements for CW-TCM services with the exception of children in out-of-home placement or receiving case management for child protection reasons require an eligible in-person contact.

For children and youth in foster care for whom a responsible social service agency has placement and care responsibility, the contact must be seen in- person to claim targeted case management. Foster care is defined by Minnesota Statutes, 260C.007, subdivision 18 and 260D.02, subdivision 10.

Children receiving case management for child protection reasons must be seen in person.

Exception – if the child is placed more than 60 miles beyond the county or reservation boundaries, telephone contact or ITV, is claimable for up to two consecutive months and there must be face-to-face contact at least once every three months. Providers must have a Targeted Case Management Provider Interactive Video Assurance Statement (DHS-8398) on their provider file to provide services via ITV.

SOURCE: MN Dept. of Human Svcs., Child Welfare Targeted Case Management (CW-TCM), Jan. 11, 2024, (Accessed Nov. 2024).

Dental

Teledentistry is the delivery of dental care services or consultations while the patient is at an originating site and the dentist is at a distant site. MHCP allows payment for teledentistry services. Refer to Telehealth Services for more information. Reimbursement for teledentistry is the same as face-to-face encounters. The distant site can bill for the services provided by a licensed dentist. Affiliate practice or originator within Minnesota Board of Dentistry defined scope of practice must be present at originating site.

MHCP allows the following CDT codes for these diagnostic services when performed through teledentistry services:

Periodic oral evaluation (with an established patient)
Limited oral exam
Oral evaluation for a patient under 3 years of age
Comprehensive oral evaluation (new or established patient)
Intraoral (complete series of radiographic images)
Intraoral (periapical first radiographic image)
Intraoral (periapical each additional radiographic image)
Bitewing (single radiographic image)
Bitewings (two radiographic images)
Bitewings (four radiographic images)
Intraoral—occlusal radiographic image
Panoramic radiographic imaging
Medical dental consultation

Limitations

MHCP will pay for only one reading or interpretation of diagnostic tests such as X-rays, lab tests and diagnostic assessment.
Payment is not available to providers for sending materials.
Out-of-state coverage policy applies to services provided via teledentistry services
Consultations performed by providers who are not located in Minnesota and contiguous counties require authorization prior to the service being provided.

SOURCE (Dental): MN Dept. of Human Svcs., Provider Manual, Dental Svcs. Jan. 16, 2024 (Accessed Nov. 2024).

Early Intensive Developmental and Behavioral Intervention (EIDBI) services

Telehealth is an option for certain Early Intensive Developmental and Behavioral Intervention (EIDBI) services.

SOURCE: MN Dept. of Human Svcs., EIDBI Services Benefits billing grid, updated July 2024 & MN Dept. of Human Services, EIDBI Benefit Policy Manual, EIDBI Telehealth Services. 8/6/24. (Accessed Nov. 2024).

The following EIDBI services may be billed without the member present:

Comprehensive Multi-Disciplinary Evaluation (CMDE)
Individualized Treatment Plan (ITP)
Family/Caregiver Training and Counseling
Coordinated Care Conference
Travel time

See grid for more information.

SOURCE: MN Dept. of Human Svcs., EIDBI Services Benefits billing grid, updated June 2024, (Accessed Nov. 2024).

Medical Assistance (MA) covers medically necessary telehealth services and consultations. The telehealth services and consultations must be provided with the same service thresholds, authorization requirements and reimbursement rates as services delivered in person.

Because the Early Intensive Developmental and Behavioral Intervention (EIDBI) benefit is available under MA, telehealth is an option for some EIDBI services. For additional telehealth requirements, refer to MHCP Provider Manual – Telehealth services.

For information about the Telehealth for Early Intervention training, refer to EIDBI – Individual provider trainings.

An eligible EIDBI provider may deliver the following EIDBI services via telehealth:

CMDE.
Coordinated care conference.
Family/caregiver training and counseling.
Individual treatment plan (ITP) development and progress monitoring.
Intervention – group and individual only (higher intensity intervention sessions cannot occur via telehealth).
Observation and direction.

EIDBI telehealth services do not cover:

Connection charges.
Origination, set-up or site fees.
Communication between health care providers that consists solely of email or fax transmission (i.e., a copy of written or printed material).
Communication between a person and health care provider that consists solely of email or fax transmission (i.e., a copy of written or printed material).
Higher intensity intervention sessions.

EIDBI telehealth services must be:

Compliant with industry interoperable standards (i.e., ability for systems and organizations to share data and information).
Compliant with Health Insurance Portability and Accountability Act (HIPAA) privacy and security requirements and regulations.
Medically necessary for the person and/or family.

For additional telehealth provider requirements, refer to MHCP Provider Manual – Physician and professional services – Telehealth.

Providers must deliver EIDBI telehealth services with the same service thresholds, authorization requirements and reimbursement rates as services delivered in person.

SOURCE: MN Dept. of Human Services, EIDBI Benefit Policy Manual, EIDBI Telehealth Services. 8/6/24. (Accessed Nov. 2024).

Medical assistance covers medically necessary EIDBI services and consultations delivered via telehealth, as defined under section 256B.0625, subdivision 3b, in the same manner as if the service or consultation was delivered in person.

SOURCE: MN Statute Sec. 256B.0949, Subdivision. 13. (Accessed Nov. 2024).

Rehabilitation Services

The CPT and HCPCS codes that describe a telehealth services are generally the same codes that describe an encounter when the health care provider and patient are at the same site.

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.

MHCP-enrolled providers submit claims for telehealth services using the CPT or HCPCS code that describes the services they provide.

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.

The following limitations apply:

Payment for telehealth services is limited to three sessions per week per member
Payment is not available for sending materials to a member, other providers or other facilities

MHCP does not cover the following under telehealth:

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

See manual for documentation requirements.

SOURCE: MN Dept. of Human Svcs., Provider Manual, Rehabilitation Svcs. Jan. 25, 2022 (Accessed Nov. 2024).

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

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 Telemedicine Provider Assurance Statement (DHS-6806) (PDF) before billing for telehealth MTMS encounters.

Non Covered Services

Encounters in the inpatient setting
Encounters in skilled nursing facilities
Encounters for MTMS for dual-eligible members

MHCP will reimburse pharmacies, clinics and hospitals for MTMS only for face-to-face or telehealth encounters on the lowest of five patient need levels, according to the following qualifying criteria:

The number of medications the patient is currently taking (drug combination products are counted as one medication)
The number of drug therapy problems the patient has at present
The number of medical conditions for which the patient is currently being treated

SOURCE: MN Dept. of Human Svcs., Provider Manual, Medication Therapy Management Svcs. Nov. 3, 2021 (Accessed Nov. 2024).

Medication therapy management services may be provided via telehealth as defined in subdivision 3b and may be delivered into a patient’s residence. Reimbursement shall be at the same rates and under the same conditions that would otherwise apply to the services provided. To qualify for reimbursement under this paragraph, the pharmacist providing the services must meet the requirements of paragraph (b).

SOURCE: 256B.0625(Subd)(13h)(d), (Accessed Nov. 2024).

Behavioral Health Home Services

If an member accepts the offer for a face-to-face visit at six months, providers who are eligible to provide services via telehealth may do so. Providers must have a valid Telehealth Provider Assurance Statement (DHS-6806) (PDF) on file with DHS and must comply with all MA telehealth requirements for equipment, privacy and billing to serve individuals receiving BHH services through telehealth. Refer to the following sections for requirements, billing and additional information:

Telehealth subsection of the Physician and Professional Services MHCP Provider Manual section
Telehealth Delivery of Mental Health Services

SOURCE: MN Department of Human Services, Behavioral Health Home Services, Sept. 13, 2024. (Accessed Nov. 2024).

Targeted Case Management

Interactive video means the delivery of targeted case management services in real time through the use of two-way interactive audio and visual communication, or accessible video-based platforms.

MH-TCM services may be provided through ITV according to Minnesota Statutes 256B.0625, subdivision 20b. ITV or face-to-face contact meets the minimum face-to-face contact requirements for MH-TCM services with the exception of children in out-of-home placement who require an in-person or face-to-face visit only.

Children and youth in foster care for whom a responsible social service agency has placement and care responsibility, must be seen in person to claim targeted case management. Foster care is defined by Minnesota Statutes 260C.007, subdivision 18 and 260D.02, subdivision 10.

Providers must have a Targeted Case Management Provider Interactive Video Assurance Statement (DHS-8398) (PDF) on their provider file to provide services via ITV.

SOURCE: MN Dept. of Human Services, Adult Mental Health Targeted Case Management and Children’s Mental Health Targeted Case Management, Nov. 13. 2023 (Accessed Nov. 2024).

Screening, Brief Intervention, and Referral to Treatment (SBIRT)

Providers must have documentation of services provided and have followed all clinical standards to bill for services via telehealth or telephonic (audio-only) telehealth. Refer to the Telehealth Services section of the MHCP Provider Manual under Billing for information about billing for services provided via telehealth.

SOURCE: MN Dept. of Human Services, Screening, Brief Intervention and Referral to Treatment, Dec. 29, 2022 (Accessed Nov. 2024).

Services provided by a school-based health center may include but are not limited to…

emerging services such as mobile health and telehealth.

SOURCE: MN Statute, Sec. 145.903, (Accessed Nov. 2024).

Doula Services

A telehealth labor and delivery doula visit can be billed if the member’s needs were met by the doula during the labor and delivery process; and the doula was available to the member with no other commitments throughout the entirety of the labor and delivery process by telephone or video conference.

If the doula was unavailable during the entirety of the labor and delivery process but was able to provide key support during some of the labor and delivery, they may bill for a non-labor and delivery visit for their time spent with the member.

Providers must submit a completed and signed Telehealth Provider Assurance Statement (DHS-6806) (PDF) to the Minnesota Department of Human Services to bill for telehealth services. Review Telehealth Services in the MHCP Provider Manual for additional details.

SOURCE: MN Dept of Human Services, Doula Services, Apr. 19, 2024, (Accessed Nov. 2024).

Reproductive Services

Telehealth services are covered for MHCP members.

Certain specific services are not covered. See applicable section.

SOURCE: MN Dept of Human Services, Reproductive Health/OB-GYN, Apr. 1, 2024, & Free-Standing Birth Center Services, Mar. 13, 2024, (Accessed Nov. 2024).

Telehealth services are covered for MHCP members. Providers must submit a completed and signed Telehealth Provider Assurance Statement (DHS-6806) (PDF) to the Minnesota Department of Human Services to bill for telehealth services. Review Telehealth Services in the MHCP Provider Manual for more information.

SOURCE: MN Dept of Human Services, Obstetrics, Apr. 26, 2024, & Family Planning, Apr. 1, 2024, (Accessed Nov. 2024).

Federally Qualified Health Center and Rural Health Clinic

Face-to-face includes telehealth services provided by an eligible provider.

SOURCE: MN Dept of Human Services, Federally Qualified Health Center and Rural Health Clinic, Mar. 18, 2024, (Accessed Nov. 2024).

Remote Reassessments

Assessments performed according to subdivisions 17 to 20 and 23 must be in person unless the assessment is a reassessment meeting the requirements of this subdivision. Remote reassessments conducted by interactive video or telephone may substitute for in-person reassessments.

For services provided by the developmental disabilities waiver under section 256B.092, and the community access for disability inclusion, community alternative care, and brain injury waiver programs under section 256B.49, remote reassessments may be substituted for two consecutive reassessments if followed by an in-person reassessment.

For services provided by alternative care under section 256B.0913, essential community supports under section 256B.0922, and the elderly waiver under chapter 256S, remote reassessments may be substituted for one reassessment if followed by an in-person reassessment.

For personal care assistance provided under section 256B.0659 and community first services and supports provided under section 256B.85, remote reassessments may be substituted for two consecutive reassessments if followed by an in-person reassessment.

A remote reassessment is permitted only if the lead agency provides informed choice and the person being reassessed or the person’s legal representative provides informed consent for a remote assessment. Lead agencies must document that informed choice was offered.

The person being reassessed, or the person’s legal representative, may refuse a remote reassessment at any time.

During a remote reassessment, if the certified assessor determines an in-person reassessment is necessary in order to complete the assessment, the lead agency shall schedule an in-person reassessment.

All other requirements of an in-person reassessment apply to a remote reassessment, including updates to a person’s support plan.

SOURCE: MN Statute Sec. 256B.0911 & Senate File 4399 (2024 Session), (Accessed Nov. 2024).

Worker training and development services; remote visits

Except as provided in paragraph (b), the worker training and development services specified in subdivision 18a, paragraph (c), clauses (3) and (4), may be provided to recipients with chronic health conditions or severely compromised immune systems via two-way interactive audio and visual telecommunications if, at the recipient’s request, the recipient’s primary health care provider:

determines that remote worker training and development services are appropriate; and
documents the determination under clause (1) in a statement of need or other document that is subsequently included in the recipient’s CFSS service delivery plan.

The worker training and development services specified in subdivision 18a, paragraph (c), clause (3), provided at the start of services or the start of employment of a new support worker must not be conducted via two-way interactive audio and visual telecommunications.

Notwithstanding any other provision of law, a CFSS service delivery plan developed or amended via remote worker training and development services may be executed by electronic signature.

A recipient may request to return to in-person worker training and development services at any time.

SOURCE: MN Statute Sec. 256B.85 & Senate File 4399 (2024 Session), (Accessed Nov. 2024).

Substance Use Disorder

Subject to federal approval, substance use disorder services that are otherwise covered as direct face-to-face services may be provided via telehealth as defined in section 256B.0625, subdivision 3b. The use of telehealth to deliver services must be medically appropriate to the condition and needs of the person being served. Reimbursement shall be at the same rates and under the same conditions that would otherwise apply to direct face-to-face services.

SOURCE: MN Statute Sec. 254B.05 & Senate File 4399 (2024 Session), (Accessed Nov. 2024).

“Direct service time” means the time that a mental health professional, clinical trainee, mental health practitioner, or mental health behavioral aide spends face-to-face with a client and the client’s family or providing covered services through telehealth as defined under section 256B.0625, subdivision 3b. Direct service time includes time in which the provider obtains a client’s history, develops a client’s treatment plan, records individual treatment outcomes, or provides service components of children’s therapeutic services and supports. Direct service time does not include time doing work before and after providing direct services, including scheduling or maintaining clinical records.

SOURCE: MN Statute Sec. 256B.0943 & House File 4483 (2024 Session), (Accessed Nov. 2024).

Durable Medical Equipment

Face-to-face encounters may occur through telehealth. Review Medicaid’s Telehealth webpage for more information.

SOURCE: MN Dept. of Human Services, Equipment & Supplies, Oct. 2, 2024. (Accessed Nov. 2024).

Vaccine Counseling

Effective Jan. 1, 2022, MHCP covers vaccine counseling. Providers may counsel for COVID-19 vaccinations and standard vaccines. Counseling may be provided both in-person and through telehealth. Providers billing for vaccine counseling services must have the ability to administer the vaccine for which they are counseling. Providers cannot bill for vaccine counseling separately if the counseling is a required component of another service provided in the same visit.

SOURCE: MN Dept. of Human Services, Immunizations and Vaccinations, Jan. 31, 2024. Child and Teen Checkups (C&TC), Oct. 30, 2023. (Accessed Nov. 2024).

Community Paramedic

Telehealth vists are covered when they are medically appropriate and adhere to the requirements of our telehealth policy.

SOURCE: MN Dept. of Human Services, Community Paramedic Services Sept. 25, 2023. (Accessed Nov. 2024).

ELIGIBLE PROVIDERS

Distant site

Site at which the health care provider is located while providing health care services or consultations by means of telehealth, which can include the provider’s home.

Providers must self-attest that they meet all of the conditions of the Minnesota Health Care Programs (MHCP) telehealth policy by completing and submitting a Telehealth Provider Assurance Statement (DHS-6806) (PDF) to be eligible for reimbursement.

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.

SOURCE: MN Dept. of Human Services, Telehealth Services Manual, Jun. 2, 2023. (Accessed Nov. 2024).

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 Apr. 4, 2024, (Accessed Nov. 2024).

“health care provider” means a health care provider as defined under section 62A.673; a community paramedic as defined under section 144E.001, subdivision 5f; a community health worker who meets the criteria under subdivision 49, paragraph (a); a mental health certified peer specialist under section 245I.04, subdivision 10; a mental health certified family peer specialist under section 245I.04, subdivision 12; a mental health rehabilitation worker under section 245I.04, subdivision 14; a mental health behavioral aide under section 245I.04, subdivision 16; a treatment coordinator under section 245G.11, subdivision 7; an alcohol and drug counselor under section 245G.11, subdivision 5; or a recovery peer under section 245G.11, subdivision 8

Telehealth visits provided through audio and visual communication or accessible video-based platforms may be used to satisfy the face-to-face requirement for reimbursement under the payment methods that apply to a federally qualified health center, rural health clinic, Indian health service, 638 tribal clinic, and certified community behavioral health clinic, if the service would have otherwise qualified for payment if performed in person.

SOURCE: MN Statute Sec. 256B.0625, Subd. 3b(d). (Accessed Nov. 2024).

Individualized Education Program (IEP)

Use place of service 02 on claims to indicate when the child receives the health-related service via telecommunication technology when the child is in a location other than a child’s home.

Eligible providers include the following:

Charter schools
Education districts
Intermediate districts
Public school districts
Tribal schools (schools that receive funding from the Bureau of Indian Affairs-BIA)
Service cooperatives
Special education cooperatives
State academies

SOURCE: MN Dept. of Human Svcs., Provider Manual, IEP Services, Revised May 19, 2022. (Accessed Nov. 2024).

Early Intensive Developmental and Behavioral Intervention (EIDBI) services

Eligible providers include health care professionals who are licensed or registered by the state to perform health care services within the provider’s scope of practice and in accordance with state law. Eligible providers are defined as:

Mental health professionals (as defined under Minn. Stat. §245.462, subd. 18 or Minn. Stat. §245.4871, subd. 27).
Mental health practitioners (as defined by Minn. Stat. §245.462, subd. 17 or Minn. Stat. §245.4871, subd. 26) working under the general supervision of a mental health professional.

Comprehensive multi-disciplinary evaluation (CMDE) providers, qualified supervising professionals (QSPs), level I and some level II providers may meet the requirements outlined above and may apply to provide EIDBI services via telehealth.

SOURCE: MN Dept. of Human Services, EIDBI Benefit Policy Manual, EIDBI Telehealth Services. 8/6/24. (Accessed Nov. 2024).

All enrolled EIDBI individual providers that qualify and plan to deliver telehealth services must self-attest that they meet all conditions of the MHCP telehealth policy. Review the telehealth criteria on the EIDBI telehealth services webpage.

Level III EIDBI providers do not qualify to provide services via telehealth.

Individual providers should complete and submit the Provider Assurance Statement for Telehealth (DHS-6806) (PDF) to DHS through the MPSE portal or by fax to add telehealth services to your current enrollment record.

SOURCE: MN Dept. of Human Svcs., Provider Manual, Early Intensive Developmental and Behavioral Intervention (EIDBI) Provider Enrollment Criteria and Forms, Revised Feb. 23, 2024. (Accessed Nov. 2024).

Mental Health Services

Eligible providers include any of the following:

Mental health professionals who are qualified under Minnesota Statute 2451.04
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
Clinical trainees

Providers must self-attest that they meet all of the conditions of the MHCP telehealth policy by completing and submitting a Telehealth Provider Assurance Statement (DHS-6806) (PDF) to be eligible to provide and be reimbursed for services provided via telehealth.

SOURCE: MN Dept. of Human Svcs., Provider Manual, Telehealth Delivery of Mental Health Services, Revised Oct. 17, 2022 (Accessed Nov. 2024).

Providers currently authorized to provide services may conduct the same services via telehealth. Providers must self-attest that they meet all of the conditions of the MHCP telehealth policy by completing and submitting the Telehealth Provider Assurance Statement (DHS-6806) (PDF) to be eligible to provide and be reimbursed for services via telehealth.

SOURCE: MN Dept. of Human Svcs., Provider Manual, Substance Use Disorder Telehealth, May 23, 2023 (Accessed Nov. 2024).

Targeted Case Management (TCM)

The following MHCP-enrolled TCM providers may deliver TCM through interactive video:

Child Welfare Targeted Case Management
Children’s Mental Health Targeted Case Management
Adult Mental Health Targeted Case Management
Vulnerable Adult/Developmental Disability Targeted Case Management

Organizational providers who want to deliver and bill for TCM services using interactive video must assure they meet the requirements of the interactive video policy and attest to the safety and effectiveness of interactive video for the person served, according to Minnesota Statutes, 256B.0625, subdivision 20b. Complete and submit the Targeted Case Management Provider Interactive Video Assurance Statement (DHS-8398) (PDF) to DHS through the MPSE portal or by fax to add interactive video services to your current enrollment record.

SOURCE: MN Dept. of Human Svcs., Provider Manual, Targeted Case Management (TCM) Enrollment Criteria and Forms, Feb. 29, 2024 (Accessed Nov. 2024).

Rehabilitation Services

The following provider types are eligible to provide telehealth services:

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.

To be eligible for reimbursement, 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). This includes individually enrolled private-practice therapists and enrolled therapists working within a rehabilitation billing entity that submit claims on the 837P Professional claim type.

SOURCE: MN Dept. of Human Svcs., Provider Manual, Rehabilitation Svcs. Jan. 25, 2022. (Accessed Nov. 2024).

Dental

Eligible providers

Dentist
Advanced dental therapists
Dental therapists
Dental hygienists
Licensed dental assistants
Other licensed health care professionals

SOURCE: MN Dept. of Human Svcs., Provider Manual, Dental Svcs. Jan. 16, 2024. (Accessed Nov. 2024).

Medical Assistance Services and Payment Rates

SOURCE: MN Statute 256B.0625, Subd. 3b, Sec. 7(d). (Accessed Nov. 2024).

Doula Services

SOURCE: MN Dept of Human Services, Doula Services, Jan. 12, 2024, (Accessed Nov. 2024).

Reproductive Services

SOURCE: MN Dept of Human Services, Reproductive Health/OB-GYN, Apr. 1, 2024; Free-Standing Birth Center Services, Mar. 13, 2024; MN Family Planning Program (MFPP), Mar. 12, 2024; Abortion Services, Feb. 27, 2024, (Accessed Nov. 2024).

Federally Qualified Health Center and Rural Health Clinic

Face-to-face includes telehealth services provided by an eligible provider.

SOURCE: SOURCE: MN Dept of Human Services, Federally Qualified Health Center and Rural Health Clinic, Mar. 18, 2024,(Accessed Nov. 2024).

ELIGIBLE SITES

The site at which the member is located at the time health care services are provided to them by means of telehealth, which can include the member’s home.

Providers who have an approved Telehealth Provider Assurance Statement (DHS-6806) (PDF) on file with MHCP who submit professional claims for services via telehealth should use claim format MN-ITS 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. 2, 2023. (Accessed Nov. 2024).

Physician and Professional Services

Providers should have a Telehealth Provider Assurance Statement (DHS-6806) (PDF) on their provider file 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 member’s home. It’s the location where health services and health-related services are provided or received through telecommunication technology. The member 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 member’s home. The location where health services and health-related services are provided or received through telecommunication technology. Member is located in their home (which is a location other than a hospital or other facility where the member 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 member 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.

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 Apr. 4, 2024, (Accessed Nov. 2024).

Mental Health Delivery

Providers should have a Telehealth Provider Assurance Statement (DHS-6806) (PDF) on their provider file beginning June 1, 2022, to bill claims for services provided via telehealth. Providers must have documentation of services provided and must have followed all clinical standards to bill for telehealth.

Place of service 02 (newly redefined): Telehealth provided other than the patient’s home. It’s the location where health services and health-related services are provided or received through telecommunication technology. The patient is not located in their home when receiving health services or health-related service through telecommunication technology.

Place of service 10 (new place of service): Telehealth provided in patient’s home. The location where health services and health-related services are provided or received through telecommunication technology. Patient is located in their home (which is a location other than a hospital or other facility where the patient receives care in a private residence) when receiving health services or health-related services through telecommunication technology.

When reporting a service with place of service 02 or 10, you are certifying that you are rendering services to a patient located in an eligible originating site via an interactive audio and visual telecommunications system.

SOURCE: MN Dept. of Human Svcs., Provider Manual, Telehealth Delivery of Mental Health Services, Revised Oct. 17, 2022 (Accessed Nov. 2024)

Individualized Education Program (IEP)

Use place of service 10 on claims to indicate when the child receives the health-related service via telecommunication technology in the child’s home. This is a location other than a hospital or other facility where the child receives care in a private residence.

Use place of service 02 on claims to indicate when the child receives the health-related service via telecommunication technology when the child is in a location other than a child’s home.

SOURCE: MN Dept. of Human Svcs., Provider Manual, Individualized Education Program, May 19, 2022 (Accessed Nov. 2024)

02 – Telehealth provided other than in the child’s home. The child is not located in their home when receiving health services or health-related services through telecommunication technology.

10 – Telehealth provided in the child’s home. The child is located in their home (which is a location other than a hospital or other facility where the patient receives care in a private residence) when receiving health services or health-related services through telecommunication technology.

SOURCE: MN Dept. of Human Svcs., Provider Manual, IEP Billing and Authorization Requirements, Oct. 15, 2024 (Accessed Nov. 2024).

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 Nov. 2024).

Telehealth Delivery of Substance Use Disorder Services

MHCP allows payment for telehealth services in substance use disorder treatment for services that are otherwise covered as direct face-to-face services.

Place of service 02 (newly defined): Telehealth provided other than the patient’s home. The location where health services and health-related services are provided or received through telecommunication technology. The patient is not located in their home when receiving health services or health-related services through telecommunication technology.

Place of service 10 (new place of service): Telehealth provided in patient’s home. The location where health services and health-related services are provided or received through telecommunication technology. The patient is located in their home (which is a location other than a hospital or other facility where the patient receives care in a private residence) when receiving health services or health-related services through telecommunication technology.

SOURCE: MN Dept. of Human Svcs., Provider Manual, Substance Use Disorder Telehealth, May 23, 2023, (Accessed Nov. 2024).

Dental

Affiliate practice or originator within Minnesota Board of Dentistry defined scope of practice must be present at originating site.

SOURCE: MN Dept. of Human Svcs., Provider Manual, Dental Svcs. Jan. 16, 2024. (Accessed Nov. 2024).

Rehabilitation Services

Eligible originating sites:

Office of physician or practitioner
Hospital (inpatient or outpatient)
Critical access hospital (CAH)
Rural health clinic (RHC) and Federally Qualified Health Center (FQHC)
Hospital-based or CAH-based renal dialysis center (including satellites)
Skilled nursing facility (SNF)
End-stage renal disease (ESRD) facilities
Community mental health center
Dental clinic
Residential facilities, such as a group home and assisted living
Home (a licensed or certified health care provider may need to be present to facilitate the delivery of telehealth services provided in a private home)
School

SOURCE: MN Dept. of Human Svcs., Provider Manual, Rehabilitation Svcs. Jan. 25, 2022. (Accessed Nov. 2024).

Outpatient Services of Tribal Facilities

MA-covered services provided through tribal facilities may be paid at either the IHS encounter rate or the applicable fee-for-service rate. Tribes may choose either payment rate for each separate 638 facility. All services of a single facility will be paid at the chosen rate. Service categories eligible for reimbursement at the IHS outpatient reimbursement rate are: …

Telemedicine

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 Nov. 2024).

Targeted Case Management

When services have been delivered via ITV, the appropriate place of service must be provided.

Place of service 02: ITV contact provided other than the client’s home. The client is not located in their home when receiving MH-TCM service through ITV.
Place of service 10: ITV contact provided in the client’s home. The client is located in their home when receiving MH-TCM service through ITV.

MHCP does not reimburse for connection charges, or origination, set-up or site fees.

SOURCE: MN Dept. of Human Services, Adult Mental Health Targeted Case Management and Children’s Mental Health Targeted Case Management, Nov. 13. 2023 (Accessed Nov. 2024).

GEOGRAPHIC LIMITS

Child Welfare Targeted Case Management (CW-TCM)

Interactive video (ITV) may be means of delivery of targeted case management services. However, if the child is placed more than 60 miles beyond the county or reservation boundaries, telephone contact or ITV, is claimable for up to two consecutive months and there must be face-to-face contact at least once every three months. Providers must have a Targeted Case Management Provider Interactive Video Assurance Statement (DHS-8398) on their provider file to provide services via ITV.

SOURCE: MN Dept. of Human Services, Child Welfare Targeted Case Management (CW-TCM) Jan. 11, 2024. (Accessed Nov. 2024).

Dental

Consultations performed by providers who are not located in Minnesota and contiguous counties require authorization prior to the service being provided.

SOURCE: MN Dept. of Human Svcs., Provider Manual, Dental Svcs. Jan. 16, 2024 (Accessed Nov. 2024).

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. 8/6/24. (Accessed Nov. 2024).

Physician and Professional Services

MHCP does not pay an originating site facility fee. Services billed on an outpatient claim with the GQ modifier will pay zero.

SOURCE: MN Dept. of Human Services, Provider Manual, Physician and Professional Services (Telehealth), As revised Apr. 4, 2024, (Accessed Nov. 2024).

Mental Health Delivery

MHCP does not pay an originating site facility fee. Services billed on an outpatient claim with the GQ modifier will pay zero.

SOURCE: MN Dept. of Human Svcs., Provider Manual, Telehealth Delivery of Mental Health Services, Revised Oct. 17, 2022 (Accessed Nov. 2024).

Prior to the delivery of nonemergency services, a provider-based clinic that charges a facility fee shall provide notice to any patient, including patients served by telehealth as defined in section 62A.673, subdivision 2, paragraph (h), stating that the clinic is part of a hospital and the patient may receive a separate charge or billing for the facility component, which may result in a higher out-of-pocket expense.

SOURCE: MN Statute Sec. 62J.824, (Accessed Nov. 2024).

READ LESS

Mississippi

Last updated 12/13/2024

POLICY

All health insurance and employee benefit plans [includes medicaid] …

POLICY

All health insurance and employee benefit plans [includes medicaid] in this state must provide coverage for telemedicine services to the same extent that the services would be covered if they were provided through in-person consultation. All health insurance and employee benefit plans in this state must reimburse providers who are out-of-network for telemedicine services under the same reimbursement policies applicable to other out-of-network providers of healthcare services.

SOURCE: MS Code Sec. 83-9-351. (Accessed Dec. 2024).

Providers of telehealth services must be an enrolled Mississippi Medicaid provider acting within their scope-of-practice and license or medical certification or Mississippi Department of Health (MDSH) certification and in accordance with state and federal guidelines, including but not limited to, authorization of prescription medications at both the originating and distant site.

The Division of Medicaid requires that providers utilize telehealth technology sufficient to provide real-time interactive communications that provide the same information as if the telehealth visit was performed in-person. Equipment must also be compliant with all applicable provisions of the Health Insurance Portability and Accountability Act (HIPAA).

SOURCE: MS Admin. Code Title 23, Part 225, Rule. 1.2 (Accessed Dec. 2024).

ELIGIBLE SERVICES/SPECIALTIES

The Division of Medicaid covers medically necessary telehealth services as a substitution for an in-person visit for consultations, office visits, and/or outpatient visits when all the required medically appropriate criteria is met which aligns with the description of the Current Procedural Terminology (CPT) evaluation and management (E&M) and Healthcare Common Procedure Coding System (HCPCS) guidelines.

The Division of Medicaid does not:

Cover a telehealth service if that same service is not covered in an in-person setting.
Cover a separate reimbursement for the installation or maintenance of telehealth hardware, software and/or equipment, videotapes, and transmissions.
Cover early and periodic screening, diagnosis, and treatment (EPSDT) well child visits through telehealth.
Cover physician or other practitioner visits through telehealth for non-established beneficiaries.
Cover the installation or maintenance of any telecommunication devices or systems.
Consider the following as telehealth services:
- Telephone conversations,
- Chart reviews;
- Electronic mail messages;
- Facsimile transmission;
- Internet services for online medical evaluations, or
- Communication through social media, or
- Any other communication made in the course of usual business practices including, but not limited to,
  - Calling in a prescription refill, or
  - Performing a quick virtual triage.

The Division of Medicaid reimburses all providers delivering a medically necessary telehealth service at the distant site at the current applicable Mississippi Medicaid fee-for-service rate or encounter for the service provided. The provider must include the appropriate modifier on the claim indicating the service was provided through telehealth.

Providers delivering simultaneous distant and originating site services to a beneficiary are reimbursed:

The current applicable Mississippi Medicaid fee-for-service rate for the medical service(s) provided, and
Either the originating or distant site facility fees, not both, except for RHC, FQHC and CMHC when such services are appropriately provided by the same organization.

SOURCE: MS Admin. Code Title 23, Part 225, Rule. 1.3-1.5 (Accessed Dec. 2024).

The Division of Medicaid covers up to twelve (12) in-person or telehealth tobacco cessation counseling sessions per State Fiscal Year, when provided by:

A physician, or
Other licensed practitioner that has prescriptive authority, operating within their scope of practice.

SOURCE: MS Admin. Code Title 23, Part 200, Rule. 5.4 (Accessed Dec. 2024).

Certified Community Behavioral Health Clinic

The CCBHC uses telehealth/telemedicine, video conferencing, remote patient monitoring, asynchronous interventions, and other technologies, to the extent possible, in alignment with the preferences of the person receiving services to support access to all required services.

For those presenting with emergency or urgent needs, the initial evaluation may be conducted by phone or through use of technologies for telehealth/telemedicine and video conferencing, but an in-person evaluation is preferred. If the initial evaluation is conducted telephonically, once the emergency is resolved, the person receiving services must be seen in person at the next subsequent encounter and the initial evaluation reviewed.

For individuals and families who live within the CCBHC’s service area but live a long distance from CCBHC clinic(s), the CCBHC should consider use of technologies for telehealth/telemedicine, video conferencing, remote patient monitoring, asynchronous interventions, and other technologies in alignment with the preferences of the person receiving services, and to the extent practical. These criteria do not require the CCBHC to provide continuous services including telehealth to individuals who live outside of the CCBHC service area. CCBHCS may consider developing protocols for populations that may transition frequently in and out of the services area such as children who experience out-of-home placements and adults who are displaced by incarceration or housing instability.

Telehealth/telemedicine may be used to connect individuals in crisis to qualified mental health providers during the interim travel time. Technologies also may be used to provide crisis care to individuals when remote travel distances make the 2-hour response time unachievable, but the ability to provide an in- person response must be available when it is necessary to assure safety. The CCBHC should consider aligning their programs with the CMS Medicaid Guidance on the Scope of and Payments for Qualifying Community-Based Mobile Crisis Intervention Services if they are in a state that includes this option in their Medicaid state plan.

The CCBHC directly, or through a DCO, provides screening, assessment, and diagnosis, including risk assessment for behavioral health conditions. In the event specialized services outside the expertise of the CCBHC are required for purposes of screening, assessment, or diagnosis (e.g., neuropsychological testing or developmental testing and assessment), the CCBHC refers the person to an appropriate provider. When necessary and appropriate screening, assessment and diagnosis can be provided through telehealth/telemedicine services. Note: See program requirement 3 regarding coordination of services and treatment planning.

The preferences of the person receiving services regarding the use technologies such as telehealth/telemedicine, video conferencing, remote patient monitoring, and asynchronous interventions.

In the event specialized or more intensive services outside the expertise of the CCBHC or DCO are required for purposes of outpatient mental and substance use disorder treatment the CCBHC makes them available through referral or other formal arrangement with other providers or, where necessary and appropriate, through use of telehealth/telemedicine, in alignment with state and federal laws and regulations.

SOURCE: MS Temporary Rule Title 24, (Accessed Dec. 2024).

ELIGIBLE PROVIDERS

At the distant site the following provider types are allowed to render telehealth services:

Physicians,
Physician assistants,
Nurse practitioners,
Psychologists,
Licensed Clinical Social Workers (LCSW),
Licensed Professional Counselors (LPCs),
Licensed Marriage and Family Therapists (LMFTs),
Board Certified Behavior Analysts or Board-Certified Behavior Analyst Doctorals
Community Mental Health Centers (CMHCs)
Private Mental Health Centers
Federally Qualified Health Centers
Rural Health Clinics; or
Physical, occupational or speech therapy
Mississippi State Department of Health (MSDH) clinics.

The Division of Medicaid requires a telepresenter who meets the requirements of Miss. Admin Code Part 225, Rule 1.1.D. at the originating site unless the originating site is the beneficiary’s home or as determined by the Division.

SOURCE: MS Admin. Code Title 23, Part 225, Rule. 1.3(B) and (C). (Accessed Dec. 2024).

The Mississippi Division of Medicaid will allow additional coverage of telehealth services during a state of emergency as declared by either the Governor of Mississippi or the President of the United States. See administrative code for details of enhanced services that will terminate at the discretion of the MS Division of Medicaid.

SOURCE: MS Admin. Code Title 23, Part 225, Rule. 1.7. (Accessed Dec. 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 Dec. 2024).

Rural Health Clinics

The Division of Medicaid reimburses for telehealth services which meet the requirements in Miss. Admin. Code Part 225 as follows:

An encounter for face-to-face telehealth services provided by the RHC acting as a distant site provider.
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.
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 Dec. 2024).

Federally Qualified Health Centers

The Division of Medicaid reimburses for telehealth services which meet the requirements of Miss. Admin. Code Part 225 as follows:

An encounter for face-to-face telehealth services provided by the FQHC acting as a distant site provider.
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.
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 Dec. 2024).

Home Health Services

A face-to-face encounter, for home health services, as an in person visit, including telehealth, which occurs between a physician or allowed non-physician practitioner and a beneficiary for the primary reason the beneficiary requires home health services and must occur no more than ninety (90) days before or thirty (30) days after the start of home health services.

SOURCE: MS Admin Code, Title 23, Part 215, Ch. 1: Home Health Services, Rule 1.1, (Accessed Dec. 2024).

Certified Community Behavioral Health Clinic

The preferences of the person receiving services regarding the use technologies such as telehealth/telemedicine, video conferencing, remote patient monitoring, and asynchronous interventions.

SOURCE: MS Temporary Rule Title 24, (Accessed Dec. 2024).

ELIGIBLE SITES

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

At the following originating sites:
- Office of a physician or practitioner,
- Outpatient Hospital (including a Critical Access Hospital (CAH)),
- Rural Health Clinic (RHC),
- Federally Qualified Health Center (FQHC),
- Community Mental Health/Private Mental Health Centers,
- Therapeutic Group Homes,
- Indian Health Service Clinic,
- School-based clinic,
- School which employs a school nurse,
- Inpatient hospital setting, or
- Beneficiary’s home.

SOURCE: MS Admin. Code Title 23, Part 225, Rule. 1.3. (Accessed Dec. 2024).

The Division of Medicaid defines the telepresenter as medical personnel who:

Is a Mississippi Medicaid provider, or employed by a Mississippi Medicaid provider and directly supervised by the provider or an appropriate employee of the provider if the medical personnel’s license or certification requires supervision,
Is trained to use the appropriate technology at the originating site,
Is able to facilitate comprehensive exams under the direction of a distant site practitioner who is, or is employed by, a Mississippi Medicaid provider.
Must remain in the exam room for the entirety of the exam unless otherwise directed by the distant site provider for the appropriate treatment of the beneficiary, and
Must act within the scope of their practice, license, or certification.

SOURCE: MS Admin Code Title 23, Part 225, Rule 1.1. (Accessed Dec. 2024).

The Mississippi Division of Medicaid will allow additional coverage of telehealth services during a state of emergency as declared by either the Governor of Mississippi or the President of the United States. Details of enhanced services include the following that will terminate at the discretion of the Mississippi Division of Medicaid:

A beneficiary may seek treatment utilizing telehealth services from an originating site not listed in the Mississippi Medicaid State Plan regarding Telehealth (SPA 3.1-A Introductory Pages 1 and 2). These emergency exceptions include the following:

A beneficiary’s residence may be an originating site without prior approval by the Division of Medicaid.
Health care facilities not listed in the State Plan wishing to act as an originating site must first be granted approval by the Division of Medicaid before rendering originating site telehealth services.

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

See regulation for additional details.

SOURCE: MS Admin. Code Title 23, Part 225, Rule. 1.7. (Accessed Dec. 2024).

SOURCE: MS Code Section 43-13-117. (Accessed Dec. 2024).

Division of Medicaid (DOM) added place of service (POS) code 10 to indicate a Telehealth service was provided to a beneficiary located at their home. POS code 10 may not be loaded with updated billing rules at MESA Go-Live. Providers should continue to submit claims with the appropriate POS code. Impacted claims with POS 10 will be adjusted, and there will be no additional action needed by Providers.

SOURCE: MS Medicaid Provider Bulletin, Vol. 28 Issue 3 (Sept. 2022). (Accessed Dec. 2024).

GEOGRAPHIC LIMITS

No Reference Found

FACILITY/TRANSMISSION FEE

The Division of Medicaid reimburses the provider at the originating site the Mississippi Medicaid telehealth originating site facility fee for telehealth services per completed transmission, in addition to 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 Dec. 2024).

Federally Qualified Health Centers

The Division of Medicaid reimburses … a fee per completed transmission for telehealth services provided by the RHC acting as an originating site provider. The FQHC may not bill for an encounter visit unless a separately identifiable service is performed. The originating site facility fee will be paid at the existing fee-for-service rate in effect as of January 1, 2021.

SOURCE: MS Admin. Code Title 23, Part 211, Rule. 1.5. (Accessed Dec. 2024).

Rural Health Clinics

MS Medicaid provides … a fee per completed transmission for telehealth services provided by the RHC acting as an originating site provider. The RHC may not bill for an encounter visit unless a separately identifiable service is performed. The originating site facility fee will be paid at the existing fee-for-service rate in effect as of January 1, 2021.

SOURCE: MS Admin Code Title 23, Part 212, Ch. 1, Rule. 1.5 (Accessed Dec. 2024).

The originating site is eligible to receive a facility fee, but facility fees are not payable to the distant site. Health insurance and employee benefit plans shall not limit coverage to provider-to-provider consultations only. Patients in a patient-to-provider consultation shall not be entitled to receive a facility fee.

SOURCE: MS Code Sec. 83-9-351. (Accessed Dec. 2024).

READ LESS

Missouri

Last updated 09/06/2024

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, 2.65 p. 101 (8/9/24), Provider Manual, Rural Health Clinics, Section 1,14 p. 9 (9/1/23) & MO HealthNet, Provider Manual, Behavioral Services, Section 1.19, p. 59 (9/1/23). (Accessed Sept. 2024).

The MO HealthNet Division reimburses for eligible services provided via telemedicine when the service can be performed by a MO HealthNet provider with the same standard of care as a face to face service.

Reimbursement for the distant site provider is equal to the current fee schedule allowed amount for the service provided.

SOURCE: MO HealthNet, Telemedicine Overview, (Accessed Sept. 2024).

The department of social services shall reimburse providers for services provided through telehealth if such providers can ensure services are rendered meeting the standard of care that would otherwise be expected should such services be provided in person. 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. Payment for services rendered via telehealth shall not depend on any minimum distance requirement between the originating and distant site. 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 Sept. 2024).

Reimbursement to the health care provider delivering the telemedicine service at the distant site shall be made at the same amount as the current fee schedule for an in person service.

SOURCE: MO Code of State Regulations, Title 13 Sec. 70-3.330(5), (Accessed Sept. 2024).

The COVID-19 public health emergency will expire on May 11, 2023. Effective May 12, 2023 MO HealthNet, will continue to allow any licensed health care provider, enrolled as a MO HealthNet provider, to provide telehealth services if the services are within the scope of practice for which the health care provider is licensed. The services must be provided with the same standard of care as services provided in person.

Telehealth services may be provided to a MHD participant, while the participant is at an originating site, and the provider is at another location (the distant site.) The originating site facility fee cannot be billed to MO HealthNet when the originating site is the participant’s home.

There is not a separate telehealth fee schedule. Reimbursement to health care providers delivering the medical service at the distant site is equal to the current fee schedule amount for the service provided.

SOURCE: MO HealthNet Provider Hot Tips, March 27, 2023, (Accessed Sept. 2024).

ELIGIBLE SERVICES/SPECIALTIES

Any licensed health care provider shall be authorized to provide telehealth services if such services are within the scope of practice for which the health care provider is licensed and are provided with the same standard of care as services provided in person. This section shall not be construed to prohibit a health carrier, as defined in section 376.1350, from reimbursing nonclinical staff for services otherwise allowed by law.

Nothing in subsection 3 of this section shall apply to:

Informal consultation performed by a health care provider licensed in another state, outside of the context of a contractual relationship, and on an irregular or infrequent basis without the expectation or exchange of direct or indirect compensation;
Furnishing of health care services by a health care provider licensed and located in another state in case of an emergency or disaster; provided that, no charge is made for the medical assistance; or
Episodic consultation by a health care provider licensed and located in another state who provides such consultation services on request to a physician in this state

SOURCE: MO Revised Statute Sec. 191.1145. (Accessed Sept. 2024).

Reimbursement to the health care provider delivering the medical service at the distant site is equal to the current fee schedule amount for the service provided. Use the appropriate CPT code for the service along with place of service 02 (telehealth/telemedicine).

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

When a participant is located in a residential or inpatient place of service (Place of service codes 14, 21, 33, 51, 55, 56 or 61), providers delivering behavioral health services via telemedicine must bill with the GT modifier and with the place of service where the participant is physically located. In these instances, providers must not bill with place of service 02.

SOURCE: MO HealthNet, Physician Manual, Sec. 2.65 p. 101-102 (8/9/24) & MO HealthNet, Provider Manual, Behavioral Services, Section 1.19, p. 60 (9/1/23). (Accessed Sept. 2024).

Services provided through telemedicine/telehealth must meet the standard of care that would otherwise be expected should such services be provided in person.

Prior to the delivery of telemedicine/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.

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 Sept. 2024).

Billing Requirements:

All billing requirements required to perform and bill for a service (prior authorizations, pre-certs, forms) apply to telemedicine services.
Check the MO HealthNet Fee Schedule to ascertain requirements that must be submitted for billing telemedicine services.

SOURCE: MO HealthNet Telemedicine Billing Presentation, (Accessed Sept. 2024).

Behavioral Health Services

Telemedicine is subject to the same precertification requirements. Claims submitted for behavioral health telemedicine services without a required precertification will be denied.

SOURCE: MO HealthNet Provider Tips (Nov. 22, 2022). (Accessed Sept. 2024).

Behavioral Health Crisis Centers

Direct services shall be provided by a licensed physician (includes psychiatrist) or licensed psychiatric mental health nurse practitioner (PMHNP), advanced practice registered nurse (APRN), physician assistant, resident physician (includes psychiatrist), and/or assistant physician in a written collaborative practice arrangement with a physician and with experience treating the target population. Services may be provided via telemedicine.

SOURCE: 9 CSR 30-7.010, (Accessed Sept. 2024).

Comprehensive Substance Abuse Treatment & Rehabilitation (CSTAR) Program

Communication with a collateral contact may be made face to face, by phone, or by telehealth platforms. See manual for code list.

SOURCE: MO HealthNet, CSTAR Manual, Sec. 2.9 K p. 44 (9/1/23). (Accessed Sept. 2024).

Telemedicine is considered a face-to-face service. Services in all levels of care may be provided via telemedicine, including individual services within residential levels of care such as medication services, individual counseling, and medication services support.

SOURCE: MO HealthNet, Community Substance Treatment and Rehabilitation/American Society of Addiction Medicine (12/04/2023), p. 24, (Accessed Sept. 2024).

Community Psych Rehab Program

Several services are covered if delivered via telehealth. See manual for specific services.

SOURCE: MO HealthNet, Community Psych Rehab Program Manual, (9/1/23), (Accessed Sept. 2024).

Home Health

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

SOURCE: MO HealthNet, Home Health Manual, Sec. 2.7, p. 12. (11/1/23), (Accessed Sept. 2024).

Teledentistry

MHD covers teledentistry services for participants under the age of 21, blind, pregnant or in a SNF. This benefit allows any licensed dental provider, enrolled with MO HealthNet, to provide teledentistry services if the services are within the scope of practice for which the dental provider is licensed. Teledentistry services must be performed with the same standard of care as an in-person, face-to-face service.

Prior to the delivery of teledentistry services in a school, the parent or guardian of the child shall provide authorization for such service. The authorization shall include the ability for the parent or guardian to authorize services via teledentistry in the school for the remainder of the school year.

The MO HealthNet Dental Program allows reimbursement for CDT codes D9995 (Synchronous; real time encounter) and D9996 (Asynchronous; information stored and forwarded to dentist for subsequent review).

Teledentistry services must be billed by the distant site facility (physical location of the dentist or clinic providing the dental service to an eligible Medicaid participant through teledentistry). Dentists must bill either D9995 or D9996 and the CDT code(s) for services provided. Reimbursement to dental providers delivering the service at the distant site is equal to the current fee schedule amount for the service provided. There is not a separate teledentistry fee schedule. The originating site (physical location of the participant) is where diagnostic data is collected to be communicated to an off-site dentist for diagnosis or where a dental service is performed. The originating site cannot bill MHD for CDT codes D9995 or D9996. The originating site can bill procedure code Q3014 on the CMS-1500 claim form to receive reimbursement for use of the facility where teledentistry services were rendered. The distant site service must be billed on the 2019 ADA Dental Claim Form with the CDT code (D9995 or D9996) and any additional services provided, using place of service code 02 – Telehealth.

SOURCE: MO HealthNet, Dental Manual, Sec. 2.18, pgs. 25. (9/1/23). (Accessed Sept. 2024).

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 Sept. 2024).

Recovery Support Programs

Recovery coaching shall be a one-to-one service delivered face-to-face or, with department approval, through telehealth.

SOURCE: MO Code of State Regulation, Title 9, Sec. 30-3.310, (Accessed Sept. 2024).

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 service. 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(3), (4)(D), (Accessed Sept. 2024).

Health Assessment and Coordination Services (DD Waiver)

Health Assessment and Coordination (HAC) services are consultative telemedicine services designed for individuals with I/DD receiving Home and Community Based Services (HCBS) waiver services. The services are intended to coordinate care with local emergency departments, urgent cares and primary care physicians to enable real time support, consultation and coordination on health issues. HAC services assist individuals, families and support providers in understanding the health symptoms with which individuals present in order to identify the most appropriate next steps. Services are available 24 hours a day, seven (7) days a week and include immediate evaluations, video-assisted examinations, treatment plans, discussion and coordination with individuals and/or caregivers.

SOURCE: MO HealthNet, DD Waiver, Sec. 6.14, p. 80-81 (5/6/24). (Accessed Sept. 2024).

Certain procedure codes are listed throughout Certified Community Behavioral Health Clinics/Certified Community Behavioral Health Organizations Manual as allowed.

SOURCE: MO HealthNet, Certified Community Behavioral Health Clinics/Certified Community Behavioral Health Organizations Manual (12/28/23), (Accessed Sept. 2024).

Certain procedure codes are listed throughout the Community Psychiatric Rehabilitation Manual as allowed.

SOURCE: MO HealthNet, Community Psychiatric Rehabilitation Manual (9/1/23), (Accessed Sept. 2024).

Personal Care

Performing ongoing monitoring of the provision of services in the plan of care and assessing the quality of care being delivered. Such monitoring shall include:

At least one (1) annual face-to- face visit in the participant’s home as outlined in RSMo Section 208.918. Face-to -face is defined as an interaction that occurs in person and does not include interactions that occur through telecommunication or electronic technologies.
Monthly case management activities which must be completed by telephone, videoconference, or in-person with the consumer.
Other monitoring may include electronic monitoring, telephone checks, written case notes, or other DHSS-approved methods. The ongoing monitoring shall not preclude the provider’s responsibility of ongoing diligence of case management activity oversight.

SOURCE: MO HealthNet Personal Care Manual, p. 39 (4/16/24). (Accessed Sept. 2024).

ELIGIBLE PROVIDERS

Any licensed health care provider shall be authorized to provide telemedicine [or telehealth, as referred to in Rural Health Clinic manual] services if such services are within the scope of practice for which the health care provider is licensed and are provided with the same standard of care as services provided in person.

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

SOURCE: MO HealthNet, Physician Manual, Sec. 2.65 p. 101 (8/9/24), Provider Manual, Rural Health Clinics, Section 1.14, p. 9 (9/1/23) (Accessed Sept. 2024).

Distant site shall mean a telemedicine site where the health care provider providing the telemedicine service is physically located.

Provider Requirements:

Any licensed health care provider is authorized to provide telemedicine services if the service is within the scope of practice for which the health care provider is licensed and is provided with the same standard of care as services provided in person.
To be reimbursed for telemedicine services, health care providers treating patients must enroll as a MO HealthNet provider prior to rendering services. Visit Provider Enrollment for more information.

Outpatient Hospital Facility Fee

Hospitals may bill a facility fee for distant site services provided in their facilities.
The distant site service must be reported on the UB04 claim form with the procedure code and GT modifier.

The physician providing the service will bill for their distant site services on the medical claim form.

RHC

RHCs may use either their RHC provider number or their non-provider number when operating as a distant site.

FQHC Cost Report

The telemedicine charges and costs, including the depreciation cost for equipment, are allowed on the FQHC cost report.
The clinic must have medical records in their clinic for the person being seen to be able to report these charges on their cost report. If the person being seen is not one of the clinic’s patients, all costs will need to be removed from the cost report

See document for billing scenarios.

SOURCE: MO HealthNet Telemedicine Billing Presentation, (Accessed Sept. 2024).

Any licensed health care provider may provide telemedicine services if such services are within the scope of practice for which the health care provider is licensed and are provided with the same standard of care as services provided in person. Additionally, a health care entity may reimburse nonclinical staff for services otherwise allowed by law. This includes applied behavior analysis services rendered by a registered behavior technician under the supervision of a licensed behavior analyst or licensed psychologist or any individual provider delivering services within a Department of Mental Health (DMH) licensed, contracted, and/or certified organization (13 CSR 70-3.330(2)(A).

To be reimbursed for telemedicine services, health care providers treating patients in this state via telemedicine must be fully licensed to practice in this state and be enrolled as a MO HealthNet provider prior to rendering services.

SOURCE: MO HealthNet, Provider Manual, Behavioral Services, Section 1.19 p. 59 (9/1/23), (Accessed Sept. 2024).

The originating site fee and distant site services can be billed by the same provider for the same date of service as long as the distant site is not located in the originating site facility. Review the Telemedicine Overview for additional information on billing for Telemedicine.

SOURCE: MO HealthNet Telemedicine Billing Presentation, (Accessed Sept. 2024).

MO HealthNet covers Telehealth services. MO HealthNet allows any licensed health care provider, enrolled as a MO HealthNet provider, to provide telehealth services if the services are within the scope of practice for which the health care provider is licensed. The services must be provided with the same standard of care as services provided in person.

SOURCE: MO Medicaid Provider Tips, Telehealth services, Jan. 11, 2022, (Accessed Sept. 2024).

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

SOURCE: MO HealthNet, Physician Manual, p. 41 (8/9/24). (Accessed Sept. 2024).

Health care professional shall mean a physician or other health care practitioner licensed, accredited, or certified by the state of Missouri to perform specified health services consistent with state law.

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 HealthNet 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 Sept. 2024).

Distant Site on School Grounds

The provider must get consent from the parent or guardian to provide telemedicine services. The parent or guardian may authorize services via telemedicine for a whole school year. Distant site services provided on school grounds should be billed with place of service 03 and a GT modifier.

SOURCE: MO HealthNet Telemedicine Billing Presentation, (Accessed Sept. 2024).

Rural Health Clinics (RHC)

RHCs may bill with either their non-RHC provider number or their RHC provider number. 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.

SOURCE: MO HealthNet, Rural Health Clinic, Sec. 1.14, p. 10 (9/1/23). (Accessed Sept. 2024).

RHCs may use either their RHC provider number or their non-RHC provider number when operating as a distant site.

Use POS 02 when billing the distant site when you use your non-RHC provider number.

SOURCE: MO HealthNet Telemedicine Billing Presentation, (Accessed Sept. 2024).

Federally Qualified Healthcare Clinics (FQHC)

FQHC providers must remove originating site charges and payments for telemedicine services from their year-end cost reports.

FQHC providers must leave the Rendering Provider ID field (24j on CMS-1500) blank on their claims when billing the Q3014 originating site facility charge.

SOURCE: MO HealthNet Telemedicine Billing Presentation, (Accessed Sept. 2024).

Interventions for Level 3.7-WM Medically Monitored Inpatient Withdrawal Management/Adults:

A physician (or AP/PA/APRN/resident physician) assesses the individual in person, including telehealth with video and audio capabilities, within 24 hours of admission or a review and update by a physician within 24 hours of admission of the record of a physical examination be conducted no more than seven (7)days prior to admission. A physician is available to assess the individual thereafter as medically necessary

SOURCE: MO HealthNet, Community Substance Treatment and Rehabilitation/American Society of Addiction Medicine (12/04/2023), p. 96, (Accessed Sept. 2024).

ELIGIBLE SITES

SOURCE: MO HealthNet, Physician Manual, Sec. 2.65, p. 102 (8/9/24) & MO HealthNet, Provider Manual, Behavioral Services, Section 1.19 p. 60 (9/1/23). (Accessed Sept. 2024).

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

SOURCE: MO HealthNet, Provider Manual, Behavioral Services, Section 1.19 p. 60 (9/1/23). (Accessed Sept. 2024).

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).

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, Sec. 1.14, p. 9-10 (9/1/23). (Accessed Sept. 2024).

Originating site is the 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.

Place of Service:

POS: 02 – Reimbursement to the health care providers delivering the medical service at the distant site is equal to the current fee schedule amount for the service provided. Use the appropriate Current Procedural Terminology (CPT) code for the service along with place of service 02 (with some exceptions) when submitting telemedicine claims for the distant site.
Behavioral Health: Residential or Inpatient POS: 14, 21, 33, 51, 55, 56 or 61 – Providers delivering behavioral health services via telemedicine for participants located in a residential or inpatient place of service must bill with the GT modifier and with the place of service where the participant is physically located.

Outpatient Hospital Facility Fee

Hospitals may bill a facility fee for distant site services provided in their facilities.
The distant site service must be reported on the UB04 claim form with the procedure code and GT modifier.
The physician providing the service will bill for their distant site services on the medical claim form.

School Grounds

The provider must get consent from the parent or guardian to provide telemedicine services. The parent or guardian may authorize services via telemedicine for a whole school year.
Distant site services provided on school grounds should be billed with place of service 03 and a GT modifier.

Rural Health Clinics

RHCs, both provider-based and independent, must continue to bill telemedicine services using their non-RHC provider number when operating as an originating site.

Federally Qualified Health Centers

FQHC providers must remove originating site charges and payments for telemedicine services from their year-end cost reports.
FQHC providers must leave the Rendering Provider ID field (24j on CMS-1500) blank on their claims when billing the Q3014 originating site facility charge.

FQHC Cost Report

The telemedicine charges and costs, including the depreciation cost for equipment, are not allowed on the FQHC cost report.
FQHC providers must remove charges and payments for telemedicine services from their year-end cost reports.

See originating and distant site scenario examples in Reimbursement Scenarios document.

SOURCE: MO HealthNet Telemedicine Billing Presentation, (Accessed Sept. 2024).

Effective August 19, 2018, the MO HealthNet Division will require Place of Service (POS)02 for Telehealth services. POS 02 is to be used by the provider furnishing telehealth services from a distant site with the exception of services provided on school grounds. Distant site services provided on school grounds should be billed with POS 03 and a GT modifier.

SOURCE: MO Provider Bulletin Volume 41, No. 10, Aug. 17, 2018 (Accessed Sept. 2024).

SOURCE: MO Revised Statute Ch. 208 Sec. 208.670. (Accessed Sept. 2024).

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 Sept. 2024).

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.

SOURCE: MO Code of State Regulations, Title 13 Sec. 70-3.330, (Accessed Sept. 2024).

Originating site – Where the patient receiving telemedicine services is physically located.

Originating site fee and distant site services – Billable by same provider for the same date of service as long as the distant site provider is not located in the originating site facility.

Place of Service – Use the appropriate Current Procedural Terminology (CPT) code for the service with place of service (POS) 02 when submitting telemedicine claims for the distant site.

Exceptions to billing POS 02 –

School Grounds: For distant site services provided on school grounds use POS 03 and GT modifier
Residential/Inpatient: Behavioral health services at POS codes 14, 21, 33, 51, 55, 56 or 61 must bill with the GT modifier and the POS where the participant is physically located.
Rural Health Clinics (RHCs): Bill with GT modifier for distant site services billed on the UB04 claim form.
PBRHC/UB04 – Rev code + CPT + GT + billed charge
IRHC/UB04 – Rev code + T1015 + GT

SOURCE: MO HealthNet, Telemedicine Overview, (Accessed Sept. 2024).

Place of Service for CSTAR

02 – Telemedicine

SOURCE: MO HealthNet, Community Substance Treatment and Rehabilitation/American Society of Addiction Medicine (12/04/2023), p. 108, (Accessed Sept. 2024).

POS 03 (school) must be used for services provided in the school or on the school grounds. If a school district is providing telehealth services on school grounds, the GT modifier must be used.

SOURCE: MO HealthNet, Therapy Provider Manual, (9/1/2023), p. 22, (Accessed Sept. 2024).

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 Sept. 2024).

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, 2.65 p. 102 (8/9/24); & MO HealthNet, Provider Manual, Behavioral Services, Section 1.19 p. 60 (9/1/23). (Accessed Sept. 2024).

SOURCE: Provider Manual, Rural Health Clinics, Section 1,14, p. 9 (9/1/23). (Accessed Sept. 2024).

Outpatient Hospital Facility Fee

Hospitals may bill a facility fee for distant site services provided in their facilities.
The distant site service must be reported on the UB04 claim form with the procedure code and GT modifier.
The physician providing the service will bill for their distant site services on the medical claim form.

Federally Qualified Health Centers

FQHC providers must remove originating site charges and payments for telemedicine services from their year-end cost reports.
FQHC providers must leave the Rendering Provider ID field (24j on CMS-1500) blank on their claims when billing the Q3014 originating site facility charge.

FQHC Cost Report

The telemedicine charges and costs, including the depreciation cost for equipment, are not allowed on the FQHC cost report.
FQHC providers must remove charges and payments for telemedicine services from their year-end cost reports.

See originating and distant site scenario examples in Reimbursement Scenarios document.

SOURCE: MO HealthNet Telemedicine Billing Presentation, (Accessed Sept. 2024).

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(5), (Accessed Sept. 2024).

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 Sept. 2024).

Originating site fee and distant site services – Billable by same provider for the same date of service as long as the distant site provider is not located in the originating site facility.

Q3014 – CPT code for originating site reimbursement for the use of the facility where telemedicine services are rendered. This code cannot be billed when the participant is receiving services at home.

SOURCE: MO HealthNet, Telemedicine Overview, (Accessed Sept. 2024).

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Montana

Last updated 10/30/2024

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 Oct. 2024).

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 Oct. 2024).

ELIGIBLE SERVICES/SPECIALTIES

All Montana Medicaid covered services delivered via telemedicine/telehealth are reimbursable if the services:

Are medically necessary and clinically appropriate for delivery via telemedicine/telehealth;
Follow the guidelines set forth in the applicable Montana Healthcare Programs provider manual; and
Are not a service specifically required to be face-to-face as defined in the applicable Montana Healthcare Programs provider manual.

There are no specific requirements for technologies used to deliver services via telemedicine/telehealth and can be provided using secure portal messaging, secure instant messaging, telephone conversations, and audio-visual conversations.

Rates of payment for services delivered via telemedicine/telehealth will be the same as rates of payment for services delivered via traditional (e.g., in-person) methods set forth in the applicable regulations. Please refer to the fee schedules posted on the Provider Information website for current rates.

SOURCE: MT Medicaid, All Provider Notice, Coverage and Reimbursement for Telemedicine/Telehealth Services, Mar. 21, 2023, (Accessed Oct. 2024).

Applied Behavior Analysis Services

Telehealth delivery for ABA services, with approved Telehealth Exception Request form. Face-to-face service delivery is preferred. Telehealth may be substituted if clinically appropriate. Complete the Telehealth Exception Request Form available on the Applied Behavior Analysis Services page of the Provider Information website. You must read and accept the end user agreement at the link. Telehealth exception requests must be approved prior to the delivery of services via telehealth.

SOURCE: MT Medicaid, All Provider Notice, Comprehensive Waiver, Applied Behavior Analysis, and Targeted Case Management, Mar. 12, 2023, & Resumption of Face-to-Face Requirements for Selected Programs, Apr. 10, 2023, (Accessed Oct. 2024).

MT Developmental Disabilities Program and Targeted Case Management Providers: Comprehensive Waiver, Applied Behavior Analysis, and Targeted Case Management Updates

Telehealth delivery for some waiver services when clinically appropriate. Please see the applicable Montana Developmental Disabilities Program Service Manual for information on services that require face-to face-delivery and do not allow for telehealth.

SOURCE: MT Medicaid, All Provider Notice, Comprehensive Waiver, Applied Behavior Analysis, and Targeted Case Management, Mar. 12, 2023, (Accessed Oct. 2024).

Developmental Disabilities Program (DDP)

0208 Waiver Services
- Face-to-face service delivery is preferred. Telehealth may be substituted for some services when clinically appropriate. Please see the applicable Montana Developmental Disabilities Program Service Manual for information on services that require face-to-face delivery and do not allow for telehealth.
Targeted Case Management Developmental Disabilities
- Returning to a minimum of 3 face-to-face contacts per year.
Applied Behavior Analysis Services
- Face-to-face service delivery is preferred. Telehealth may be substituted if clinically appropriate. Complete the Telehealth Exception Request Form available on the Applied Behavior Analysis Services page of the Provider Information website. You must read and accept the end user agreement at the link. Telehealth exception requests must be approved prior to the delivery of services via telehealth.

SOURCE: MT Medicaid, All Provider Notice, Resumption of Face-to-Face Requirements for Selected Programs, Apr. 10, 2023, (Accessed Oct. 2024).

Behavioral Support Services: Telehealth is allowed for specific H0046 activities (but not for the required face-to-face contact). A modifier of GT and a place of service code of 02 shall be put on the claim for units delivered as Telehealth. The waiver cannot be billed for any equipment or software required for or associated with telehealth capability.

A modifier of GT and a place of service code of 02 shall be put on the claim for units delivered as Telehealth. The waiver cannot be billed for any equipment or software required for or associated with telehealth capability. [Repeated for multiple services throughout manual. See manual for details.]

SOURCE: MT Medicaid, DD Services Manual, pg. 13, July 1, 2024, (Accessed Oct. 2024).

Permanent updates to face-to-face services are ‘proposed’ effective May 12, 2023 for Treatment Bureau, Children’s Mental Health Bureau, Health Resources Division, and Senior and Long-Term Care Division. See notice for details.

SOURCE: MT Medicaid, All Provider Notice, Resumption of Face-to-Face Requirements for Selected Programs, Apr. 10, 2023, (Accessed Oct. 2024).

Children’s Mental Health Bureau

Services delivered via telehealth are reimbursable when medically necessary and clinically appropriate for delivery via telemedicine.

Face-to-face service delivery is preferred. Telehealth may be substituted if clinically indicated or if the youth does not have access to face-to-face services. Case notes must include reason, including documentation of attempts to identify local supports, if related to access.

SOURCE: MT Dep. of Public Heath and Human Services, Children’s Mental Health Bureau Medicaid Services, Provider Manual, May 12, 2023, (Accessed Jun. 2024).

Healthy Montana Kids

Outpatient medical and behavioral health services (non-surgical) include services provided via telehealth.

SOURCE: MT Children’s Health Insurance Plan, Healthy Montana Kids (HMK). Evidence of Coverage (Jan. 2024), p. 23 & 28. (Accessed Oct. 2024).

Physical, Occupational and Speech Therapy

Telehealth services are available for Physical, Occupational and Speech Therapy when ordered by a physician or mid-level practitioner. 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, Therapies Manual, Covered Services (Mar. 2020). (Accessed Oct. 2024).

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 Oct. 2024).

Durable Medical Equipment

Face-to-face assessments of the patient by the prescriber can be performed using telemedicine. Telemedicine guidance can be found in the General Information for Providers Manual.

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 (6/19/24). (Accessed Oct. 2024).

Diabetes Prevention Program (DPP) Information

Telehealth cohorts must provide live interaction, via technology, with the lifestyle coach following the same protocol as in-person cohorts.

SOURCE: MT Dept. of Public Health and Human Svcs. Diabetes Prevention Program (DPP) Information, MT Healthcare Programs Notice, Apr. 30, 2024, (Accessed Oct. 2024).

Mobile Crisis Response Services

Services must be delivered in-person; when furnished by a mobile crisis team, the responding team must have at least one team member responding in-person. One team member may respond via telehealth and must remain connected throughout the duration of the response.

SOURCE: Dep. of Public Health and Human Services, Behavioral Health and Developmental Disabilities (BHDD) Division, Policy Number 452, July 1, 2023, (Accessed Oct. 2024).

Indian Health Services

Refer to IHS fee schedule.

SOURCE: MT Dep of Public Health and Human Svcs,, Indian Health Services, 7/26/23, (Accessed Oct. 2024).

Mental Health Centers and Therapeutic Group Homes – Children’s Mental Health Services

With the finalization of the rulemaking MAR 37-1031, the following face-to-face flexibilities were made permanent effective May 12, 2023:

Comprehensive School and Community Treatment (CSCT)
- Face-to-face service delivery is preferred. Telehealth may be substituted if clinically indicated or if the youth does not have access to face-to-face services. Case notes must include reason, including documentation of attempts to identify local supports, if related to access.
Community Based Psychiatric Rehabilitation Services (CBPRS)
- Face-to-face service delivery is preferred. Telehealth may be substituted if clinically indicated or if the youth does not have access to face-to-face services. Case notes must include reason, including documentation of attempts to identify local supports, if related to access
Home Support Services (HSS)
- Maintain minimum weekly units at 8, allow up to 4 of the 8 units to be telehealth service delivery.
- Maintain bi-weekly clinical lead requirements, allow up to 1 telehealth meeting per month.
- Face-to-face services delivery is preferred. Telehealth may be substituted if clinically indicated or if the youth does not have access to face-to-face services. Case notes must include reason, including documentation of attempts to identify local supports, if related to access.
Therapeutic Foster Care
- Maintain 2 scheduled treatment sessions in each four-week period, allow for 1 visit in the four week period to be telehealth delivery.
- Face-to-face service delivery is preferred. Telehealth may be substituted if clinically indicated or if the youth does not have access to face-to-face services. Case notes must include reason, including documentation of attempts to identify local supports, if related to access.
Targeted Case Management – Youth with Serious Emotional Disturbance
- No permanent updates; pre-PHE Administrative Rules of Montana apply

There are no specific requirements for technologies used to deliver services via telemedicine/telehealth and it can be provided using secure portal messaging, secure instant messaging, telephone conversations, and audio-visual conversations.

SOURCE: Montana Healthcare Programs Provider Notice, Telehealth Policy Clarification for Children’s Mental Health Services, Effective May 12, 2023, Revised April 2, 2024. (Accessed Oct. 2024).

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 Oct. 2024).

Distance Provider – The enrolled provider delivering a medically necessary and clinically appropriate service from the distance site.

Distant Site – A site where the enrolled provider providing the service is located at the time the service is provided. While all applicable licensure and programmatic requirements apply to the delivery of the service, there are no additional geographic or facility restrictions on distant sites for services delivered via telehealth.

Enrolled Provider – A practitioner enrolled in the Montana Healthcare Programs.

SOURCE: MT Medicaid, All Provider Notice, Coverage and Reimbursement for Telemedicine/Telehealth Services, Mar. 21, 2023, (Accessed Oct. 2024).

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 Oct. 2024).

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 Oct. 2024).

Enrolled Originating Site Provider – 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 healthcare service. An enrollee’s residence is not reimbursable as an enrolled originating site provider.

Originating Site – A site where a patient is located at the time healthcare services are provided via a telecommunications system or where an asynchronous store-and-forward service originates.

SOURCE: MT Medicaid, All Provider Notice, Coverage and Reimbursement for Telemedicine/Telehealth Services, Mar. 21, 2023, (Accessed Oct. 2024).

When performing a telemedicine consult, use the appropriate CPT E/M consult code. The place of service is the location of the provider providing the telemedicine service.

SOURCE: MT Dept. of Public Health and Human Svcs., Medicaid and Medical Assistance Programs Manual, Physician Related Svcs., Billing Procedures (3/5/21). (Accessed Oct. 2024).

Member’s residences do not qualify for originating provider reimbursement.

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 Oct. 2024).

“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 Oct. 2024).

GEOGRAPHIC LIMITS

SOURCE: MT Medicaid, All Provider Notice, Coverage and Reimbursement for Telemedicine/Telehealth Services, Mar. 21, 2023, (Accessed Oct. 2024).

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 Oct. 2024).

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 Oct. 2024).

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 Oct. 2024).

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 Oct. 2024).

The waiver cannot be billed for any equipment or software required for or associated with telehealth capability. [Repeated for multiple services throughout manual. See manual for details.]

SOURCE: MT Medicaid, DD Services Manual, July 1, 2024, (Accessed Oct. 2024).

FQHCs/RHCs: How is the Prospective Payment System (PPS) rate calculated?

Non-RHC or non-FQHC services reimbursed outside of the PPS reimbursement methodology are not factored into the PPS rate. The list of services that are not calculated into the PPS rate includes: …

Originating telemedicine site

0780 is the revenue code for the telehealth originating site fee.

SOURCE: MT Medicaid, FQHC and RHC Provider Manual, Nov. 2021, pg. 3, 9, (Accessed Oct. 2024).

Originating site fee (Q3014) listed as reimbursable.

SOURCE: MT Plan First, Procedures and Service Codes, Effective Oct. 1, 2024, (accessed Oct. 2024).

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Nebraska

Last updated 12/19/2024

POLICY

Ensuring patient safety, accessibility of services, and clinically appropriate …

POLICY

Ensuring patient safety, accessibility of services, and clinically appropriate care are the key priorities

Follow Applicable Laws

Health care practitioners providing telehealth services must follow all applicable laws.
Providers must be enrolled with Nebraska Medicaid and must be licensed (when required).
Providers must deliver telehealth services safely and effectively.
All treatments or services must be delivered according to current Medicaid service definitions.
All treatments and services must be rendered in a clinically appropriate manner and be medically necessary or related to a treatment plan.

SOURCE: NE Medicaid Program, Bulletin 23-38: Guidance on Telehealth, Dec. 29, 2023, (Accessed Dec. 2024).

Medicaid will reimburse a consulting health care practitioner when all of the following requirements are met:

After obtaining and analyzing the transmitted information, the consulting health care practitioner reports back to the referring health care practitioner;
The consulting health care practitioner must bill for services using the appropriate modifier; and
Payment is not made to the referring health care practitioner who sends the medical documentation.

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.

Telehealth services are reimbursed by Medicaid at the same rate as the service when it is delivered in person in accordance with each service specific chapter in Title 471 NAC.

SOURCE: NE Admin. Code Title 471 Sec. 1-004.08-.09, Ch. 1, (Accessed Dec. 2024).

In-person contact between a health care practitioner and a patient shall not be required under the medical assistance program established pursuant to the Medical Assistance Act and Title XXI of the federal Social Security Act, as amended, for health care services delivered through telehealth that are otherwise eligible for reimbursement under such program and federal act. Such services shall be subject to reimbursement policies developed pursuant to such program and federal act. This section also applies to managed care plans which contract with the department pursuant to the Medical Assistance Act only to the extent that:

Health care services delivered through telehealth are covered by and reimbursed under the medicaid fee-for-service program; and
Managed care contracts with managed care plans are amended to add coverage of health care services delivered through telehealth and any appropriate capitation rate adjustments are incorporated.

The reimbursement rate for a telehealth consultation shall, as a minimum, be set at the same rate as the medical assistance program rate for a comparable in-person consultation, and the rate shall 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 Dec. 2024).

ELIGIBLE SERVICES/SPECIALTIES

See page 3 to 5 for list of services that:

are no longer available through telehealth after Dec. 31, 2023
will continue to be covered through telehealth without an end date
New allowances for telehealth starting Jan. 1, 2024.

To bill for services administered through telehealth, please use the following place of service codes and modifiers. Failure to use the place of service codes and modifiers for services provided via telehealth may lead to refunds or further sanctions.

Place of Service codes:

Place of Service 02 – use when telehealth is administered while the patient is in a location besides their home.
Place of Service 10 – use when telehealth is administered while the patient is in their home.

Modifiers:

Multiple modifiers can be added to a single CPT code. The payment modifier goes first, followed by any informational modifiers. The telehealth modifier is an informational modifier and should be placed after any payment modifier.
- 93 – synchronous telemedicine service rendered via telephone or other real-time interactive audio-only.
- 95 – telehealth services are provided in real-time with an audio-visual component Information on telehealth codes will be included in our fee schedules. For more information on Medicaid rates and fee schedules please visit our website: https://dhhs.ne.gov/Pages/Medicaid-Provider-Ratesand-Fee-Schedules.aspx

SOURCE: NE Medicaid Program, Bulletin 23-38: Guidance on Telehealth, Dec. 29, 2023, (Accessed Dec. 2024).

Federally Qualified Health Centers & Rural Health Clinics

FQHC and RHC payment for telehealth services is the Medicaid rate for the 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 Dec. 2024).

Assertive Community Treatment (ACT)

ACT Team interventions may be provided via telehealth when provided according to the regulations 471 NAC 1-006.

SOURCE: NE Admin. Code Title 471 Sec. 35-013.11, Ch. 35, (Accessed Dec. 2024).

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 Dec. 2024).

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 pursuant to subsection (1) of this section 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 Dec. 2024).

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 during provision of such service. This requirement may be waived by the child’s parent or legal guardian. The medical record must document the waiver.

SOURCE: NE Admin. Code Title 471, Sec. 1-004.05, Ch. 1, (Accessed Dec. 2024).

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 Dec. 2024).

Interpretation Services

When supplied as part of a visit via telehealth, the patient’s record must reflect the requirements for telehealth and interpretation.

SOURCE: NE Medicaid Program, Bulletin 24-22: Coverage of Interpretation Services, Oct. 31, 2024, (Accessed Dec. 2024).

ELIGIBLE PROVIDERS

Place of Service codes:

Place of Service 02 – use when telehealth is administered while the patient is in a location besides their home.
Place of Service 10 – use when telehealth is administered while the patient is in their home.

Modifiers:

Multiple modifiers can be added to a single CPT code. The payment modifier goes first, followed by any informational modifiers. The telehealth modifier is an informational modifier and should be placed after any payment modifier.
- 93 – synchronous telemedicine service rendered via telephone or other real-time interactive audio-only.
- 95 – telehealth services are provided in real-time with an audio-visual component Information on telehealth codes will be included in our fee schedules. For more information on Medicaid rates and fee schedules please visit our website: https://dhhs.ne.gov/Pages/Medicaid-Provider-Ratesand-Fee-Schedules.aspx

SOURCE: NE Medicaid Program, Bulletin 23-38: Guidance on Telehealth, Dec. 29, 2023, (Accessed Dec. 2024).

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 Dec. 2024).

ELIGIBLE SITES

Place of Service codes:

Place of Service 02 – use when telehealth is administered while the patient is in a location besides their home.
Place of Service 10 – use when telehealth is administered while the patient is in their home.

Modifiers:

Multiple modifiers can be added to a single CPT code. The payment modifier goes first, followed by any informational modifiers. The telehealth modifier is an informational modifier and should be placed after any payment modifier.
- 93 – synchronous telemedicine service rendered via telephone or other real-time interactive audio-only.
- 95 – telehealth services are provided in real-time with an audio-visual component Information on telehealth codes will be included in our fee schedules. For more information on Medicaid rates and fee schedules please visit our website: https://dhhs.ne.gov/Pages/Medicaid-Provider-Ratesand-Fee-Schedules.aspx

SOURCE: NE Medicaid Program, Bulletin 23-38: Guidance on Telehealth, Dec. 29, 2023, (Accessed Dec. 2024).

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 Dec. 2024).

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

The 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 Dec. 2024).

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 Dec. 2024).

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Nevada

Last updated 12/04/2024

POLICY

The Director shall include in the State Plan for …

POLICY

The Director shall include in the State Plan for Medicaid:

A requirement that the State 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;
A requirement that the State shall pay the nonfederal share of expenses for services described in paragraph (a) in the same amount as though provided in person or by other means:
- If the services:
  - Are received at an originating site described in 42 U.S.C. § 1395m(m)(4)(C) or furnished by a federally-qualified health center or a rural health clinic; and
  - Except for services described in subparagraph (2), are not provided through audio-only interaction; or
For counseling or treatment relating to a mental health condition or a substance use disorder, including, without limitation, when such counseling or treatment is provided through audio-only interaction; 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) or (b). 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 as described in paragraph (a) or (b).
Refusing to pay for services as described in paragraph (a) or (b) 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.

SOURCE: NV Revised Statute 422.2721, Similar provisions also apply to Managed Care plans in Sec. 695G.162 (Accessed Dec. 2024).

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 delivered via telehealth may require prior authorization. It is the provider’s responsibility to refer to the individual medical coverage policies through the MSM for coverage requirements.

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, & 3403.7, (Nov. 28, 2023). (Accessed Dec. 2024).

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.

SOURCE: Nevada Dept. of Health and Human Services Billing Guidelines Telehealth Billing Instructions, p. 1 (2/22/23). (Accessed Dec. 2024).

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 (MNT): May be provided through Telehealth services. See MSM Chapter 3400 for the Telehealth policy.

Podiatry: Telehealth services are covered when deemed medically necessary; refer to MSM Chapter 3400, Telehealth Services for services and prior authorization requirements.

Provider Office Services: Telehealth services are also covered by Nevada Medicaid. See MSM Chapter 3400, Telehealth Services for the complete coverage and limitations for Telehealth.

SOURCE: NV Dept. of Health and Human Svcs., Physician Medicaid Services Manual, Section (Aug. 27, 2024) (Accessed Dec. 2024).

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. 10 (9/5/24). (Accessed Dec. 2024).

The following services must be provided in-person and are not considered appropriate services to be provided via telehealth:

Personal care services provided by a Personal Care Attendant (PCA) as identified in provider qualifications found in MSM Chapter 2600, Intermediary Service Organization and MSM Chapter 3500, Personal Care Services;
Home Health Services provided by a Registered Nurse (RN), Physical Therapist (PT), Occupational Therapist, Speech Therapist, Respiratory Therapist, Dietician or Home Health Aide as identified in provider qualifications found in MSM Chapter 1400, Home Health Agency (HHA); and
Private Duty Nursing services provided by an RN as identified in provider qualifications found in MSM Chapter 900, Private Duty Nursing.3403.7

SOURCE: NV Dept. of Health and Human Svcs., Medicaid Services Manual, Telehealth Services Chapter 3400 Section 3403.6, p. 3 (Nov. 28, 2023). (Accessed Dec. 2024).

A health maintenance organization [or managed care organization] that provides medical services to recipients of Medicaid under the State Plan for Medicaid or insurance pursuant to the Children’s Health Insurance Program pursuant to a contract with the Division of Health Care Financing and Policy of the Department of Health and Human Services shall provide referrals to providers of dental services who provide services through teledentistry.

A managed care organization that provides dental services to recipients of Medicaid under the State Plan for Medicaid or insurance pursuant to the Children’s Health Insurance Program pursuant to a contract with the Division of Health Care Financing and Policy of the Department of Health and Human Services shall:

Maintain a list of providers of dental services included in the network of the managed care organization who offer services through teledentistry;
At least quarterly, update the list and submit a copy of the updated list to the emergency department of each hospital located in this State;
Allow such providers of dental services to include on claim forms codes for teledentistry services provided through both real-time interactions and asynchronous transmissions of medical and dental information.

SOURCE: NV Revised Statute Ch. 695G.162 and 695C.1708, [slight variations exist between sections] (Accessed Dec. 2024).

Mental Health and Alcohol/Substance Abuse Services

Nevada shall ensure that Mobile Crisis Response teams respond in person at the location in the community where a crisis arises or a family’s location of choice. For individuals 18 years of age and younger, responses in urban Clark and Washoe counties will be conducted face-to-face and in-person, with an average response time within one hour; average response times for these individuals in rural areas are within two hours. For adults, responses in urban areas shall be within one hour and within two hours in rural areas. Telehealth responses in these locations shall be initiated as soon as possible, within one hour, with face-to-face and in-person team members arriving within one hour in urban areas and within two hours in rural areas. Nevada identifies these Mobile Crisis Response teams that comply with ARPA and the US SSA as DMCT.

Reference Chapter 3400 related to telehealth modality. The use of telehealth shall be

Dictated by client preference
Utilized to include additional member(s) of the team not onsite
Utilized to provide follow-up services to the individual following an initial encounter with the DMCT
Utilized to include highly trained members of the team, such as psychiatrists, psychiatric nurse practitioners, or others who can prescribe and/or administer medications

Services not eligible for reimbursement when rendered by a DMCT under Nevada Medicaid include: …

Crisis services delivered solely via telehealth without the availability of an in-person response to the individual in crisis

Supervisors review in-person or via telehealth the response to crisis episode with all involved QMHP-level Intern and QMHA-level staff, and shall appropriately document the time and content of that supervisory discussion.

All engaged DMCT staff shall receive training in the following areas prior to participating in a mobile response to a crisis episode: …

Use of Telehealth equipment

SOURCE: Nevada Dept. of Health and Human Services, Mental Health and Alcohol/Substance Abuse Manual, (7/31/24) (Accessed Dec. 2024).

HCBS State Plan Option Adult Day Health Care and Habilitation

Assessment: New Referral – If an applicant appears to meet program criteria, a face-to-face assessment or via telehealth under certain circumstances will be scheduled to determine needs-based eligibility using the Comprehensive SocialHealth Assessment (CSHA) tool. The DHCFP HCC will contact the applicant/representative within seven working days of the referral date to schedule a time to conduct an assessment.

SOURCE: Nevada Dept. of Health and Human Services, HCBS State Plan Option Adult Day Health Care and Habilitation, (1/1/24). (Accessed Dec. 2024).

Certified Community Behavioral Health Center Services

Initial services will not be denied to those who do not live in the CCBHC catchment area (where applicable), including the provision of crisis services and other services, and coordination and follow-up with providers in the recipient’s catchment area. Telehealth services may be provided.

Care coordination includes: Ensuring access to high-quality physical health care (both acute and chronic) and behavioral health care, as well as social services, housing, educational systems and employment opportunities as necessary to facilitate wellness and recovery of the whole person. This may include the use of telehealth services.

SOURCE: Nevada Dept. of Health and Human Services, Certified Community Behavioral Health Center Services, (1/1/23) (Accessed Dec. 2024).

School Health Services

Only those services listed in MSM Sections 2803.3 – Preventive Health Screenings and Treatment through 2803.16 – Telehealth of this chapter are covered benefits.

SHS Covered Services include: …

Telehealth services when clinically appropriate and within the health care professional’s scope of practice as established by its licensing agency. Refer to MSM Sections 2803.2L and 2803.16 of this chapter.

Services provided via telehealth must be clinically appropriate and within the health care professional’s scope of practice as established by its licensing agency.

SOURCE: Nevada Dept. of Health and Human Services, School Health Services, (11/28/23) (Accessed Dec. 2024).

Applied Behavioral Health

Effective with dates of service on or after September 23, 2024, claim details billed by provider types (PT) 34 (Therapy) or 85 (Applied Behavior Analysis) for the procedure codes listed below (see announcement) will deny with error code 679 (This service is not covered under telehealth) when billed with Place of Service (POS) code 10.

SOURCE: NV Medicaid Web Announcement 3449, Attention Provider Types 34 (Therapy) and 85 (Applied Behavior Analysis): Some Procedure Codes Billed with Place of Service Code 10 Now Deny With Error Code 679, Sept. 24, 2024, (Accessed Dec. 2024).

Doula Services

For services rendered via telehealth, refer to MSM Chapter 3400 – Telehealth Services. Please refer to the Telehealth Billing Instructions for additional information.

SOURCE: Nevada Dept. of Health and Human Services, Doula Services, Billing Guidelines (11/13/24) (Accessed Dec. 2024).

Crisis Stabilization

Inclusive Services

Telehealth Services (in accordance with MSM Chapter 3400)

SOURCE: Crisis Services: Certified Community Behavioral Health Center (CCBHC) Delivering Mobile Crisis Response as a Designated Mobile Crisis Team (DMCT) Attached to a CCBHC, (9/3/24), Crisis Services: Mobile Crisis Response Delivered By A Designated Mobile Crisis Team (DMCT), 9/3/24, (Accessed Dec. 2024).

Non-Covered Service

A crisis intervention/stabilization service delivered solely via telehealth without an in-person response

SOURCE: Nevada Dept. of Health and Human Services, Crisis Services: Crisis Stabilization Center, Billing Guidelines (9/3/24), Crisis Services: Certified Community Behavioral Health Center (CCBHC) Delivering Mobile Crisis Response as a Designated Mobile Crisis Team (DMCT) Attached to a CCBHC, (9/3/24), Crisis Services: Mobile Crisis Response Delivered By A Designated Mobile Crisis Team (DMCT), 9/3/24, (Accessed Dec. 2024).

ELIGIBLE PROVIDERS

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 distant site is the site where the provider delivering services is located at the time the service is provided via a telecommunications system. The provider at the distant site must use the appropriate Place of Service (POS) code in addition to the appropriate modifier when billing for services provided via telehealth. Note that for distant site services billed under Critical Access Hospital (CAH) method II on institutional claims and billed by outpatient providers on institutional claims, the GT modifier (telehealth service rendered via interactive audio and video telecommunications system) is required.

Note: The distant site may not also be the originating site.

SOURCE: Nevada Dept. of Health and Human Services Billing Guidelines Telehealth Billing Instructions, p.1 (2/22/23) (Accessed Dec. 2024).

Indian Health Services and Tribal Clinics must follow guidelines set forth in MSM Chapter 3400 (Telehealth Services)

Distant site: Use encounter code T1015. Distant site Telehealth services may be reimbursable as encounters (see Encounters below).

SOURCE: Nevada Dept. of Health and Human Svcs., Medicaid Services Manual, Indian Health Services and Clinics, pg. 1, (5/1/20), (Accessed Dec. 2024).

Providers must follow guidelines set forth in Medicaid Services Manual (MSM) Chapter 3400, Telehealth Services. Telehealth may be used by a licensed professional operating within the scope of their practice under state law.

SOURCE: Nevada Dept. of Health and Human Svcs., Medicaid Services Manual, Nurse Midwife, pg. 7, (11/14/22), (Accessed Dec. 2024).

The distant site is defined as the location where a provider of health care is providing telehealth services to a patient located at an originating site. The 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 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.

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 3403.1 3403.2, (Nov. 28, 2023). (Accessed Dec. 2024).

The distant site is the site where the provider delivering services is located at the time the service is provided via a telecommunications system. The provider at the distant site must use Place of Service (POS) Code 02 when billing for services provided via telehealth. Use of the POS code certifies the service meets telehealth requirements. Note that for distant site services billed under Critical Access Hospital (CAH) method II on institutional claims, the GT modifier (telehealth service rendered via interactive audio and video telecommunications system) is required.

SOURCE: Nevada Dept. of Health and Human Services, School Health Services, pg. 78 (8/28/24), (Accessed Dec. 2024).

An FQHC 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 must bill the telehealth originating Healthcare Common Procedural Coding System (HCPCS) code and the distant encounter site may bill the encounter code. Refer to MSM Chapter 3400 – Telehealth Services.

SOURCE: NV Dept. of Health and Human Svcs., Medicaid Services Manual, Federally Qualified Health Centers, Jan. 31, 2024, pg. 11, (Accessed Dec. 2024).

A licensed professional operating within the scope of their practice under state law may provide Telehealth services. Providers must follow guidelines set forth in MSM Chapter 3400 (Telehealth Services).

Originating Site: The FQHC may bill an encounter rate in lieu of the originating site fee, if the distant site (provider) is providing ancillary services. The originating site code, Q3014, must be used when billing in lieu of an encounter code.
Distant Site: FQHCs providing services for a recipient from a distant site may bill the appropriate encounter rate with Place of Service (POS) Code 02. Use of the POS code certifies the service meets telehealth requirements.

SOURCE: Nevada Dept. of Health and Human Services Billing Guidelines Federally Qualified Health Centers Billing Instructions, p. 1 (8/30/2019). (Accessed Dec. 2024).

Crisis Stabilization

The CSC provider must be staffed at all times (24/7/365) with a multidisciplinary team capable of meeting the needs of individuals experiencing all levels of crisis in the community; including:

Psychiatrists or psychiatric nurse practitioners (telehealth may be used if audio and visual are utilized)

SOURCE: Nevada Dept. of Health and Human Services, Crisis Services: Crisis Stabilization Center, Billing Guidelines (9/3/24)

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, (11/28/23). (Accessed Dec. 2024).

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)
Recipient’s home (no facility fee)

SOURCE: Nevada Dept. of Health and Human Services Billing Guidelines Telehealth Billing Instructions, p. 1-2 (2/22/23) (Accessed Dec. 2024).

Originating site: Use procedure code Q3014. Originating site Telehealth services are not reimbursable as encounters.

SOURCE: Nevada Dept. of Health and Human Services Billing Guidelines, Indian Health Services (IHS) and Tribal Clinics, (05/01/2020) (Accessed Dec. 2024).

The following 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: …

Telehealth originating site

SOURCE: NV Dept. of Health and Human Services, Medicaid Services Manual, Physician Services Chapter 600 Section 604.2, (Jul. 1, 2024), (Accessed Dec. 2024).

The originating site is the location where an eligible Medicaid/Nevada Check Up recipient is at the time the service is provided via a telecommunications system.

SOURCE: Nevada Dept. of Health and Human Services, School Health Services, pg. 78 (8/28/24), (Accessed Dec. 2024).

SOURCE: NV Dept. of Health and Human Svcs., Medicaid Services Manual, Federally Qualified Health Centers, Jan. 31, 2024, pg. 11, (Accessed Dec. 2024).

Originating Site: The FQHC may bill an encounter rate in lieu of the originating site fee, if the distant site (provider) is providing ancillary services. The originating site code, Q3014, must be used when billing in lieu of an encounter code.
Distant Site: FQHCs providing services for a recipient from a distant site may bill the appropriate encounter rate with Place of Service (POS) Code 02. Use of the POS code certifies the service meets telehealth requirements.

SOURCE: Nevada Dept. of Health and Human Services Billing Guidelines Federally Qualified Health Centers Billing Instructions, p. 1 (8/30/2019). (Accessed Dec. 2024).

GEOGRAPHIC LIMITS

A Medicaid Managed Care Organization shall not refuse to provide the coverage described in subsection 1 or the reimbursement described in subsection 2 because of:

The distant site from which a provider of health care provides services through telehealth or the originating site at which an insured receives services through telehealth; or
The technology used to provide the services

SOURCE: NV Revised Statute Sec. 695G.162. (Accessed Dec. 2024).

FACILITY/TRANSMISSION FEE

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.

SOURCE: NV Dept. of Health and Human Svcs., Medicaid Services Manual, Telehealth Services Chapter 3400, Section 3403.1, (11/28/23). (Accessed Dec. 2024).

Q3014 – Telehealth originating site facility fee.

In order to bill the Q3014 facility fee, an originating site must be enrolled as a Nevada Medicaid provider. Eligible sites 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 Paramedicine Services

Originating sites that cannot bill the facility fee (Q3014):

Recipient smart phones
Recipient home computers
Recipient’s home

Providers that bill per diem or encounter rates may bill an encounter rate in lieu of the originating site fee. Per diem or encounter-based providers would not bill HCPCS code Q3014 and an encounter code, as the facility fee is already included in the per diem/encounter rates. 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 Billing Guidelines Telehealth Billing Instructions, p. 2 (2/22/23) (Accessed Dec. 2024).

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 Dec. 2024).

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. 78 (8/28/24), (Accessed Dec. 2024).

Q3014 is listed as an allowable service for FQHC/CCBHC and CCBHC.

SOURCE: NV Medicaid, CCBHC Allowable Services and FQHC/CCBHC Allowable Services, (Accessed Dec. 2024).

SOURCE: NV Dept. of Health and Human Svcs., Medicaid Services Manual, Federally Qualified Health Centers, Jan. 31, 2024, pg. 11, (Accessed Dec. 2024).

Q3014 Telehealth Services is listed as an eligible CPT service for registered dietitians, community paramedics, community health workers, residential substance use treatment in an institution for mental disease, substance use treatment clinic and opioid treatment program.

SOURCE: Nevada Dept. of Health and Human Services Billing Guidelines Registered Dietitians Billing Instructions, (12/19/2019), Community Paramedics, Billing Instructions, (11/4/2019), Community Health Workers Billing Guide, (2/1/2022), residential substance use treatment in an institution for mental disease billing guide, (10/29/24), substance use treatment clinic (10/29/24), opioid treatment program (10/29/24). (Accessed Dec. 2024).

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New Hampshire

Last updated 12/16/2024

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 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.

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.

Nothing in this section shall be construed to prohibit the Medicaid program from providing coverage for only those services that are medically necessary and subject to all other terms and conditions of the coverage. Services delivered through telehealth under this section shall comply with all applicable state and federal law or regulation as allowed by the Medicaid program. Any conflict with the provisions of this section and federal law or regulation shall preempt and supersede any provision of this section.

This section shall be conditioned upon review and approval of a state plan amendment submitted by the department to the Centers for Medicare and Medicaid Services, as deemed necessary.

SOURCE: NH Revised Statutes 167:4-d (Accessed Dec. 2024).

All recipients shall be eligible for telehealth services when:

Telehealth, including teledentistry, is determined medically necessary pursuant to He-W 530.01(e); and
The recipient has consented to using telehealth, including teledentistry, as a method of receiving services.

Payment for Services

Payment to medical providers, described in He-C 5004.03 above, shall be made in accordance with rates established by the department in accordance with RSA 161:4, VI(a).
Services delivered via telehealth shall be reimbursed pursuant to RSA 167:4-d III(b) and (c).
Medical providers shall use appropriate CPT procedure codes and modifiers when billing.
Dental providers shall use CDT procedure codes when billing.
All claims for payment shall be submitted to the department’s fiscal agent.
All providers shall maintain supporting records in accordance with He-W 520.
All providers shall be responsible for determining that the recipient is Title XIX eligible on the date of service.
Payment for store and forward and remote patient monitoring shall only be available as funding and resources within the current state fiscal year are available.

Source: NH Admin Rules, HE-C 5004.02, and .13 (Accessed Dec. 2024).

An individual providing services by means of telemedicine or telehealth directly to a patient shall:

Use the same standard of care as used in an in-person encounter;
Maintain a medical record; and
Subject to the patient’s consent, forward the medical record to the patient’s primary care or treating provider, if appropriate; and
Provide meaningful language access if the individual is practicing in a facility that is required to ensure meaningful language access to limited-English proficient speakers pursuant to 45 C.F.R. section 92.101 or RSA 354-A, or to deaf or hard of hearing individuals pursuant to 45 C.F.R. section 92.102, RSA 521-A, or RSA 354-A.

Under this section, Medicaid coverage for telehealth services shall comply with the provisions of 42 C.F.R. section 410.78 and RSA 167:4-d.

SOURCE: NH Revised Statute 310-A:1-g, (Accessed Jul. 2024).

Medicaid covers services delivered via telehealth, as well as remote patient monitoring and store and forward services.

SOURCE: NH Medicaid, General Billing Manual, Oct. 2023, (Accessed Dec. 2024).

ELIGIBLE SERVICES/SPECIALTIES

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:

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;
By which telemedicine services for primary care and remote patient monitoring 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. A provider shall not be required to establish care via face-to-face in-person service when:
- 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

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.

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. See eligible provider section for list of eligible providers.

SOURCE: NH Revised Statutes 167:4-d (Accessed Dec. 2024).

Telehealth services shall be subject to the same service limits set forth in He-W 530.03.

Teledentistry services shall be subject to the same service limits set forth in He-W 566.04.

Telehealth services, provided through a medicaid managed care organization (MCO), as defined in He-W 506.03(h) shall be furnished in an amount, duration, and scope that is no less than the amount, duration, and scope for the same services furnished to recipients under fee-for-service as defined in He-W 506.03(f).

Installation to provide telehealth services or maintenance of telehealth hardware, software, or other equipment shall not be covered by Medicaid.

Source: NH Admin Rules, HE-C 5004.04 and 05, 09 (Accessed Dec. 2024).

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 Dec. 2024).

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 Dec. 2024).

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 Dec. 2024).

A Comprehensive Medication Review (CMR) is an interactive person-to-person or telehealth medication review and consultation conducted in real-time between the patient and/or other authorized individual, such as prescriber or caregiver, and the pharmacist or other qualified provider and is designed to

SOURCE: NH Medicaid Provider Provider Communication, To NH Medicaid Enrolled Providers, July 12, 2024, (Accessed Dec. 2024).

ELIGIBLE PROVIDERS

“Distant site” means the location of the health care provider delivering services through telemedicine at the time the services are provided.

Pursuant to RSA 167:4-d(f), medical providers shall 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 under RSA 151:2-b;
Midwives, governed by RSA 326-D;
Psychologists, governed by RSA 329-B;
Allied health professionals, governed by RSA 328-F;
Dentists, governed by RSA 317-A;
Mental health practitioners governed by RSA 330-A;
Community mental health providers employed by community mental health programs pursuant to RSA 135-C:7;
Alcohol and other drug use professionals, governed by RSA 330-C;
Dietitians, governed by RSA 326-H; and
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.

Each participating medical provider shall:

Be licensed to practice by the state of New Hampshire;
Be a NH enrolled Title XIX provider;
Request and obtain prior authorization in accordance with He-W 531.07 and dental request per He-W 566.07;
Assure the same rights to confidentiality and security as provided in face-to-face services; and
Ensure the patient’s informed consent to the use of telehealth and advise members of any relevant privacy considerations.

Medical providers shall adhere to the same standards of clinical practice and record keeping that apply to other covered services.

Source: NH Admin Rules, HE-C 5004.03, (Accessed Dec. 2024).

“Distant site ” means the location of the health care provider delivering services through telemedicine at the time the services are provided.

“Telehealth services” shall comply with 42 C.F.R. section 410.78, except for 42 C.F.R. section 410.78(b)(4). These 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 under RSA 151:2-b;
Midwives, governed by RSA 326-D;
Psychologists, governed by RSA 329-B;
Allied health professionals, governed by RSA 328-F;
Dentists, governed by RSA 317-A;
Mental health practitioners governed by RSA 330-A;
Community mental health providers employed by community mental health programs pursuant to RSA 135-C:7;
Alcohol and other drug use professionals, governed by RSA 330-C;
Dietitians, governed by RSA 326-H; and
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, (Accessed Dec. 2024).

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 Dec. 2024).

ELIGIBLE SITES

“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 telehealth, 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 Admin Rules, HE-C 5004.1, (Accessed Dec. 2024).

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 Dec. 2024).

“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 Dec. 2024).

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 Dec. 2024).

Medicaid to Schools Program

SOURCE: NH Medicaid to Schools Billing Guidelines and Billable Procedure Codes Companion to the Technical Assistance Guide, pg. 2 ( Mar. 1, 2022), ( Accessed Dec. 2024).

Telehealth: 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.

Place of service: School services will align with one of the following place of service codes that should be included on all claims:

03: school
02: telehealth

SOURCE: NH Medicaid: Medicaid to Schools Provider Manual, Mar. 2024, (Accessed Dec. 2024).

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 Dec. 2024).

FACILITY/TRANSMISSION FEE

No reference found.

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New Jersey

Last updated 08/20/2024

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 Aug. 2024).

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.

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 Aug. 2024).

SOURCE: NJ Statute C.30:4D-6K. (Accessed Aug. 2024).

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 Aug. 2024).

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 criteria (see regulation).

SOURCE: NJAC 10:31-2.3. (Accessed Aug. 2024).

Teledentistry

Effective for dates of service on or after July 1, 2023, the Division of Medical Assistance and Health Services (DMAHS) will limit synchronous teledentistry (using CDT code D9995 – synchronous real-time encounter) as a telehealth service to those with intellectual and developmental disabilities, those enrolled in MLTSS, and homebound individuals. Teledentistry must be billed with CDT code D0140 – limited oral evaluation – problem focused.

For Federally Qualified Health Centers – the encounter code (D0120 with modifier 22), along with D9995 and D0140, must be billed for the same date with all services submitted on the same claim.
For All Other Providers – both D9995 and D0140 must be billed for the same date with both services submitted on the same claim.

SOURCE: NJ Division of Medical Assistance and Health Services. Newsletter Vol. 33, No. 13, Aug. 2023, p. 1, 3. (Accessed Aug. 2024).

ELIGIBLE PROVIDERS

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 Aug. 2024).

Telepsychiatry

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 Medicaid client 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 Aug. 2024).

Local Education Agency Behavioral Health Services

NJ Medicaid or a managed care organization contracted with the Division to provide benefits to Medicaid beneficiaries, shall reimburse a local education agency for behavioral health services covered under Medicaid, delivered in-person or via telehealth, and provided to a student who is an eligible Medicaid beneficiary. Services provided under this subsection shall be:

Reimbursable by Medicaid regardless of whether the student participates in an Individualized Education program, 504 Accommodation Plan, Individualized Health Care Plan, or Individualized Family Service Plan; or whether the covered services are provided at no charge to the student; and
Provided by a licensed medical practitioner approved as a Medicaid provider or a local education agency approved as a Medicaid provider.

A local education agency shall utilize Medicaid reimbursement payments issued under this section to provide behavioral health services for students and their families which may include behavioral health assessment, case management, health education, and social emotional learning. The division, in conjunction with the Department of Education and the Department of the Treasury, shall assist a local education agency in implementing a plan to submit Medicaid claims for covered behavioral health services and obtain Medicaid reimbursements under this section.

SOURCE: NJ A3334 (2023 Session). (Accessed Aug. 2024).

Home Health Agencies

All telehealth services shall be provided in accordance with N.J.S.A. 45:1-61 through 66 and N.J.A.C. 13:35-6B.

All telehealth services shall be in addition to, and not in lieu of, direct patient care.

Clinical notes of all telehealth services shall be incorporated into the patient’s medical/health record according to the agency’s policies and procedures.

SOURCE: NJ Administrative Code 8:42-6.7. (Accessed Aug. 2024).

ELIGIBLE SITES

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 Aug. 2024).

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 Aug. 2024).

A provider must use the new Facility Code value of “10” for “Telehealth Provided in a Patient’s Home”. In addition, the description for the existing Facility Code “02” has been changed and must be reported when “Telehealth is Provided in Other Than a Patient’s Home”. The assignment of these Facility Code changes is applicable to both Fee-For-Service and encounter claims.

SOURCE: NJ Division of Medical Assistance and Health Services. Medicaid Alert 2023-02, Apr. 2023. (Accessed Aug. 2024).

Multiple billing supplements list Place of Service Code 02 (Telehealth is Provided in Other Than a Patient’s Home) and 10 (Telehealth Provided in a Patient’s Home) as allowed.

SOURCE: NJMMIS, Billing Supplements, Multiple Supplements including Psychologist and Physician, (Accessed Aug. 2024).

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 Aug. 2024).

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 Aug. 2024).

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New Mexico

Last updated 11/18/2024

POLICY

Reimbursement for professional services at the originating-site and the …

POLICY

SOURCE: NM Administrative Code 8.310.2.12(M)(d). (Accessed Nov. 2024).

New Mexico Medicaid will reimburse the originating site for services provided under telemedicine at the same rate as when the services are furnished without the use of a telecommunication system.

SOURCE: NM Human Services Dept. Behavioral Health Policy and Billing Manual for Providers Treating Medicaid Beneficiaries (2021) p. 30 (Accessed Nov. 2024).

Telemedicine is also covered by NM Managed Care.

SOURCE: NM Medical Assistance Division Managed Care Policy Manual, p. 323. Oct. 1, 2020. (Accessed Nov. 2024).

Effective October 1, 2022, New Mexico is updating its State Plan to clarify that telehealth and teleconsultation services are reimbursed at the same rate as face-to-face.

SOURCE: New Mexico State Plan Amendment, NM-22-0021, (Dec. 2022), (Accessed Nov. 2024).

Managed Care Program

The benefit package includes telemedicine services as detailed in 8.310.2 NMAC.

SOURCE: NM Admin Code Sec. 8.309.4.16 (Accessed Nov. 2024).

The benefit package includes telemedicine services as detailed in 8.310.2 NMAC. The MCO must:

promote and employ broad-based utilization of statewide access to Health Insurance Portability and Accountability Act (HIPAA)-compliant telemedicine service systems including, but not limited to, access to text telephones or teletype (TTYs) and 711 telecommunication relay services;
follow state guidelines for telemedicine equipment or connectivity;
follow accepted HIPAA and 42 CFR part two regulations that affect telemedicine transmission, including but not limited to staff and contract provider training, room setup, security of transmission lines, etc; the MCO shall have and implement policies and procedures that follow all federal and state security and procedure guidelines;
identify, develop, and implement training for accepted telemedicine practices;
participate in the needs assessment of the organizational, developmental, and programmatic requirements of telemedicine programs;
report to HSD on the telemedicine outcomes of telemedicine projects and submit the telemedicine report; and
ensure that telemedicine services meet the following shared values, which are ensuring: competent care with regard to culture and language needs; work sites are distributed across the state, including native American sites for both clinical and educational purposes; and coordination of telemedicine and technical functions at either end of network connection.

SOURCE: NM Admin Code 8.308.9.18. (Accessed Nov. 2024).

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 Nov. 2024).

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 Nov. 2024).

The alternative benefits package includes telemedicine services.

SOURCE: NM Centennial Care Managed Care Policy Manual, Oct. 1. 2020, (Accessed Nov. 2024).

ELIGIBLE SERVICES/SPECIALTIES

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 Nov. 2024).

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 Nov. 2024).

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 Nov. 2024).

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, Revised Aug. 2023 pg. 19. (Accessed Nov. 2024).

Medication-Assisted Abortion Services

HSD is adding an option for providing this medical service via telehealth. This service will also be reimbursed at a global rate. The code S0199 with the 95 Modifier will be opened to allow for the telehealth visits for medication-assisted abortion services that include the telehealth visits with counseling. Ancillary services related to the medication assisted abortion are included in the global reimbursement and should not be billed separately. However, services unrelated to the surgical abortion, but provided in the same visit, should be billed separately. For example, if the member receives contraceptive services, vaccines, or behavioral health services those shall be reimbursed separately from the global rate below.

SOURCE: NM Medical Assistance Program Manual, Supplement, Changes to Claim Submittal Process and Rates for Abortion Procedures, Aug. 21, 2023, Number 23-07, (Accessed Nov. 2024).

Crisis Services

Crisis Triage Centers: The following individuals and practitioners must be contracted or employed by the provider agency as part of its crisis triage center service delivery:…

a charge nurse on duty 24 hours/day, seven days/week this requirement may be met by a through access to a supervising nurse who is available via telehealth.

Community-based Mobile Crisis Intervention Services: All Mobile Crisis Intervention and Mobile Responsive and Stabilization Services must be under the supervision of an independently licensed behavioral health professional who must be available to provide real time clinical assessment in person or via telehealth.

Therapeutic Interventions: Services provided by licensed behavioral health practitioners via telehealth technologies are covered subject to the limitations as set forth in state regulations.

SOURCE: State Plan Amendment, Supplement A to Attachment 3.1A, (Accessed Nov. 2024).

Mobile crisis services are furnished by a multidisciplinary mobile crisis team (MCT) that includes at least two members. The team includes at least one behavioral health care professional able to conduct a mobile crisis screening and assessment within their permitted scope of practice under state law and who may be available via telehealth.

SOURCE: NM Medical Assistance Program Manual, Supplement, Implementation of Mobile Crisis Intervention Services and Mobile Response and Stabilization, Mar. 18, 2024, Number 24-03, (Accessed Nov. 2024).

Mobile Crisis Providers

MCT/MRSS Staffing Requirements – Mobile crisis intervention services are furnished by a multidisciplinary team that includes at least two members. The team includes at least one behavioral health care professional able to conduct a clinical assessment within their permitted scope of practice under state law and who may be available via telehealth.

See supplement for codes for mobile crisis providers.

SOURCE: NM Medical Assistance Program Supplement, Mobile Crisis Providers, Number 24-14, Oct. 7, 2024, (Accessed Nov. 2024).

Crisis Triage Centers – Staffing Requirements

Minimum staffing requirements:…

The CTC shall have an RN present on-site 24 hours a day, seven days a week or as long as clients are present in programs that do not offer residential services, to provide direct nursing services. This requirement does not apply to CTCs offering 23 hours or less non-residential services; instead these CTCs may have onsite medical professionals who have access to immediate support and supervision by an RN or a higher-level provider in accordance with Section 24-25-1 et al. NMSA 1978 New Mexico Telehealth Act.
An on-call physician or advanced practice registered nurse shall be available 24 hours a day by phone, and available on-site as needed or through telehealth.
Consultation by a psychiatrist or prescribing psychologist may be provided through telehealth.

SOURCE: NM Administrative Code 8.321.11.29. (Accessed Nov. 2024).

Medication Assisted Treatment Services in Correctional Settings

Facility contracts with medical service provider (to include onsite or telemedicine resources).

SOURCE: NM Administrative Code 8.321.12.9. (Accessed Nov. 2024).

Staffing Requirements – Correctional Facilities

Correctional facilities shall:

Develop adequate staffing patterns including healthcare practitioners authorized by law to prescribe, administer, and monitor medication-assisted treatment (to include telehealth-supported clinical review or services if necessary).

SOURCE: NM Administrative Code 8.325.12.11. (Accessed Nov. 2024).

ABA Services

Training and participation by members of the Family Set are also seen as important components. Every Treatment Plan must include ample units of ABA Stage 3 97156 and 97157. For a member of the Family Set who is unable to participate in every ABA Stage 3 session, the BA/Mentored BA is required to provide alternative methods such as the use of telemedicine to encourage the participation of the recipient’s Family Set members.

The ABA Treatment Plan must identify all target behaviors that are to be addressed by the ABA Stage 3 practitioners. The following elements are required in the treatment plan: …

Be recipient-centered, Family Set-focused, and minimally intrusive, with a focus on family engagement, training, and support; if members of the Family Set cannot face-to-face attend the recipient’s sessions, then other opportunities must be explored, such as the members of the Family Set participating via telemedicine (in real-time or through store-and-forward means)

See supplement for additional details.

SOURCE: NM Medical Assistance Program Supplement, Applied Behavior Analysis (ABA) Guidance, Number 24-13, Sept. 17, 2024, (Accessed Nov. 2024).

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 Nov. 2024).

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 Nov. 2024).

Behavioral Health

Distant site – The location where the telemedicine provider is physically located at the time of the telemedicine service. See subsection M of 8.310.2.

SOURCE: NM Human Services Dept. Behavioral Health Policy and Billing Manual for Providers Treating Medicaid Beneficiaries (2021) p. 27 (Accessed Nov. 2024).

Mobile Response

Children’s Mobile Response and Stabilization Services (MRSS) teams include at least one behavioral health care professional able to conduct a mobile crisis screening and assessment within their permitted scope of practice under state law, who may be available via telehealth.

Community Health Worker

A CHW service provided in accordance with NMAC 8.310.2.12.M may be billed using one of the following modifiers:

GT: Interactive telecommunication; or
95: Synchronous Telemedicine Service Rendered via Real-Time Interactive Audio and Video Telecommunications System.

SOURCE: NM Medical Assistance Program Supplement, Number 24-08, May 31, 2024, (Accessed Nov. 2024).

ABA Services Delivered via Telehealth

New Mexico does not require an in-state AEP/Qualifying Psychologist/BCBA-D/BCBA/BCaBA/RBT/BCAT/noncertified BT to have a telemedicine license. However, if the AEP is an out of state MD/DO, the New Mexico Medical Board does require this practitioner to obtain a telemedicine license (or a full NM medical license).

The BICC, BACB, and New Mexico Regulation and Licensing Department (RLD) psychologist’s practice board allows and supports the use of telehealth to deliver ABA services. MAD allows and encourages the utilization of telemedicine to deliver MAD ABA services to assist AEPs and AP agencies provide cost effective and home and community-based services to rural and frontier areas of New Mexico.

SOURCE: NM Medical Assistance Program Supplement, Applied Behavior Analysis (ABA) Guidance, Number 24-13, Sept. 17, 2024, (Accessed Nov. 2024).

Mobile Crisis Providers

Telehealth is allowable, however in vivo MCT and MRSS response is preferred. MCT and MRSS providers can use telehealth to ensure rapid response and clinical decision-making to ensure the crisis is resolved safely.

SOURCE: NM Medical Assistance Program Supplement, Mobile Crisis Providers, Number 24-14, Oct. 7, 2024, (Accessed Nov. 2024).

ELIGIBLE SITES

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 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 Nov. 2024).

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 Nov. 2024).

School-based services provided via telemedicine are covered.

SOURCE: NM Administrative Code 8.320.6.13(I). (Accessed Nov. 2024).

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 Nov. 2024).

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 Nov. 2024).

Behavioral Health

Originating site -The location of an eligible Medicaid recipient at the time the service is furnished via an interactive telecommunications system. See subsection M of 8.310.2.

Importantly, a health coverage plan may not impose originating-site restriction (e.g., home) with respect to telemedicine services. There should be no distinguishing between provided telemedicine services to patients in rural locations or those in urban locations, (NMSA, 1978, Section 13-7-14. B).

SOURCE: NM Human Services Dept. Behavioral Health Policy and Billing Manual for Providers Treating Medicaid Beneficiaries (2021) p. 27 (Accessed Nov. 2024).

GEOGRAPHIC LIMITS

No Reference Found

FACILITY/TRANSMISSION FEE

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.

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(d). (Accessed Nov. 2024).

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 Nov. 2024).

Indian Health Services and Tribal 638s

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 Nov. 2024).

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 Nov. 2024).

READ LESS

New York

Last updated 12/10/2024

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.

NYS Medicaid covered services provided via telehealth include assessment, diagnosis, consultation, treatment, education, care management and/or self-management of a NYS Medicaid member. This definition includes audio-only services when audio-visual is unavailable, or a member chooses audio-only. Decisions on what type of visit the NYS Medicaid member receives should be based on their best interest, not that of the provider nor for the convenience of the provider. A visit must contain all elements of the billable procedure codes or rate codes and all required documentation.

Under NYS Law Chapter 45 Article 29-G §2999-DD, healthcare services delivered by means of telehealth are 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. Exceptions from payment parity exist for some facility types, including Article 28 licensed facilities. Such exceptions exclude certain costs, including facility fees when such costs were not incurred to deliver telehealth services because neither the patient nor the provider were located at the facility or clinic setting when the service was delivered. This law is effective until April 1, 2026.

See manual for modifiers and place of service codes to be used when billing for telehealth modalities, as well as billing instructions for telehealth by site and location.

SOURCE: NY Dept. of Health Medicaid Telehealth Policy Manual (May 2024), p. 3, 6-7, 12-15, 25-28. (Accessed Dec. 2024).

Payment for telehealth services shall be made in accordance with section 538.3 of this Part only if the provision of such services appropriately reduces the need for on-site or in-office visits and certain modality-specific standards are met. As required by Social Services Law § 367-u and, except for services paid by State only funds, contingent upon federal financial participation, reimbursement shall be made in accordance with fees determined by the commissioner based on and benchmarked to in-person fees for equivalent or similar services. Reimbursement shall not be made for services that do not warrant separate reimbursement as identified by the department during fraud, waste and abuse detection efforts. The department reserves the right to request additional documentation and deny payment for services deemed duplicative or included in a primary service. Any potential fraud, waste, or abuse, identified through claims monitoring or any other source, will be referred to the Office of Medicaid Inspector General.

SOURCE: NY Code of Rules and Regs. Title 18, Sec. 538, as added by Final rule per Notice Of Adoption. (Accessed Dec. 2024).

Recent Legislation Effective until April 1, 2026

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) and extended by S 8307 (2024 Session). (Accessed Dec. 2024).

Mental Health

A program applying for use of Telehealth Services must complete a “Telehealth Services Standards Compliance Attestation” form (AppendixA) and append it to the administrative action. The attestation assures OMH that the Provider’s plan for the use of telehealth conforms to the technological and clinical standards prescribed by 14 NYCRR Part 596 and applicable guidance. The “Technical Guidelines Checklist for Local Providers” (Appendix B) may be used as a guide to assist the program in purchasing equipment or choosing a telehealth platform.

SOURCE: NY Office of Mental Health, Telehealth Services Guidance for OMH Providers, 2023, pg. 44. (Accessed Dec. 2024).

ELIGIBLE SERVICES/SPECIALTIES

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.

The acquisition, installation and maintenance of telecommunication devices or systems is not reimbursable. Providers should bill using the claim format appropriate to their category of service.

SOURCE: NY Dental Policy and Procedure Code Manual 2025, page 71-75 (Accessed Dec. 2024).

Teledentistry allows dentists and dental hygienists to deliver care from a distance; this includes performing evaluations and delivering services within scope of practice, using either synchronous or asynchronous means. When services are provided via teledentistry (audio-visual telehealth) to a member located at an originating site, the servicing provider should bill for the telemedicine encounter as if the provider saw the member in-person using the appropriate billing rules for services rendered. Required accompanying codes “D9995” or “D9996” will identify the encounter as synchronous or asynchronous. For billing of bundled routine dental care services, one claim should be submitted, using the date information is captured as the date of service for asynchronous evaluations. For bundling information, see pages 8-10 of the Dental Policy and Procedure Manual at NEW YORK STATE DENTAL POLICY AND PROCEDURE MANUAL (emedny.org).

Dental telehealth services shall adhere to the standards of appropriate patient care required in other dental health care settings, including but not limited to appropriate patient examination and review of the medical and dental history of the patient. For additional information, providers can refer to NYS Law Chapter 45 Article 29-G §2999-DD.

Teledentistry may be employed during encounters delivered under a collaborative practice arrangement, as determined by the dentist or dental hygienist.

SOURCE: NY Dept. of Health Medicaid Telehealth Policy Manual (May 2024), p. 14-15. (Accessed Dec. 2024).

Teleradiology

Reimbursement for professional services delivered via teleradiology shall be made only for the final radiology read and must be billed separately from the technical and administrative component as specified by the commissioner in administrative guidance.

Hospitals and physicians shall bill the professional and technical and administrative components separately in accordance with the relevant Radiology Fee Schedule set forth in subdivision (a) of section 533.6 of this Title.

SOURCE: NY Code of Rules and Regs. Title 18, Sec. 538.3(c), as added by Final rule per Notice Of Adoption. (Accessed Dec. 2024).

Telemental Health

Telemental Health Services may be authorized by the office for licensed, designated or otherwise approved services provided by telehealth 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 telehealth practitioner is located at the distant/hub site and is employed by or contracted with a program licensed or designated by the Office;
The person receiving services is present during the encounter;
The request for telehealth 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 telehealth practitioner at the distant/hub site is (1) authorized in New York State; (2) practicing within his/her scope of specialty practice; and (3) 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, as proposed to be amended by Final Rule and Notice Of Adoption. (Accessed Dec. 2024).

Telehealth services may be used to satisfy specific statutory examination, evaluation, or assessment requirement necessary for the involuntary removal from the community, or involuntary retention in a hospital, pursuant to section 9.27 of the Mental Hygiene Law, and for the immediate observation, care and treatment in a hospital, pursuant to section 9.39 of the Mental Hygiene Law, if such services are utilized in compliance with regulations. See Final Rule for additional details.

SOURCE: NY Code of Rules and Regs. Title 14, Sec. 596.6(12-13), as proposed to be amended by Final Rule and Notice Of Adoption. (Accessed Dec. 2024).

Restrictions for Office of Mental Health

Licensed programs may use Telehealth Technologies, including Audio-visual or Audio-only modalities for the provision of all Clinic CPT procedure codes, except:

Injectable Medication Administration with Monitoring and Education (H2010) and Injection
Only (96372) is restricted to in-person only.
Health Physical (99382-99387) (New Patient) and 99392-99397 (Established Patient) – is restricted to in-person or Audio-visual only.
Developmental (96110, 96111) and Psychological Testing (96101, 96116, 96118) is restricted to in-person or Audio-visual for testing administration.

See April 2023 Telehealth Services Guidance for OMH Providers for more information.

SOURCE: NY Dept. of Health Medicaid Telehealth Policy Manual (May 2024), p. 29. (Accessed Dec. 2024).

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.

SOURCE: NY Compilation of Codes, Rules and Regulations, Title 14, Chapter XXI, Part 830.5(d). (Accessed Dec. 2024).

Gambling Disorder Treatment

Effective January 1, 2023, New York State (NYS) Medicaid fee-for-service (FFS) and Medicaid Managed Care (MMC) Plans will begin covering Gambling Disorder treatment provided to individuals receiving services from the Office of Addiction Services and Supports (OASAS) certified programs. These services may be delivered face to face on-site at the certified location, via telehealth, and in the community. See Medicaid Update for billing guidance.

SOURCE: NY Dept. of Health, Medicaid Update, Vol. 38, Number 10, September 2022 (Accessed Dec. 2024)

Office for People with Developmental Disabilities (OPWDD) Services

OPWDD will continue to allow the use of Remote Technologies, where appropriate, to remotely deliver the following services authorized under OPWDD’s Comprehensive HCBS 1915(c) Waiver: Day Habilitation, Community Habilitation, Prevocational Services, Supported Employment, Pathway to Employment, Support Broker, and Respite Services. Remote technology cannot be an exclusive, long-term service delivery option. Additional requirements and information for the delivery of remote services is available in 21-ADM-03 Ability to use Technology to Remotely Deliver Home and Community-Based Services available at https://opwdd.ny.gov/system/files/documents/2021/07/21-adm-03-hcbs-remote-technology_final.pdf.

SOURCE: OPWDD Post-PHE Memo, Apr. 2023. (Accessed Dec. 2024).

Effective May 12, 2023, with the end of the Public Health Emergency (PHE), the State of New York will continue to allow the remote delivery of CSIDD through telephonic or other technology in accordance with State, Federal, and Health Insurance Portability and Accountability Act (HIPAA) requirements. Other technology means any two-way, real-time communication technology that meets HIPAA requirements. See Telehealth Allowance Attachment which will serve as an addendum to CSIDD ADM #2021-04R and outlines the allowance of the remote delivery of Crisis Services for Individuals with Intellectual and/or Developmental Disabilities (CSIDD).

SOURCE: OPWDD ADM#2021-04R Telehealth Allowance Attachment, Jul. 2024. (Accessed Dec. 2024).

Restrictions for OPWDD

Independent Practitioner Services for Individuals with Developmental Disabilities (IPSIDD) services are prohibited from being delivered via telehealth. This guidance also does not apply to services authorized pursuant to OPWDD’s Section 1915(c) Comprehensive Home and Community-Based Services (HCBS) Waiver.

See OPWDD Regulation: 14 CRR-NY 635-13.4(c) for more information.

SOURCE: NY Dept. of Health Medicaid Telehealth Policy Manual (May 2024), p. 29. (Accessed Dec. 2024).

Office for People with Developmental Disabilities (OPWDD) Article 16 Clinics – Individuals with Intellectual/Developmental Disabilities (I/DD)

Various procedure codes are approved by OPWDD for use in Article 16 clinics via telehealth, designated as allowed for either or both live video and audio-only. See Article 16 APG Crosswalk for codes.

SOURCE: OPWDD A16 APG Crosswalk 2024. (Accessed Dec. 2024).

Doula Services for Pregnant and Postpartum People

Effective March 1, 2024, New York State (NYS) Medicaid will reimburse for doula services for all pregnant and postpartum NYS Medicaid members needing the service. Between March 1, 2024, through September 30, 2024, doula services will be carved out of the Medicaid Managed Care (MMC) benefit package. NYS Medicaid-enrolled doula providers may bill Medicaid fee-for-service (FFS) for covered doula services, including doula services provided to MMC enrollees during this period. Effective October 1, 2024, doula services will be covered by MMC Plans [inclusive of mainstream MMC Plans, Human Immunodeficiency Virus-Special Needs Plans (HIV-SNPs), as well as Health and Recovery Plans (HARPs)]. Doula services provided to MMC enrollees between March 1, 2024 and September 30, 2024 will be billed to Medicaid FFS. Doula services provided on or after October 1, 2024, will be billed to the MMC Plan of the enrollee. Doula services are provided on an individual basis with the NYS Medicaid member.

To qualify for NYS Medicaid reimbursement for perinatal doula services, the service:

- must involve a direct interaction with the NYS Medicaid member;
- must meet the minimum time frame for the doula service; and
- can be administered in-person or via telehealth, in accordance with NYS Medicaid telehealth policy (providers should refer to the NYS Department of Health “NYS Medicaid Telehealth” web page.)

SOURCE: New York State Medicaid Update – March 2024 Volume 40 – Number 3. (Accessed Dec. 2024).

Perinatal visits can occur in-person or via telehealth.

Current NYS Medicaid Telehealth policy will apply to reimbursable perinatal services.

To qualify for Medicaid reimbursement for perinatal doula services, the service:…

Can be administered in-person or via telehealth according to current Medicaid telehealth policy.

To qualify for Medicaid reimbursement for labor and delivery doula services, the service:…

Must be provided to the Medicaid member in-person except in extenuating circumstances, such as illness, emergency or precipitous birth, in which case the current telehealth policy will apply

Labor & Delivery doula services are to be provided in-person except in extenuating circumstances such as illness or precipitous birth, in which case the current NYS Medicaid Telehealth policy will apply.

SOURCE: New York State Medicaid Program, Doula Services Benefit Policy Manual, Oct. 2024. (Accessed Dec. 2024).

Coverage of doula services by Medicaid Managed Care (MMC) Plans is delayed until January 1, 2025. Doula services provided to MMC enrollees between March 1, 2024, and December 31, 2024, will continue to be billed to Medicaid fee-for-service (FFS). Effective January 1, 2025, doula services will be covered by MMC Plans [inclusive of mainstream MMC Plans, Human Immunodeficiency Virus-Special Needs Plans (HIV-SNPs), as well as Health and Recovery Plans (HARPs)].

Doula services are provided on an individual basis with the NYS Medicaid member. To qualify for NYS Medicaid reimbursement for perinatal doula services, the service:

must involve a direct interaction with the NYS Medicaid member;
must meet the minimum time frame for the doula service; and
can be administered in-person or via telehealth, in accordance with NYS Medicaid telehealth policy, which can be found on the NYS Department of Health (DOH) “NYS Medicaid Telehealth” web page.

To qualify for NYS Medicaid reimbursement for labor and delivery doula services, the service:

must involve a direct interaction with the NYS Medicaid member;
must be provided to the NYS Medicaid member in-person except in extenuating circumstances, such as illness, emergency, or precipitous birth, in which case the current telehealth policy will apply; and
must be in attendance by a licensed perinatal services provider in order for the doula to be reimbursed for the labor and delivery encounter.

SOURCE: New York State Medicaid Update – August 2024 Volume 40 – Number 8. (Accessed Dec. 2024).

Restrictions for Adult Day Health Care and Home Health Care

Telehealth is not acceptable:

For in-person initial medical, clinical, mental health, or dental assessments;
To perform the Functional Supplement component of the Uniform Assessment SystemNew York (UAS-NY);
At any time when the patient is not able to access a secure location; or
As a substitute for in-person delivery of any personal care services by a provider licensed under Article 36 of the Public Health Law, or for the delivery of meals or congregate or rehabilitative activities or for required resident/patient supervision services in any setting.

See DAL 23-27 for more information.

Restrictions for 1915(c) Children’s Home and Community-Based Services Waiver

1915(c) waiver services may not be delivered via telehealth without explicit authority in the waiver.

Restrictions for Opioid Treatment Programs (OTPs)

Per the Substance Abuse and Mental Health Services Administration (SAMHSA) Final Rule published February 2, 2024:

Screenings can be undertaken by non-OTP practitioners who work outside of the OTP and telehealth is permitted.
Telehealth screenings and full examinations for methadone must be audio-visual.
Telehealth screenings and full examinations for buprenorphine can be audio-visual or audio only.

See Medications for the Treatment of Opioid Use Disorder, 89 FR 7528, (Feb. 2, 2024) for more information.

Restrictions for School Based Health Centers (SBHCs)

The SBHC vaccine administration rate codes 1381, 1382, and 1383 are not allowable via telehealth. See Section 9.15 of the Medicaid Telehealth Manual for additional guidance on billing SBHC rate codes.

SOURCE: NY Dept. of Health Medicaid Telehealth Policy Manual (May 2024), p. 28-30. (Accessed Dec. 2024).

Genetic Counseling

Genetic counseling services may be provided in a practitioner’s office or in an Article 28 hospital outpatient department (OPD) or diagnostic and treatment center (D&TC) or via telemedicine.

SOURCE: New York State Medicaid Program, Fee for Services Laboratory Manual Policy Guidelines, Version 2021-1, pg. 17. (Accessed Dec. 2024).

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, as added by Final rule per Notice Of Adoption. (Accessed Dec. 2024).

To receive reimbursement from NYS Medicaid, providers submitting telehealth claims or encounters must be NYS-licensed and enrolled in NYS Medicaid. The enrollment requirement is applicable only to enrollable provider types, including pharmacies and most licensed practitioners.

SOURCE: NY Dept. of Health Medicaid Telehealth Policy Manual (May 2024), p. 6. (Accessed Dec. 2024).

Providers who may deliver telehealth 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 Telehealth Policy Manual (May 2024), p. 10. (Accessed Dec. 2024).

Telehealth provider shall also include:

Voluntary foster care agencies certified by the New York State Office of Children and Family Services and licensed pursuant to article twenty-nine-I of Public Health Law, and providers employed by those agencies.
Providers licensed or certified by the New York State Department of Education to provide Applied Behavioral Analysis therapy.
Radiologists licensed pursuant to Article 131 of the Education Law and credentialed by the site from which the radiologist practices;
All Medicaid providers and providers employed by Medicaid facilities or provider agencies who are 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 needs and are within a provider’s scope of practice.

SOURCE: NY Code of Rules and Regs. Title 18, Sec. 538.1, as added by Final rule per Notice Of Adoption & NY Dept. of Health Medicaid Telehealth Policy Manual (May 2024), p. 10. (Accessed Dec. 2024).

Effective until April 1, 2026

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) and extended by S 8307 (2024 Session). (Accessed Dec. 2024).

Telemental Health

Telehealth services may be authorized by the office for licensed, designated, or otherwise approved services provided by telehealth 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, other identified location, or other temporary location out-of-state. Services may be delivered via telehealth unless otherwise specified by guidelines established by the Office.

‘Telehealth practitioner’ means (i) a prescribing professional eligible to prescribe medications pursuant to federal regulations; or (ii) staff authorized by OMH to provide in-person services are authorized to provide behavioral health services via telehealth consistent with their scope of practice where applicable, and in accordance with guidelines established by the Office.

SOURCE: NY Code of Rules and Regs. Title 14, Sec. 596.4(i) & 596.5(a), as proposed to be amended by Final Rule and Notice Of Adoption. (Accessed Dec. 2024).

Distant or “hub” site means the distant secure location, as defined in Section 596.6(a)(1)(vi[i]) of this Part, at which the practitioner rendering the service using telehealth services is located. The distant/hub site telehealth practitioner must possess a current, valid license, permit, or limited permit to practice in New York State, or is designated or approved by the Office to provide services, amongst other requirements. Telehealth practitioners may deliver services from a site located within the United States or its territories, which may include the practitioner’s place of residence, office, or other identified space approved by the Office and in accordance with Office guidelines.

SOURCE: NY Code of Rules and Regs. Title 14, Sec. 596.4(b) & Sec. 596.6(a), as proposed to be amended by Final Rule and Notice Of Adoption. (Accessed Dec. 2024).

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 Dec. 2024).

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 providers acting within their scope of practice.

All dental telehealth providers shall identify themselves to patients, including providing the professional’s New York state license number. Dental telehealth services shall adhere to the standards of appropriate patient care required in other dental health care settings, including but not limited to appropriate patient examination and review of the medical and dental history of the patient.

SOURCE: NY Dental Policy and Procedure Code Manual 2025, page 71-72. (Accessed Dec. 2024).

Federally Qualified Health Centers (FQHCs)

FQHCs can bill the Prospective Payment System (PPS) rate code “4012” or “4013”, depending on on-site presence as outlined in “Billing Rules for Telehealth Services”, “FFS Billing for Telehealth by Site and Location” in the Medicaid Telehealth Manual. Wrap payments are available for any telehealth services, including telephonic services reimbursed by an MMC Plan, under qualifying PPS and off-site rate codes.

When a POS is allowable on a claim or encounter, providers should report POS “02” for telehealth provided other than in patient’s home, “10” for telehealth provided in the home of the patient, except in cases where POS “11” is typically submitted (private practice or office setting); POS “11” providers should continue to report POS “11” and use telehealth modifiers on the claim or encounter to identify it as telehealth.

See Manual for additional billing instructions for Telehealth by Site and Location.

SOURCE: NY Dept. of Health Medicaid Telehealth Policy Manual (May 2024), p. 18. (Accessed Dec. 2024).

An eligible threshold visit is defined as a medically necessary, face-to-face (either in person or via telehealth), medical or behavioral health service rendered by specified practitioners. See Medicaid Comprehensive Guidance for NY FQHCs and RHCs article in the March 2024 Medicaid Update for more information.

SOURCE: New York State Medicaid Update – March 2024 Volume 40 – Number 3. (Accessed Dec. 2024).

Community Health Workers

Current NYS Medicaid telehealth service policy applies to coverage of CHW services as indicated in the telehealth service policy.

SOURCE: New York State Medicaid Program, Community Health Worker Services Manual, Oct. 2024, pg. 8. (Accessed Dec. 2024).

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 Dec. 2024).

On professional claims, place of service (POS) “02”, “10”, or “11” must be coded to document the location of the NYS Medicaid member during the telehealth visit.

SOURCE: NY Dept. of Health Medicaid Telehealth Policy Manual (May 2024), p. 6. (Accessed Dec. 2024).

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 Dec. 2024).

Teledentistry

Most health care facilities and health care settings can be originating sites, as well as a Medicaid Member’s place of residence in NYS or temporary location out of state.

Place of Service (POS) code: Use 02 on professional claims to specify the location teledentistry associated services were provided.

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. 2025. P. 71-72. (Accessed Dec. 2024).

Telemental Health

The recipient can be physically located at a provider site licensed by the office, or the recipient’s place of residence, other identified location, or other temporary location out-of-state.

Originating or “spoke” site means a site where the recipient is physically located at the time mental health services are delivered to them by means of telehealth services, which may include the recipient’s place of residence, other identified location, or other temporary location out-of-state.

SOURCE: NY Code of Rules and Regs. Title 14, Sec. 596.4(b)(e), Sec. 596.5(a), & Sec. 596.6(a) as proposed to be amended by Final Rule and Notice Of Adoption. (Accessed Dec. 2024).

Upon receipt of the application for use of Telehealth Services, 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 Telehealth Services as part of the routine certification process. This review may be achieved by having the Field Office licensing staff log on to the hub and/or spoke site’s telecommunication system to ascertain the quality of the transmission. See guidance for details.

SOURCE: NY Office of Mental Health, Telehealth Services Guidance for OMH Providers, 2023, pg. 44. (Accessed Dec. 2024).

Hospital Inpatient Billing for Audio-Visual Telehealth

When a telehealth consult is being provided by a distant-site physician to a NYS Medicaid member who is an inpatient in the hospital, payment for the telehealth encounter may be billed by the distant-site physician. Other than physician services, all other practitioner services are included in the All Patient Revised – Diagnosis Related Group (APR-DRG) payment to the facility.

Skilled Nursing Facility Billing for Audio-Visual Telehealth

When the services of the telehealth practitioner are included in the nursing home rate, the telehealth practitioner must bill the nursing home. If the services of the telehealth practitioner are not included in the nursing home rate, the telehealth practitioner should bill NYS Medicaid as if practitioner saw the NYS Medicaid member in-person. The CPT code billed should be appended with the applicable telehealth modifier. Practitioners providing services via telehealth should confirm with the nursing facility whether their services are in the nursing home rate.

SOURCE: NY Dept. of Health Medicaid Telehealth Policy Manual (May 2024), p. 28. (Accessed Dec. 2024).

GEOGRAPHIC LIMITS

Any secure site within the fifty United States (U.S.) or U.S. territories, is eligible to be a distant site for delivery and payment purposes, including but not limited to, Federally Qualified Health Centers (FQHCs) and providers homes, for NYS Medicaid-enrolled patients.

SOURCE: NY Dept. of Health Medicaid Telehealth Policy Manual (May 2024), p. 6. (Accessed Dec. 2024).

FACILITY/TRANSMISSION FEE

Exceptions from payment parity exist for some facility types, including Article 28 licensed facilities. Such exceptions exclude certain costs, including facility fees when such costs were not incurred to deliver telehealth services because neither the patient nor the provider were located at the facility or clinic setting when the service was delivered.

Private office, Urgent care or Emergency Department facility seeking consultation: The Originating-site practitioner may bill CPT code Q3014; and if 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.

See Medicaid Telehealth Manual for further site and location billing instructions.

SOURCE: NY Dept. of Health Medicaid Telehealth Policy Manual (May 2024), p. 12. (Accessed Dec. 2024).

Skilled nursing facilities may not bill for the “Q3014” originating site fee.

SOURCE: NY Dept. of Health Medicaid Telehealth Policy Manual (May 2024), p. 28. (Accessed Dec. 2024).

Teledentistry

Procedure code Q3014 may be used by the provider at the originating site. Must be reported on claim line #1. Report any additional services rendered on subsequent lines.

SOURCE: Dental Procedure Manual. 2025. P.72. (Accessed Dec. 2024).

See Medicaid Telehealth Manual for when the originating site practitioner may bill CPT code Q3014.

SOURCE: NY Dept. of Health Medicaid Telehealth Policy Manual (May 2024), p. 15-17. (Accessed Dec. 2024).

READ LESS

North Carolina

Last updated 12/09/2024

POLICY

Medicaid shall cover the procedure, product, or service related …

POLICY

Medicaid shall cover the procedure, product, or service related to this policy when 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.

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.

General

An eligible beneficiary shall be enrolled in the NC Medicaid Program (Medicaid is NC Medicaid program, unless context clearly indicates otherwise).
Provider(s) shall verify each Medicaid 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.

Provider Provider(s) shall bill their usual and customary charges. For a schedule of rates, refer to: https://medicaid.ncdhhs.gov/

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).

Unless otherwise required for a specific service, Medicaid 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.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, June 1, 2023. (Accessed Dec. 2024).

See NC Medicaid’s bulletin on flexibilities to support providers and members as a result of Hurricane Helene.

SOURCE: NC Div. of Medical Assistance, Bulletin: Hurricane Helene Policy Flexibilities to Support Providers and Members – Oct. 11, 2024, (Accessed Dec. 2024).

ELIGIBLE SERVICES/SPECIALTIES

Medicaid shall cover services delivered via telehealth, virtual communications, and remote patient monitoring services when the all the following additional criteria are followed before rendering services via telehealth, virtual communications, or remote patient monitoring:

Provider(s) shall ensure that services can be safely and effectively delivered using telehealth, virtual communications, or remote patient monitoring.
Provider(s) shall consider a beneficiary’s behavioral, physical and cognitive abilities to participate in services provided using telehealth, virtual communications, or remote patient monitoring.
The beneficiary’s safety must be carefully considered for the complexity of the services provided.
In situations where a caregiver or facilitator is necessary to assist with the delivery of services via telehealth, virtual communications, or remote patient monitoring, their ability to assist and their safety must also be considered.
Delivery of services using telehealth, virtual communications, or remote patient monitoring must conform to professional standards of care: ethical practice, scope of practice, and other relevant federal, state and institutional policies and requirements, such as Practice Act and Licensing Board rules;
Provider(s) shall obtain and document verbal or written consent. In extenuating circumstances when consent is unable to be obtained, this must be documented.
Beneficiaries are not required to seek services through telehealth, virtual communications, or remote patient monitoring, and shall be allowed access to in-person services, if the beneficiary requests;
Provider(s) shall verify the beneficiary’s identity using two points of identification before initiating service delivery via telehealth, virtual communications, or remote patient monitoring.
Provider(s) shall ensure that beneficiary privacy and confidentiality is protected to the best of their ability.

A range of services may be delivered via telehealth, virtual communication, and remote patient monitoring to Medicaid 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.

Each set of eligible services has its own set of eligible provider(s) as defined in Attachment A of this policy or Refer to https://medicaid.ncdhhs.gov/ for the related coverage policies.

Telehealth, including:

office or other outpatient services and office and inpatient consultation codes; and
hybrid telehealth visit with supporting home visit codes.

In addition to the eligible services and providers listed in Attachment A of this policy, the policies listed under “Related Clinical Coverage Policies” at the top of this document also include telehealth coverage information, such as telehealth-eligible services and providers. Please refer to those policies for program-specific telehealth guidance.

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 should not be used for virtual patient communications (including telephonic evaluation and management services) or remote patient monitoring.

General Criteria Not Covered

Medicaid shall not cover the procedure, product, or service related to this policy when:

the beneficiary does not meet the eligibility requirements listed in Section 2.0;
the beneficiary does not meet the criteria listed in Section 3.0;
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.

List of eligible Office or Other Outpatient Service and Office and Inpatient Consultation Codes and Hybrid Telehealth Visit with Supporting Home Visit Codes provided on page 12 of Attachment A of the Telehealth, Virtual Communications and Remote Patient Monitoring manual.

* Family Planning beneficiaries are not eligible for new patient visit via telehealth.

Guidance: 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 at https://medicaid.ncdhhs.gov/ for billing guidance for this model.

Well-child services are not eligible to be delivered via the hybrid model.

Providers shall choose the most appropriate code based on the complexity of the services provided and document accordingly. If time is used as a determining factor, providers shall choose the code that corresponds with the length of the telehealth visit provided by the eligible provider (not the duration of the home visit performed by the delegated staff person).

The delegated staff person may perform vaccinations in the home as long as they comply with applicable vaccination requirements (e.g., staff person’s scope of practice), and may conduct other tests or screenings, as appropriate.

Any vaccinations, tests or screenings conducted in the home should be billed as if they were delivered within the office, without modifiers.

Local Health Departments may also utilize the hybrid model when the telehealth visit is rendered by an eligible provider and may bill the home visit codes listed in table C.1.

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).

Triage and screening services provided to a beneficiary by a mobile crisis provider may be provided via telehealth or telephonically. Providers shall bill the MCM HCPCS with modifier GT for services provided via telehealth or modifier KX for services provided via telephonic, audio-only communication.

Note: Due to workforce shortages, we are delaying the implementation of these new requirements. The previous policies will be posted to our clinical coverage page and the previous requirements will continue effective Feb. 15, 2023, while we develop a path forward.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Policy Update for Behavioral Health Providers Effective Feb. 15, 2023 & Updated Version March 3, 2023, (Accessed Dec. 2024).

Telephonic Claims: Modifier KX must be appended to the CPT or HCPCS code to indicate that a service has been provided via telephonic, audio-only communication.

Telehealth and telephonic 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. 8F, Research-Based Behavioral Health Treatment (RB-BHT) for Autism Spectrum Disorder (ASD), Amended Apr. 1, 2023. (appears in multiple additional manuals), (Accessed Dec. 2024).

Telehealth Claims: 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 services provided via telephonic, audio-only communication [or virtual patient communication or remote patient monitoring – depending on manual]. Depending on which manual, a list of eligible codes may be provided.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 8C, Outpatient Behavioral Health Services, Nov. 1, 2023, (appears in multiple additional manuals), (Accessed Dec. 2024).

Telehealth eligible services may be provided to both new and established patients by the eligible providers listed within this policy. See manual for eligible telehealth codes.

SOURCE: NC Div. of Medical Assistance, Clinical Coverage Policies Dialysis Services Amended Aug. 15, 2023, (appears in multiple additional manuals), (Accessed Dec. 2024).

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, amended Apr. 1, 2023. (appears in multiple additional manuals), (Accessed Dec. 2024).

Outpatient Behavioral Health

As outlined in Attachment A, select services within this clinical coverage policy can 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/.

24-Hour Coverage for Behavioral Health Crises: This coverage must incorporate the ability for the beneficiary to speak with the licensed clinician on call either in-person, via telehealth, or telephonically.

See list of behavioral health codes provided in manual and whether or not its telehealth eligible on page 40.

Note: Please refer to Clinical Coverage Policy 1-H: Telehealth, Virtual Patient Communications, and Remote Patient Monitoring for utilization and billing guidance on virtual patient communication codes (e.g., online digital E&M, telephonic E&M, and interprofessional consultation) and remote patient monitoring codes (e.g., self-measured blood pressure and remote physiologic monitoring) billable by eligible psychiatric prescribers but which are not contained in Clinical Coverage Policy 8C.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 8C, Outpatient Behavioral Health Services, Nov. 1, 2023. (Accessed Dec. 2024).

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.

Use modifier SC to bill non–behavioral health visits that occur after the first encounter in which the beneficiary appears with, presents with, or suffers illness or injury requiring additional diagnosis or treatment.

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, Aug. 15, 2023. (Accessed Dec. 2024).

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, Telehealth, Virtual Communications and Remote Patient Monitoring. 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, Apr. 1, 2023. (Accessed Dec. 2024).

Opioid Treatment Program

Access to timely services within the OTP are the following:

Clinical staff available five (5) days per week to offer and provide counseling, as needed (either in-person or telehealth)

Necessary support systems within the OTP include: …

Behavioral health crisis response (de-escalation or coordination of care), when clinically appropriate, 24-hours a day, seven days a week telephonically or via telehealth.

All other physician medical services may be provided physically on-site or through telehealth, as medically appropriate.

Clinical services may be provided on-site or through telehealth based on beneficiary’s needs.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 8A-9, Opioid Treatment Program Services, Oct. 15, 2023. (Accessed Dec. 2024).

Independent Practitioners

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, 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.

CPT codes that may be billed when service is furnished via telehealth are indicated in Attachment A, Section C: Codes.

See page 42 for list of eligible codes for telehealth services.

CPT codes that may be billed when service is furnished via telehealth are indicated in Attachment A, Section C: Codes.

SOURCE: NC Div. of Medical Assistance, Independent Practitioners, Clinical Coverage Policy No: 10B, Amended Apr. 1, 2023, (Accessed Dec. 2024).

Outpatient Specialized Therapies – Local Education Agencies

CPT codes that may be billed when service is furnished via telehealth are indicated in Attachment A, Section C: Codes.

A select set of speech and language evaluation and treatment interventions and 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, experiencing an acute crisis, during an extended school closure, or if their school is remote or underserved such that access to appropriately qualified providers is limited.

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 Apr. 1, 2023, (Accessed Dec. 2024).

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 1H Telehealth, Virtual Communications and Remote Patient Monitoring. Telehealth delivery 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.

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.

Note: CPT codes that may be billed when service is furnished via telehealth are indicated in Clinical Coverage Policy 10B, Independent Practitioners Attachment A, Section C: Codes.

SOURCE: NC Div. of Medical Assistance, Clinical Coverage Policy 10A: Outpatient Specialized Therapies, Amended June 15, 2024, (Accessed Dec. 2024).

Family Planning Services

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 set forth in Clinical Coverage Policy 1-H: Telehealth, Virtual Communications, and Remote Patient Monitoring.

List of eligible telehealth service codes provided page page 23.

Family planning services must be billed with the appropriate code using the FP modifier. All providers, except ambulatory surgical centers, must append modifier FP to the procedure code for family planning services.

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 Apr. 15, 2023, (Accessed Dec. 2024).

Home Health Services

Face to Face Encounter: 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 in accordance with Section 6407 of the Patient Protection and Affordable Care Act.

Telehealth may be implemented in accordance with 42 CFR 440.70 and clinical coverage policy 1H, Telehealth, Virtual Patient Communications and Remote Monitoring at https://medicaid.ncdhhs.gov/.

SOURCE: NC Div. of Medical Assistance, Clinical Coverage Policies 3A Home Health Services, Amended Apr. 1, 2023, (Accessed Dec. 2024).

Dietary Evaluation and Counseling and Medical Lactation Services

Non-Telehealth Claims: 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 Aug. 15 2023, (Accessed Dec. 2024).

Diabetes Outpatient Self-Management Education

See page 13 for eligible telehealth services.

SOURCE: NC Div. of Medical Assistance, Clinical Coverage Policies Diabetes Outpatient Self-Management Education Amended June 1, 2023, (Accessed Dec. 2024).

Independent Practitioners Respiratory Therapy Services

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.

Note: CPT codes that may be billed when service is furnished via telehealth are indicated in Attachment A, Section C: Codes.

See page 22 of the manual for list of eligible telehealth services.

SOURCE: NC Div. of Medical Assistance, Clinical Coverage Policies Independent Practitioners Respiratory Therapy Services Amended Apr. 1, 2023, (Accessed Dec. 2024).

Pregnancy Medical Home

See page 14 for list of telehealth eligible services.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1E-6, Pregnancy Management Program, Apr. 1, 2023. (Accessed Dec. 2024).

Enhanced Mental Health and Substance Abuse Services

List of telehealth eligible services provided on page 28-32, including for crisis management triage and screening.

As outlined in Attachments A and D, select services within this clinical coverage policy may be provided via telehealth and telephonically. Services delivered via telehealth and telephonically must follow the requirements and guidance in clinical coverage Policy 1-H, Telehealth, Virtual Communications, and Remote Patient Monitoring, at https://medicaid.ncdhhs.gov/.

Service Definition and Required Components Mobile Crisis Management (MCM) involves all support, services and treatments necessary to provide integrated crisis response, crisis stabilization interventions, and crisis prevention activities. Mobile Crisis Management services are available at all times, 24-hours-a-day, 7-days-a-week, 365-days-a-year. Crisis response provides an immediate evaluation, triage and access to acute mental health, intellectual/developmental disabilities, or substance abuse services, treatment, and supports to effect symptom reduction, harm reduction, or to safely transition persons in acute crises to appropriate crisis stabilization and detoxification supports or services. These services include immediate telephonic or telehealth response to assess the crisis and determine the risk, mental status, medical stability, and appropriate response.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Enhanced Mental Health and Substance Abuse Services Amended Oct. 1, 2024, (Accessed Dec. 2024).

Facility-Based Crisis Service for Children and Adolescents

Under certain circumstances, a beneficiary shall be seen by the psychiatrist in-person or via telehealth within 24 hours of their admission to the Facility-Based Crisis Service.

See page 20 for list of eligible telehealth codes.

Note: As specified within this policy, components of this service may be provided via telehealth by the psychiatrist. Due to this service containing other elements that are not permitted via telehealth, the GT modifier is not appended to the HCPCS code to indicate that a service component has been provided via telehealth.

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 15, 2023, pg. 5, (Accessed Dec. 2024).

Children’s Developmental Service Agencies (CDSAs)

See page 19-20 for telehealth eligible services.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No. 8-J, Children’s Developmental Service Agencies (CDSAs) Amended Nov. 1, 2023, (Accessed Dec. 2024).

North Carolina Innovations

In addition to telehealth criteria specified in clinical coverage Policy 1-H, Telehealth, Virtual Patient Communications, and Remote Patient Monitoring, at https://medicaid.ncdhhs.gov/. The provision of NC Innovations waiver services using telehealth may only occur when it is clinically indicated for the beneficiary and the beneficiary needs only verbal cueing or prompting to complete tasks

See page 38 for list of telehealth billable services.

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.

Supported Living

The Supported Living provider shall be responsible for providing an individualized level of supports determined during the assessment process, including risk assessment, and identified and approved in the Individual Support Plan (ISP) and have 24 hour per day availability, including back-up and relief staff and in the case of emergency or crisis. Some beneficiaries receiving Supported Living services may be able to have unsupervised periods of time based on the assessment process. In these situations, a specific plan for addressing health and safety needs must be included in the ISP and the Supported Living provider shall have staffing available in the case of emergency or crisis. Requirements for the beneficiary’s safety in the absence of a staff person must be addressed and may include use of tele care options. When assessed to be appropriate Assistive Technology elements may be utilized in lieu of direct care staff.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy 8-P, North Carolina Innovations Amended Apr. 1, 2023, (Accessed Dec. 2024).

Research-Based Behavioral Health Treatment (RB-BHT) for Autism Spectrum Disorder (ASD)

See list of telehealth billable services on page 20-21.

Acute Inpatient Hospital Services

Teleconsults – Refer to clinical coverage policy 1H, Telemedicine and Telepsychiatry, at https://medicaid.ncdhhs.gov/, for billing instructions and coverage criteria.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy 2A-1, Acute Inpatient Hospital Services Amended Sept. 23, 2024, (Accessed Dec. 2024).

Childbirth Education

HCPCS Code S9442 is eligible for telehealth service.

Note: Telehealth eligible services may be provided to both new and established patients by the eligible providers listed within this policy.

Maximum beneficiaries (excluding partners) in both telehealth and non-telehealth group classes is limited to 10.

For telehealth group classes, the provider is responsible for making the beneficiary aware of the public nature of online classes.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy 1M-2, Childbirth Education Amended Aug. 15, 2023 (Accessed Dec. 2024).

Health and Behavior Intervention

CPT codes 96158 and 96159 are eligible for telehealth service.

Note: Telehealth eligible services may be provided to both new and established patients by the eligible providers listed within this policy.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy 1M-3, Health and Behavior Intervention Amended Aug. 15, 2023, (Accessed Dec. 2024).

Obstetrical Services

Select services within this clinical coverage policy may be provided via telehealth. Services delivered via telehealth must follow the requirements and guidance set forth in Clinical Coverage Policy 1-H: Telehealth, Virtual Patient Communications, and Remote Patient Monitoring here: Refer to https://medicaid.ncdhhs.gov

Note: Prenatal and postpartum visits conducted via telehealth (interactive audio and video) shall count as a visit within a global or package service. Telephone calls or online communications do not replace a telehealth or in person visit for prenatal care and do not count towards global or package services. The postpartum delivery period should not be confused with the twelve-month postpartum MPW coverage.

Hybrid Telehealth Visit with Supporting Home Visit – Physicians, nurse practitioners, physician assistants and certified nurse midwives shall conduct antepartum or postpartum care via a telehealth visit, with a supporting visit to the beneficiary’s private residence made by an appropriately trained, delegated staff person, when medically necessary.

Telehealth Claims: Global/Package Billing – Append the GT modifier to the global or package code to indicate that one or more of the visits were conducted via telehealth under that package. This modifier is not appropriate for virtual patient communications or remote patient monitoring

Individual Visit Billing- When OB services are provided and billed per visit (refer to Section 3.2.4 for billing individual prenatal visits) append GT modifier to each visit conducted via telehealth. This modifier is not appropriate for virtual patient communications or remote patient monitoring.

Telehealth claims shall be filed with the provider’s usual place of service code(s) and not place of service 02 (Telehealth).

Billing Prenatal and Postpartum Services Via Telehealth – Eligible providers, including physicians, nurse practitioners, physician assistants, and certified nurse midwives may conduct antepartum and postpartum care visits via telehealth. These visits may not be conducted via virtual patient communication (for example, telephone conversations). To promote early initiation of prenatal care, providers shall conduct the initial antepartum visit and pregnancy risk screen via telehealth or in-person in the office or clinic setting. When the initial visit is conducted via telehealth, a follow-up visit must be conducted in person within the first trimester of pregnancy.

Providers performing tobacco cessation counseling are required to bill with CPT codes 99406 or 99407 with an appropriate tobacco use disorder diagnosis code. Append modifier GT if performed via telehealth.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy 1E-5, Obstetrical Services Amended June 15, 2024, (Accessed Dec. 2024).

1915(c) TBI Waiver

NC Medicaid has submitted a 1915(c) TBI Waiver amendment to (CMS) to make the following Appendix K flexibilities permanent: …

Allow real time two-way interactive audio and video telehealth for Life Skills Training, Cognitive Rehabilitation, Day Support, Supported Employment; Supported Living and Community Networking to be delivered via telehealth.

SOURCE: NCDHHS NC Medicaid Division of Health Benefits, Update: TBI Waiver 1915 (c) and Appendix K Flexibilities, Nov. 3, 2023, (Accessed Dec. 2024).

Traumatic Brain Injury Appendix K

The following telehealth policies will be implemented Mar. 1, 2024:

Waiver members may access Life Skills Training, Cognitive Rehabilitation, Day Supports, Supported Employment, Supported Living, Community Networking via telehealth.
Telehealth is not intended to supplant a full meaningful day, but rather to complement it. Services that support community integration are not eligible for 100% telehealth delivery.
The provider shall document that any platforms used to conduct telehealth activities are in accordance with the requirements of the Health Insurance Portability and Accountability Act (HIPAA).
The use of telehealth shall not exceed 25% of the authorized service hours per week (i.e. if an individual is authorized 40 hours a week, the individual may use the real time two-way interactive audio and video telehealth 10 hours week).

Effective March 1, 2024, monthly and quarterly care coordination/waiver member meetings for individuals receiving residential supports or new to waiver shall occur face-to-face.

SOURCE: NCDHHS NC Medicaid Division of Health Benefits, Update: NC Medicaid Guidance on Sunsetting of Traumatic Brain Injury Appendix K Flexibilities, Jan. 30 2024, (Accessed Dec. 2024).

Innovations Waiver

NC Medicaid submitted a 1915(c) Innovations Waiver amendment to (CMS) to make the following Appendix K flexibilities permanent:

Allow access to real time two-way interactive audio and video telehealth for Community Living Support including Day Support, Supported Employment, Supported Living, and Community Networking.

Members may access Community Living Support; Day Support, Supported Employment, Supported Living, and Community Networking via telehealth.

Telehealth is not intended to replace a full meaningful day, but rather to complement it. Services that support community integration are not eligible for 100% telehealth delivery.
The provider shall document any platform used to conduct telehealth activities is in accordance with the requirements of the Health Insurance Portability and Accountability Act (HIPAA).
The use of telehealth shall not exceed 25% of the authorized service hours per week

(i.e. if an individual is authorized 40 hours a week, the individual may use the real time two-way interactive audio and video telehealth 10 hours week).

SOURCE: NCDHHS NC Medicaid Division of Health Benefits, Update: Innovation Waiver 1915 (c) and Appendix K Flexibilities, Jan. 30, 2024, (Accessed Dec. 2024).

Counseling may be provided in person, through live audio/video (telehealth) or telephonically. Additionally, this service may be billed by multiple providers and may be billed multiple times on different days. Different than for COVID-19 counseling, use of this code for Beyfortus counseling is limited to beneficiaries 0 to 19 months of age.

There is no requirement for a specific diagnosis code. The following coding criteria will apply:

Requires 25 modifier if in addition to OV E&M, if applicable.
Requires GT modifiers if provided via telehealth.
Requires KX modifiers if provided telephonically.

SOURCE: NCDHHS NC Medicaid Division of Health Benefits, Update: NC Medicaid Respiratory Syncytial Virus (RSV) Guidelines for 2023-2024, Jan. 24, 2024, (Accessed Dec. 2024).

CPT 99401 can be billed at only one visit for each beneficiary per day, but there are no quantity limits for the number of times this education can be provided to an individual beneficiary. Counseling may be provided in person, through live audio/video (telehealth) or telephonically. Additionally, this service can be billed by multiple providers and can be billed multiple times on different days.

There is no requirement for a specific diagnosis code. The following coding criteria will apply:

Requires 25 modifier if in addition to OV E&M, if applicable.
Requires GT modifiers if provided via telehealth.
Requires KX modifiers if provided telephonically.

SOURCE: NCDHHS NC Medicaid Division of Health Benefits, Update: COVID-19 Vaccine and Reimbursement Guidelines for 2023-2024 for NC Medicaid, Dec. 14, 2023, (Accessed Dec. 2024).

Individual Placement and Support (IPS) – Mental Health & Substance Use

The IPS Team shall have weekly vocational unit meetings inclusive of all IPS staff to review caseloads, share beneficiaries’ progress, successes, and needs, job leads, and other issues. In-person meetings are preferred. IPS teams can use a virtual telehealth platform that is Health Insurance Portability and Accountability Act (HIPAA) compliant for vocational unit meetings for no more than three meetings a month. It is recommended that cameras are used during this meeting. Telephonic participation in the vocational unit meetings is not allowed.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy 8H-2, Individual Placement and Support (IPS) – Mental Health & Substance Use, Amended Nov. 1, 2023, (Accessed Dec. 2024).

Teledentistry

Teledentistry eligible services may be provided to both new and established patients by the eligible providers listed within this policy.

D9995 – Teledentistry – synchronous; real-time encounter

Medicaid enrolled dentists may render provider to provider teledentistry services via synchronous, live audio and video transmission
Dentist in the distant site must have enough information and evidence to make a diagnosis
Must be billed with oral evaluation codes D0140 or D0170
Reported in addition to other procedures delivered on the same date of service
Dental treatment rendered through teledentistry must be documented in the beneficiary record including the date/time/duration of encounter, reasons for the encounter, technology used, records reviewed, diagnosis, and treatment recommendations
Limited to four teledentistry services (D9995 or D9996) in a six-month period
The originating site is the facility in which the beneficiary is located
The distant site is the facility from which the provider furnishes the teledentistry service
All services sites/providers must be Medicaid enrolled
Consultation must take place by an encrypted two-way real-time interactive audio and video telecommunications system
Enter “02” (Telehealth) as the place of treatment for teledentistry claims

SOURCE: NC Medicaid Clinical Coverage Policy 4A: Dental Services, Dec. 15, 2023, (Accessed Dec. 2024).

Medical and Routine Eye Exams

Medical and routine eye exams and visual aids are not covered under the NC Medicaid Clinical Coverage Policy 1H, Telehealth, Virtual Communications and Remote Patient Monitoring. Therefore, providers may not utilize the modalities included in Clinical Coverage Policy 1H when providing a medical or routine eye exam or providing visual aid services for NC Medicaid Direct beneficiaries or NC Medicaid Managed Care members.

SOURCE: NCDHHS Update, Reminder: Medical and Routine Eye Exams and Visual Aids are not Covered Under Telehealth, Feb. 29, 2024, (Accessed Jul. 2024).

Assertive Community Treatment Act (ACT) Program

The specific roles and responsibilities required by the psychiatric care providers cannot be adequately met when relying on telemedicine or telepsychiatry, and therefore are not covered when delivering this community based service.

SOURCE: NC Medicaid Clinical Coverage Policy 8A-1: Assertive Community Treatment Act (ACT) Program, Apr. 1, 2023, (Accessed Dec. 2024).

ELIGIBLE PROVIDERS

The distant site is the location from which the provider furnishes 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 in Attachment A below.

Each set of eligible services has its own set of eligible provider(s) as defined in Attachment A of this policy or Refer to https://medicaid.ncdhhs.gov/ for the related coverage policies.

Up to three different consulting providers may be reimbursed for a separately identifiable telehealth service provided to a beneficiary per date of service.

To be eligible to bill for the procedure, product, or service related to this policy, the provider(s) shall:

meet Medicaid qualifications for participation;
have a current and signed Department of Health and Human Services (DHHS) Provider Administrative Participation Agreement; and
bill only for procedures, products, and services that are within the scope of their clinical practice, as defined by the appropriate licensing entity.

The following HCPCS code can be billed for the Telehealth originating site facility fee by the originating site (the site at which the beneficiary is located): Q3014

When the originating site is a hospital, the originating site facility fee must be billed with RC780 and Q3014.

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.

* Family Planning beneficiaries are not eligible for new patient visit via telehealth.

Guidance: Hybrid Telehealth with Supporting Home Visit (“Hybrid Model”)

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 at https://medicaid.ncdhhs.gov/ for billing guidance for this model.

Well-child services are not eligible to be delivered via the hybrid model.

Any vaccinations, tests or screenings conducted in the home should be billed as if they were delivered within the office, without modifiers.

Local Health Departments may also utilize the hybrid model when the telehealth visit is rendered by an eligible provider and may bill the home visit codes listed in table C.1.

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).

Eligible providers listed on Telehealth Services code charts include:

Physicians;
Nurse practitioners;
Psychiatric Nurse Practitioner
Certified nurse midwives;
Physician’s assistants; and
Clinical pharmacist practitioners

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.

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.

Independent Practitioners

Telehealth eligible services may be provided to beneficiaries by the eligible providers listed within this policy.

SOURCE: NC Div. of Medical Assistance, Independent Practitioners, Clinical Coverage Policy No: 10B, Amended Apr. 1, 2023, (Accessed Dec. 2024).

Teledentistry

Teledentistry eligible services may be provided to both new and established patients by the eligible providers listed within this policy.

D9995 – Teledentistry – synchronous; real-time encounter

Medicaid enrolled dentists may render provider to provider teledentistry services via synchronous, live audio and video transmission
Dentist in the distant site must have enough information and evidence to make a diagnosis
All services sites/providers must be Medicaid enrolled
Enter “02” (Telehealth) as the place of treatment for teledentistry claims

SOURCE: NC Medicaid Clinical Coverage Policy 4A: Dental Services, Dec. 15, 2023, (Accessed Dec. 2024).

Obstetrical Services

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy 1E-5, Obstetrical Services Amended June 15, 2024, (Accessed Dec. 2024).

The psychiatrist shall conduct a psychiatric assessment of each beneficiary in person or via telehealth within 24 hours of admission. The psychiatrist shall provide consultation to and supervision of staff; this supervision must be available onsite whenever needed and must occur onsite no less than one day per week, averaged over each quarter.

A beneficiary shall be seen by the psychiatrist in-person or via telehealth within 24 hours of their admission to the Facility-Based Crisis Service.

Peer Support Services

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/.

Note: Telehealth eligible services may be provided to both new and established patients by the eligible providers listed within this policy.

The intent of the service is to be community-based rather than office-based. Service may be provided via telehealth or telephonic, audio-only communication. Telehealth or telephonic, audio-only communication time is supplemental rather than a replacement of in-person contacts and is limited to twenty (20) percent or less of total service time provided per beneficiary per fiscal year. Documentation of service rendered via telehealth or telephonic, audio-only communication with the beneficiary or collateral contacts (assisting beneficiary with rehabilitation goals) must be documented according to Subsection 5.5 of this policy.

Telehealth and telephonic, audio-only communication 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. 8G, Peer Support Services pgs. 5, 7 &17 & Attachment A, pgs. 20-21, Amended Apr. 15, 2023. (Accessed Dec. 2024).

See NC Medicaid’s bulletin on flexibilities to support providers and members as a result of Hurricane Helene.

SOURCE: NC Div. of Medical Assistance, Bulletin: Hurricane Helene Policy Flexibilities to Support Providers and Members – Oct. 11, 2024, (Accessed Dec. 2024).

Respiratory Syncytial Virus

There is no requirement for a specific diagnosis code. The following coding criteria will apply:

Requires 25 modifier if in addition to OV E&M, if applicable.
Requires GT modifiers if provided via telehealth.
Requires KX modifiers if provided telephonically.

SOURCE: NC Div. of Medical Assistance, Bulletin: NC Medicaid Respiratory Syncytial Virus (RSV) Guidelines for 2024-2025, September 6, 2024, (Accessed Dec. 2024).

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.

Telehealth, virtual communication, and remote patient monitoring claims should be filed with the provider’s usual place of service code(s) and not place of service 02 (Telehealth). Exception: Hybrid telehealth with supporting home visits should be filed with Place of Service (POS) 12 (home).

Guidance: Hybrid Telehealth with Supporting Home Visit (“Hybrid Model”)

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).

When the originating site is a hospital, the originating site facility fee must be billed with RC780 and Q3014.

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).

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).

For infant weight element for diagnostic lactation assessment, the weight cannot be conducted via telephone and audio/video.

SOURCE: NC Div. of Medical Assistance, Clinical Coverage Policies Dietary Evaluation and Counseling and Medical Lactation Services Amended Aug. 15, 2023, pg. 18, (Accessed Dec. 2024).

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

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).

Respiratory Therapy Services

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.

SOURCE: NC Div. of Medical Assistance, Clinical Coverage Policies Independent Practitioners Respiratory Therapy Services Amended Apr. 1, 2023, (Accessed Dec. 2024).

Teledentistry

Teledentistry eligible services may be provided to both new and established patients by the eligible providers listed within this policy.

D9995 – Teledentistry – synchronous; real-time encounter

The originating site is the facility in which the beneficiary is located
All services sites/providers must be Medicaid enrolled
Consultation must take place by an encrypted two-way real-time interactive audio and video telecommunications system

SOURCE: NC Medicaid Clinical Coverage Policy 4A: Dental Services, Dec. 15, 2023, (Accessed Dec. 2024).

Obstetrical Services

Telehealth claims shall be filed with the provider’s usual place of service code(s) and not place of service 02 (Telehealth).

Billing for Hybrid Telehealth Visit with a Supporting Home Visit – Providers Billing Global OB or Package Codes:

To reflect the additional cost of the delegated staff person attending the patient’s home, eligible providers may bill a telehealth originating site facility fee for each telehealth visit conducted with a supporting visit. The originating site fee shall be billed in addition to the pregnancy global package codes.
To be reimbursed for the originating site facility fee for this care model, all of the listed 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 with the date of service for which the home visit is conducted.
- The telehealth originating site facility fee 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 antepartum or postpartum hybrid telehealth visit is included in the global or package code for the pregnancy. There is no separate evaluation and management code billing outside of the package or global code for the providers portion of the home visit.

Note: Refer to Clinical Coverage Policy 1-H: Telehealth, Virtual Patient Communications, and Remote Patient Monitoring for more information about originating site facility fees.

Providers Billing Individual Prenatal Visits:

Providers shall bill the appropriate level Home Service evaluation and management code for each telehealth visit with a supporting home visit made by an appropriately trained delegated staff person.
Providers should not bill the originating site facility fee.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy 1E-5, Obstetrical Services Amended June 15, 2024, (Accessed Dec. 2024).

Peer Support Services

As outlined in Attachment A, select services within this clinical coverage policy may be provided via the telephonic, audio-only communication method. Telephonic services may be transmitted between a beneficiary and provider in a manner that is consistent with the CPT and HCPCS code definition for those services.

Refer to subsection 3.2.5.1 for Telephonic-Specific Criteria; and subsection 7.1 for Compliance requirements.

Telehealth and telephonic, audio-only communication claims should be filed with the provider’s usual place of service code(s).

Pregnancy Management Program

Non-Telehealth Claims: Providers shall follow applicable modifier guidelines.

Telehealth eligible services may be provided to new and established patients by the eligible providers listed within this policy.

Telehealth claims must 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, Pregnancy Management Program Amended Apr. 1, 2023. (Accessed Dec. 2024).

GEOGRAPHIC LIMITS

There are no restrictions on the originating or distant sites.

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.

The following HCPCS code can be billed for the Telehealth originating site facility fee by the originating site (the site at which the beneficiary is located): Q3014.

When the originating site is a hospital, the originating site facility fee must be billed with RC780 and Q3014.

Guidance: Hybrid Telehealth with Supporting Home Visit (“Hybrid Model”)

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).

Obstetrical Services

Billing for Hybrid Telehealth Visit with a Supporting Home Visit – Providers Billing Global OB or Package Codes:

To reflect the additional cost of the delegated staff person attending the patient’s home, eligible providers may bill a telehealth originating site facility fee for each telehealth visit conducted with a supporting visit. The originating site fee shall be billed in addition to the pregnancy global package codes.
To be reimbursed for the originating site facility fee for this care model, all of the listed 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 with the date of service for which the home visit is conducted.
- The telehealth originating site facility fee 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 antepartum or postpartum hybrid telehealth visit is included in the global or package code for the pregnancy. There is no separate evaluation and management code billing outside of the package or global code for the providers portion of the home visit.

Note: Refer to Clinical Coverage Policy 1-H: Telehealth, Virtual Patient Communications, and Remote Patient Monitoring for more information about originating site facility fees.

Providers Billing Individual Prenatal Visits:

Providers shall bill the appropriate level Home Service evaluation and management code for each telehealth visit with a supporting home visit made by an appropriately trained delegated staff person.
Providers should not bill the originating site facility fee.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy 1E-5, Obstetrical Services Amended June 15, 2025, (Accessed Dec. 2024).

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North Dakota

Last updated 11/12/2024

POLICY

All qualified telehealth services must:

Meet the same standard

…

POLICY

All qualified telehealth services must:

Meet the same standard of care as in-person care.
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.
Use appropriate coding as noted in the following tables. Health care professionals must follow CPT®/HCPCS coding guidelines.

SOURCE: ND Div. of Medical Assistance, Telehealth, (Jul. 2024), (Accessed Nov. 2024).

ELIGIBLE SERVICES/SPECIALTIES

See excel document of Telehealth Covered Services in Telehealth Policies section on Manuals Webpage.

Institutional Claims:

Applicable Revenue Codes(s): 780 – Telehealth – facility charges related to the use of telehealth.
Applicable Modifiers:
- GT or 95: Via interactive audio and video telecommunication systems. Billed by performing health care professional for real-time interaction between the professional and the patient who is located at a distant site from the reporting professional. Modifiers are not required for Medicare primary claims

Services that are not covered:

Store and forward (G2010)
Virtual check-in (G2012)
Digital Assessment and Management Services (98970-98972)

SOURCE: ND Div. of Medical Assistance, Telehealth, (Jul. 2024), (Accessed Nov. 2024).

Dentistry

Teledentistry code D9995 or D9996 is required when billing ND Medicaid. Service authorization is not required. See manual for covered services.

Patient records must include the CDT© Code(s) that reflect the teledentistry encounter. The claim submission must include all applicable CDT© codes. ND Medicaid will reimburse CDT© code D9995 or D9996 once per date of service. Claim submissions must be billed using place of service (POS)/place of treatment codes:

02 Teledentistry provided in a location other than the patient’s home.
10 Telehealth provided in patient’s home.

Claims with any other place of service will be denied.

Non Covered Services

Examinations via online/email/electronic communication
Patient contact with dentist who provides the consultation using audio means only (no visual component)
Virtual check-in

SOURCE: North Dakota Human Services Dental Manual, Teledentistry, pg. 11 (Jul. 2024), (Accessed Nov. 2024).

Noncovered Services

Non-face-to-face services, except for services listed in the Telehealth policy
Services rendered via telehealth that are not on the list of approved telehealth services.

SOURCE: ND Div. of Medical Assistance, Non-Covered Medicaid Services, (Oct. 2024), (Accessed Nov. 2024).

Medicaid Services Rendered in Schools

Health Services billed by schools can be delivered via telehealth; however, no originating site fee is allowed. See Telehealth policy for additional information.

SOURCE: ND Div. of Medical Assistance, School Based Medicaid, p. 7, (Oct. 2024), (Accessed Nov. 2024).

Home Health Services

A face-to-face encounter for the initial ordering of home health services, must occur no more than 90 days before or 30 days after the start of home health services. Face-to face encounters: …

May be performed via telehealth or in-person, telephone encounters are insufficient.

SOURCE: ND Div. of Medical Services, Home Health and Private Duty Nursing, (Oct. 2024), (Accessed Nov. 2024).

Behavioral Health

Behavioral Health Manual indicates codes that can be delivered via telehealth.

SOURCE: ND Div. of Medical Assistance, Behavioral Health, (Jul. 2024), (Accessed Nov. 2024).

Substance Use Disorder

Substance use manual indicates codes that can be delivered via telehealth.

Telehealth coverage for partial hospitalization is limited to 50% or 10 hours of the weekly 20 hours of structured programming requirement.

SOURCE: ND Div. of Medical Assistance, Substance Use Disorder, (Jul. 2024), (Accessed Nov. 2024).

Pharmacy Manual

Medication Therapy Management (MTM) services: Face-to-Face (including telehealth) visit is required for new patients (CPT 99605).

Allowed for Reimbursement:

Synchronous telehealth visits with real-time audio/visual conferencing

SOURCE: ND Medicaid Pharmacy Medical Billing Manual, Apr. 2024, (Accessed Nov. 2024).

1915(I) Medicaid State Plan Amendment Home and Community Based Behavioral Health Services

Remote service delivery is allowable as specified within each service.

Telehealth is allowable as specified within each service. Telehealth limits, codes, and modifiers are available at 1915i Codes.Rates_.Limits 2.1.24.pdf (nd.gov)

SOURCE: ND Medicaid, 1915(I) Medicaid State Plan Amendment Home and Community Based Behavioral Health Services, Oct. 2024, (Accessed Nov. 2024).

Medication for Opioid Use Disorder

For OTPs, a clinical assessment that meets the requirements in 42 CFR § 8.12(f)(4) must be conducted, face to face or by telehealth, as clinically appropriate, at least once every three months for the first year of continuous treatment, and at least once every six months for each subsequent year

The member must require at least one face-to-face or telehealth check‐in per month for prescribing or dispensing OBOT/OTP medication. For those receiving buprenorphine based treatment, the prescriber has deemed it medically necessary to treat the member’s opioid addiction with buprenorphine products.

Telehealth must be provided in accordance with applicable federal and state laws and policies and follow the Controlled Substances Act (CSA) (28 USC Part 802) for prescribing and administration of controlled substances.

SOURCE: ND Medicaid, Medication for Opioid Use Disorder, Jan. 2024, (Accessed Nov. 2024).

Preventative Services and Chronic Disease Management

Preventive medicine counseling and risk factor reduction may be rendered via telehealth. See Telehealth policy for telehealth requirements.

Screening, Brief Intervention and Referral to Treatment (SBIRT)

SBIRT may be rendered via telehealth if providers document member pre-screening and the member’s score which indicates the need for a full screen. Providers must also document the member’s standardized assessment score. See Telehealth policy for telehealth requirements.

SOURCE: ND Medicaid, Preventative Services and Chronic Disease Management, Oct. 2024, (Accessed Nov. 2024).

ELIGIBLE PROVIDERS

Payment will be made only to the distant health care professional during the telehealth session. No payment is allowed to a professional at the originating site if their sole purpose is the presentation of the patient to the professional at the distant site.

Payment is made for services provided by licensed professionals enrolled with ND Medicaid within their licensed scope of practice only. All service limits set by ND Medicaid apply to telehealth services.

Telehealth services provided by an Indian Health Service (IHS) facility or a Tribal Health Program functioning as the distant site, are reimbursed at the All-Inclusive Rate (AIR), regardless of whether the originating site is outside the “four walls” of the facility or clinic.

Revenue code 0780 should only be reported along with Q3014 when the IHS or Tribal Health Program is the originating site.

When providing telehealth services to patients located in their homes or another facility, FQHCs and RHCs should continue to bill the revenue codes listed in the FQHC and RHC portions of this manual along with the CPT® or HCPCS code for the service rendered appended with modifier GT or 95.

Refer to the FQHC and RHC portions of this manual for the revenue codes to bill for the various services.

SOURCE: ND Div. of Medical Assistance, Telehealth, (Jul. 2024), (Accessed Nov. 2024).

FQHCs and RHCs – Dentistry

Revenue code 0780 should only be reported along with Q3014 when the FQHC is the originating site. When providing teledentistry services to patients located in their homes or another facility, FQHCs and RHCs should continue to bill the revenue code listed below along with the CDT© code for the service rendered appended with modifier GT or 95.

Revenue Code 512: Dental Clinic.

One dental encounter is allowed per day. The encounter must be a face to face encounter to qualify for payment. Asynchronous teledentistry performed as a stand-alone service does not qualify for an encounter payment. At least one covered service must be performed as a face to face service to qualify for the dental encounter payment.

SOURCE: North Dakota Human Services Dental Manual, Teledentistry, pg. 11-12 (Jul. 2024), (Accessed Nov. 2024).

Federally Qualified Health Center

Encounter in this chapter means a face-to-face visit or synchronous telehealth visit during which a qualifying encounter service is rendered. FQHCs may furnish services that qualify as a medical, dental, or behavior health encounter.

Payment to FQHCs for covered services furnished to members is made by means of an all-inclusive rate for each encounter. FQHCs may furnish services that qualify as a medical, dental, or behavior health encounter. Each encounter includes services and supplies incident to the service.

SOURCE: ND Div. of Medical Assistance, Federally Qualified Health Center, (Aug. 2024), (Accessed Nov. 2024).

Indian Health Services and Tribal Health Programs

ND Medicaid covers the same services for members who are enrolled in Medicaid and receiving services at IHS as those members who are enrolled in Medicaid only. Coverage and payment of services provided through synchronous telehealth is on the same basis as those provided through face-to-face contact.

An outpatient encounter can only be claimed for services rendered face-to-face (including synchronous telehealth) by one of the following practitioners compensated by an IHS facility/THP for the services provided:

Physician
Physician Assistant
Clinical Nurse Specialist
Licensed Registered Dietitian
Podiatrist

Vision encounters can only be claimed for services rendered face-to-face (including synchronous telehealth). Eligible providers include:

Optometrists
Ophthalmologist

A mental health encounter can only be claimed for services separate and distinct from another encounter type which are rendered face-to-face (including synchronous telehealth) by a qualified mental health professional which includes:

Physician

Licensed Clinical Social Worker
Licensed Professional Counselor
Licensed Professional Clinical Counselor
Licensed Marriage and Family Therapist
Licensed Psychologist
Psychiatrist
Clinical Nurse Specialist

A substance use disorder encounter can only be claimed for services rendered faceto-face (including synchronous telehealth) by a qualified behavioral health professional which includes:

Licensed SUD agency
Licensed Addiction Counselor

SOURCE: ND Div. of Medical Assistance, Indian Health Services and Tribal Health Programs, (Oct. 2024), (Accessed Nov. 2024).

Rural Health Clinic

Encounter in this policy is defined as a face-to-face or synchronous telehealth visit with the member during which a qualifying RHC service is rendered.

Payment to RHCs for covered services furnished to members is an all-inclusive rate for each encounter. RHCs may furnish services that qualify as an encounter. Each encounter includes services and supplies incident to the service.

See Telehealth policy for additional information on services rendered via telehealth. A copy of Telehealth Approved Services can be found on the website.

SOURCE: ND Div. of Medical Assistance, Rural Health Clinic, (Aug. 2024), (Accessed Nov. 2024).

ELIGIBLE SITES

Professional Claims – POS listed:

02: Telehealth provided in a location other than the patient’s home.
10: Telehealth provided in patient’s home

SOURCE: ND Div. of Medical Assistance, Telehealth, (Jul. 2024), (Accessed Nov. 2024).

Dentistry

Claim submissions must be billed using place of service (POS)/place of treatment codes:

02 Teledentistry provided in a location other than the patient’s home.
10 Telehealth provided in patient’s home.

Claims with any other place of service will be denied.

FQHCs and RHCs – Dentistry

Revenue Code 512: Dental Clinic.

SOURCE: North Dakota Human Services Dental Manual, Teledentistry, pg. 11-12(Jul. 2024), (Accessed Nov. 2024).

Teledentistry

Claim submissions must be billed using place of service (POS)/place of treatment codes:

02 Teledentistry provided in a location other than the patient’s home.
10 Telehealth provided in patient’s home.

Claims with any other place of service will be denied.

Place of Service code 02 or 10 is recorded in Box # 38 on the claim form or electronic equivalent.

Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) – Revenue code 0780 should only be reported along with Q3014 when the FQHC is the originating site. When providing teledentistry services to patients located in their homes or another facility, FQHCs and RHCs should continue to bill the revenue code listed below along with the CDT© code for the service rendered appended with modifier GT or 95.

Revenue Code 521: Clinic visit by member to RHC/FQHC.

SOURCE: North Dakota Department of Human Services: Teledentistry Policy. (Accessed Nov. 2024).

Pharmacy Manual

For services delivered via synchronous telehealth:

Both the origination site (where the member is located) and the distant site (where the provider is located) must meet the geographic location, privacy, and space requirements outlined above
Provider is responsible for supplying audio and video equipment permitting two-way, real-time interactive communication between the origination and distant sites

SOURCE: ND Medicaid Pharmacy Medical Billing Manual, Apr. 2024, (Accessed Nov. 2024).

GEOGRAPHIC LIMITS

No Reference Found

FACILITY/TRANSMISSION FEE

Q3014 is allowed: Telehealth originating site facility fee (If applicable. Cannot be billed if patient is outside of the healthcare facility, or for digital health services).

Institutional Claims: * HCPCS Code Q3014 must be billed in conjunction with Revenue Code 780 to indicate the originating site facility fee.

Payment will be made to the originating site as a facility fee only in the following places 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 telehealth service.

SOURCE: ND Div. of Medical Assistance, Telehealth, (Apr. 2024), (Accessed Jun. 2024).

Teledentistry

SOURCE: North Dakota Department of Human Services: Teledentistry Policy & North Dakota Human Services Dental Manual, Teledentistry, pg. 12 (Jul. 2024), (Accessed Nov. 2024).

Medicaid Services Rendered in Schools

Health Services billed by schools can be delivered via telehealth; however, no originating site fee is allowed. See Telehealth policy for additional information.

SOURCE: ND Div. of Medical Assistance, School Based Medicaid, p. 7, (Oct. 2024), (Accessed Nov. 2024).

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Ohio

Last updated 11/04/2024

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.

Telehealth is the interaction with a patient via synchronous, interactive, real-time electronic communication that includes both audio and video elements; OR -The following activities that are asynchronous or do not have both audio and video elements:

Telephone calls
Remote patient monitoring
Communication with a patient through secure electronic mail or a secure patient portal

For services rendered by behavioral health providers as defined in rule 5160-27-01 of the Administrative Code, telehealth is further defined in rule 5122-29-31 of the Administrative Code.

SOURCE: The Ohio Department of Medicaid. Telehealth Billing Guide. Revised 7/15/2022, p. 3-4. & OAC 5160-1-18. (Accessed Nov. 2024).

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 Nov. 2024).

Individuals who meet the definition of inmate in a penal facility or a public institution as defined in rule 5160:1-1-03 of the Administrative Code are not eligible for telehealth services under this rule.

SOURCE: OH Admin Code 5160-1-18(E)(6). (Accessed Nov. 2024).

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: OH Admin Code 5122-29-31 (Accessed Nov. 2024).

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 Nov. 2024).

Teledentistry

The department is required to establish standards for Medicaid payment for services provided through teledentistry.

SOURCE: OH Revised Code, Sec. 5164.951. (Accessed Nov. 2024).

Managed Care

Medicaid Managed Care Organizations (MCOs), MyCare Ohio Plans (MCOPs) and the OhioRISE plan (hereinafter referred to collectively as managed care entities or MCEs) will use the guidelines outlined in this document to allow their Ohio Department of Medicaid (ODM) members to continue using telehealth as an option for services.

SOURCE: OH Department of Medicaid, Telehealth Services: Guidelines for Managed Care Entities, July 15, 2022, (Accessed Nov. 2024).

ELIGIBLE SERVICES/SPECIALTIES

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, p. 12. (Accessed Nov. 2024).

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 Nov. 2024).

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 Nov. 2024).

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(C). (Accessed Nov. 2024).

Medication units may also provide telecounseling services if they provide appropriate privacy and adequate space with appropriately credentialed staff in accordance with all federal and state regulation. Telecounseling services may include individual or group sessions. Medication units that choose to provide telecounseling will:

Provide telecounseling services with appropriate application of clinical judgment to best meet patient treatment needs;
Be in compliance with paragraphs (H)(3) and (H)(4) of rule 5122-40-09 of the Administrative Code; and,
Ensure that every patient has a designated counselor who is the primary contact for behavioral health treatment and care coordination. While the patient may utilize other counselors for emergencies, all counseling, including telecounseling, will be handled by the primary counselor. All patients, whether seen in person or via telehealth, count equally toward the staffing ratio specified in paragraph (F)(1) of rule 5122-40-09 of the Administrative Code, and opioid treatment programs will maintain clear and accurate caseload records for auditing purposes.

SOURCE: OAC 5122-40-15, (Accessed Nov. 2024).

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 Nov. 2024).

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 Nov. 2024).

Managed Care Organizations must allow Applied Behavioral Analysis (ABA) services to be available through telehealth under the current guidelines that were established in June 2018. If the provider is not enrolled with Medicaid, a single case agreement would be needed.

See document for complete code list for different professions.

SOURCE: OH Department of Medicaid, Telehealth Services: Guidelines for Managed Care Entities, July 15, 2022, (Accessed Nov. 2024).

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 Nov. 2024).

Behavioral Health

See Behavioral Health manual for telehealth modifier and Place of Service allowed for the different types of services.

SOURCE: Ohio Department of Medicaid, Medicaid Behavioral Health State Plan Services, Provider Requirements and Reimbursement Manual, Version 1.25, Effective 8/27/24, (Accessed Nov. 2024).

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 Nov. 2024).

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 Nov. 2024).

Outpatient Hospital

SOURCE: The Ohio Department of Medicaid. Telehealth Billing Guide. Revised 7/15/2022, p. 8. (Accessed Nov. 2024).

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, p. 8. (Accessed Nov. 2024).

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, and payment is made in accordance with Chapter 5160-28 of the Administrative Code.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, p. 9. (Accessed Nov. 2024).

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 Nov. 2024).

Dental/Teledentistry

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, p. 9-10. (Accessed Nov. 2024).

“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 Nov. 2024).

Hospice

According to 42 CFR § 418.204 (d), Hospice services may be provided using telehealth when clinically appropriate during a public health emergency. In order to track the services that are provided through telehealth, the appropriate procedure codes below in addition to using the modifier GT must be used on any claims that include at least one telehealth component for that date of service. See guide for codes.

SOURCE: The Ohio Department of Medicaid. Telehealth Billing Guide. Revised 7/15/2022, p. 10. (Accessed Nov. 2024).

Home Health Services

Home health services, the RN assessment service and the RN consultation service can be provided using telehealth when clinically appropriate. These services should be billed using the procedure codes below. The value “02” should be used to indicate telehealth as the “Place of Service” on all claims for services provided using telehealth. See guide for codes.

SOURCE: The Ohio Department of Medicaid. Telehealth Billing Guide. Revised 7/15/2022, p. 11. (Accessed Jun. 2024).

The face-to-face encounter may be completed using telehealth.

SOURCE: Ohio Administrative Code 5160-12-01, (Accessed Nov. 2024).

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. See guide for codes.

SOURCE: The Ohio Department of Medicaid. Telehealth Billing Guide. Revised 7/15/2022, p. 11-12. (Accessed Nov. 2024).

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 Nov. 2024).

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 Nov. 2024).

Registered Nurse Assessment and Registered Nurse Consultation Services

The RN assessment may be completed using telehealth.

SOURCE: Ohio Administrative Code 5160-12-08, (Accessed Nov. 2024).

Comprehensive Maternal Care (CMC) Program

It is the responsibility of the CMC entity to:

Offer at least one alternative to traditional office visits to increase access to the patient care team and clinicians in ways that best meet the needs of the population. This may include e-visits, telehealth, phone visits, group visits, home visits, alternate location visits, or expanded hours in the early mornings, evenings, or weekends.

SOURCE: OAC 5160-19-03. (Accessed Nov. 2024).

Enhanced Ambulatory Patient Groups (EAPG)

List of CPT and HCPCS codes covered for EAPG when telehealth is used.

SOURCE: OH Dept. of Medicaid. (Accessed Nov. 2024).

Nursing Facility-Based Level Care of Home and Community-Based Services: Home Care Attendant Services

All other RN home care attendant service visits may be conducted via telehealth, unless the individual’s needs necessitate an in-person visit.

“RN home care attendant service visit” means the visit every ninety days between the RN and the individual receiving home care attendant services as required by paragraph (G)(8) of this rule. The visit may be conducted by via telehealth, unless the individual’s needs necessitate in-person visit.

SOURCE: OAC 5160-44-27, (Accessed Nov. 2024).

Nursing facility-based level of care home and community-based services programs: waiver nursing services

Non-agency LPNs, at the direction of an RN will: Conduct a visit with the directing RN at least every sixty days after the initial visit to evaluate the provision of waiver nursing services and LPN performance, and to ensure that waiver nursing services are being provided in accordance with the approved plan of care and within the LPN’s scope of practice. The visit may be conducted via telehealth.

SOURCE: OAC 5160-44-22, (Accessed Nov. 2024).

Ohio home care waiver

At least twice per year, the RN will conduct RN assessment visits in-person. All other RN assessment service visits may be conducted via telehealth, unless the individuals needs necessitate an in-person visit. When the RN performs an RN assessment visit, the RN will bill the state plan nursing assessment code set forth in appendix A to rule 5160-12-08 of the Administrative Code.

SOURCE: OAC 5160-46-04, (Accessed Nov. 2024).

Doula Services

During a coverage period, payment may be made for the following doula services: …

Antepartum and postpartum support services, including consultation and telehealth visits, provided in fifteen-minute units up to a maximum of forty-eight units

SOURCE: OAC 5160-8-43, (Accessed Nov. 2024).

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, p. 4-5 & OH Administrative Code 5160-1-18, (Accessed Nov. 2024).

To the extent permitted under rules adopted under section 5164.02 of the Revised Code and applicable federal law, the following practitioners are eligible to provide telehealth services covered pursuant to this section:

A physician licensed under Chapter 4731. of the Revised Code to practice medicine and surgery, osteopathic medicine and surgery, or podiatric medicine and surgery;
A psychologist, independent school psychologist, or school psychologist licensed under Chapter 4732. of the Revised Code;
A physician assistant licensed under Chapter 4730. of the Revised Code;
A clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner licensed under Chapter 4723. of the Revised Code;
An independent social worker, independent marriage and family therapist, or professional clinical counselor licensed under Chapter 4757. of the Revised Code;
An independent chemical dependency counselor licensed under Chapter 4758. of the Revised Code;
A supervised practitioner or supervised trainee;
An audiologist or speech-language pathologist licensed under Chapter 4753. of the Revised Code;
An audiology aide or speech-language pathology aide, as defined in section 4753.072 of the Revised Code, or an individual holding a conditional license under section 4753.071 of the Revised Code;
An occupational therapist or physical therapist licensed under Chapter 4755. of the Revised Code;
An occupational therapy assistant or physical therapist assistant licensed under Chapter 4755. of the Revised Code.
A dietitian licensed under Chapter 4759. of the Revised Code;
A chiropractor licensed under Chapter 4734. of the Revised Code;
A pharmacist licensed under Chapter 4729. of the Revised Code;
A genetic counselor licensed under Chapter 4778. of the Revised Code;
An optometrist licensed under Chapter 4725. of the Revised Code to practice optometry;
A respiratory care professional licensed under Chapter 4761. of the Revised Code;
A certified Ohio behavior analyst certified under Chapter 4783. of the Revised Code;
A practitioner who provides services through a medicaid school program;
Subject to section 5119.368 of the Revised Code, a practitioner authorized to provide services and supports certified under section 5119.36 of the Revised Code through a community mental health services provider or community addiction services provider;
Any other practitioner the medicaid director considers eligible to provide telehealth services.

In accordance with division (B) of this section and to the extent permitted under rules adopted under section 5164.02 of the Revised Code and applicable federal law, the following provider types are eligible to submit claims for medicaid payments for providing telehealth services:

Any practitioner described in division (C)(1) of this section, except for those described in divisions (C)(1)(g), (i), and (k) of this section;
A professional medical group;
A federally qualified health center or federally qualified health center look-alike, as defined in section 3701.047 of the Revised Code;
A rural health clinic;
An ambulatory health care clinic;
An outpatient hospital;
A medicaid school program;
Subject to section 5119.368 of the Revised Code, a community mental health services provider or community addiction services provider that offers services and supports certified under section 5119.36 of the Revised Code;
Any other provider type the medicaid director considers eligible to submit the claims for payment.

When providing telehealth services under this section, a practitioner shall comply with all requirements under state and federal law regarding the protection of patient information. A practitioner shall ensure that any username or password information and any electronic communications between the practitioner and a patient are securely transmitted and stored.

When providing telehealth services under this section, every practitioner site shall have access to the medical records of the patient at the time telehealth services are provided.

SOURCE: Ohio Revised Statue Sec. 5164.95, (Accessed Nov. 2024).

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

SOURCE: The Ohio Department of Medicaid. Telehealth Billing Guide. Revised 7/15/2022, p. 8-11. (Accessed Nov. 2024).

Hospitals

Telehealth services billed by hospitals under the Outpatient Hospital Behavioral Health Services (OPHBH) benefit package are billed in accordance with OAC rule 5160-2-76. ODM will accept an institutional claim and pay according to EAPG pricing when a telehealth service is rendered by a licensed independent behavioral health practitioner. The procedure code must be reported with the “GT” modifier, one of the designated modifiers indicating the location of the patient when applicable, and any other required modifiers. Also, the rendering practitioner NPI is not reported on this claim form; report only the attending practitioner NPI. Lastly, only one professional or institutional claim may be paid for a service delivered using telehealth.

SOURCE: The Ohio Department of Medicaid. Office of Policy Hospital Billing Guidelines. pg. 49, Revised 7/26/2021. (Accessed Nov. 2024).

Teledentistry

All teledentistry activities must be conducted at the practice site(s) specified in the dentist’s contract.

SOURCE: OAC 3701-56-03. (Accessed Nov. 2024).

Managed Care

Eligible Practitioners

Physician as defined in Chapter 4731. of the Revised Code.
Psychologist as defined in Chapter 4732. of the Revised Code.
Physician assistant as defined in Chapter 4730. of the Revised Code.
Clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner as defined in Chapter 4723. of the Revised Code.
Licensed independent social worker, licensed independent marriage and family therapist, or licensed professional clinical counselor as defined in Chapter 4757. of the Revised Code.
Licensed independent chemical dependency counselor as defined in Chapter 4758. of the Revised Code.
Supervised practitioners, trainees, residents, and interns as defined in rules 5160-4-05 and 5160-8-05 of the Administrative Code.
Audiologist, speech-language pathologist, speech-language pathology aides, audiology aides and individuals holding a license as defined in Chapter 4753. of the Revised Code.
Occupational and physical therapist and occupational and physical therapist assistants as defined in Chapter 4755. of the Revised Code.
Home health and hospice aides.
Private Duty Nursing as defined in Chapter 5160-12 of the Administrative Code Dentists as defined in Chapter 4715. of the Revised Code.
Medicaid school program (MSP) practitioners as described in Chapter 5160-35 of the Administrative Code.
Dietitians as defined in Chapter 4759. of the Revised Code.
Behavioral health practitioners as defined in rule 5160-27-01 of the Administrative Code.
Optometrists as defined in Chapter 4725. of the Revised Code
Other practitioners if specifically authorized in rule promulgated under Agency 5160 of Administrative Code
Pharmacists as defined in Chapter 4729:1-1 of the Administrative Code
Chiropractors as defined in Chapter 4734.60 of the Revised Code

Practitioner Site – the physical location of the treating practitioner at the time a health care service is provided through the use of telehealth. There is no limitation on the practitioner site, except for penal facilities or public institutions such as jail or prison

For behavioral health agencies certified by the Ohio Department of Mental Health and Addiction Services (OhioMHAS), allowable places of service are included in the BH Manual.

Eligible providers to submit claim, or bill for services rendered

A professional medical group.
An individual dentist or a professional dental group.
A federally qualified health center (FQHC) or rural health clinic (RHC) as defined in Chapter 5160-28 of the Administrative Code (using a professional claim form).
Ambulatory health care clinics (AHCC) as described in Chapter 5160-13 of the Administrative Code.
Outpatient hospitals (facility claim can only be submitted when services are provided by licensed psychologists, and independent practitioners not allowed to separately bill when providing services in an outpatient hospital setting.)
Hospitals operating an outpatient behavioral health program in accordance with rule 5160-2-76 of the Administrative Code
Medicaid school program (MSP) providers as defined in Chapter 5160-35 of the Administrative Code.
Private duty or non-agency nurses.
Home health and hospice agencies.
Licensed independent behavioral health providers as defined in rule 5160-27-01 of the Administrative Code.
Occupational therapist, physical therapist, speech-language pathologist, audiologist.
Dietitian
Physician, psychiatrist, ophthalmologist
Optometrist
Psychologist
Physician Assistant
Advanced Practice Registered Nurse
Pharmacists as defined in 4729:1-1 of the Administrative Code.
Pharmacy as defined in rule 5160-9-01 of the Administrative Code.
Chiropractor
Care Management Entities

If the practitioner site does not bill the MCE 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.

In such cases, ODM recommends the place of service (POS) code reported on the professional claim should reflect the location of the billing provider if the rendering practitioner’s location is unknown.

SOURCE: OH Department of Medicaid, Telehealth Services: Guidelines for Managed Care Entities, July 15, 2022, (Accessed Nov. 2024).

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.

If the patient is at one of the following locations, a specific modifier identifying the type of location is required:

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.

The place of service (POS) code reported on a professional claim must reflect the physical location of the practitioner. See billing guide for more information.

SOURCE: Ohio Administrative Code 5160-1-18. The Ohio Department of Medicaid. Telehealth Billing Guide. Revised 7/15/2022, p. 4-9 (Accessed Mar. 2023).& Appendix B (July 5, 2022). (Accessed Nov. 2024).

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, p. 4-6. (Accessed Nov. 2024).

Modifiers recognized by Ohio Medicaid:

GT Identifies a service as telehealth
U1 Used to identify the patient location of “home” when a telehealth service was delivered
U2 Used to identify the patient location of “school” when a telehealth service was delivered
U3 Used to identify the patient location of “inpatient hospital” when a telehealth service was delivered
U4 Used to identify the patient location of “outpatient hospital” when a telehealth service was delivered
U5 Used to identify the patient location of “nursing facility” when a telehealth service was delivered
U6 Used to identify the patient location of “Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID)” when a telehealth service was delivered

SOURCE: Ohio Department of Medicaid, Modifiers Recognized by Ohio Medicaid, Jan. 28, 2022, (Accessed Nov. 2024).

For services delivered via telehealth, providers may use either the place of service code that reflects the location of the practitioner or the location of the patient. The appendix to OAC 5160-27-03 includes a list of allowable places of service codes for each procedure code. Please note, place of service code 02 is not allowed. Providers should use the GT modifier to identify telehealth services.

SOURCE: Ohio Department of Medicaid, Medicaid Behavioral Health State Plan Services, Provider Requirements and Reimbursement Manual, Version 1.25, Effective 8/27/24, pg. 97 (Accessed Nov. 2024).

Teledentistry

All teledentistry activities must be conducted at the practice site(s) specified in the dentist’s contract.

SOURCE: OAC 3701-56-03. (Accessed Nov. 2024).

Managed Care

Patient Site – The physical location of the patient at the time a health care service is provided through the use of telehealth. There is no limitation on the patient site except for penal facilities or public institutions such as jail or prison. Medicaid covered individuals can access telehealth services in the following locations, but are not limited to:

Home
School
Temporary housing
Homeless shelter
Assisted Living Facility
Nursing Facility
Outpatient Hospital
Group home
Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID)
Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC)
Ambulatory Health Care Clinics
Pharmacy/ Pharmacies

The place of service (POS) code reported on a professional claim must reflect the physical location of the practitioner. The POS code set is maintained by the Centers for Medicare and Medicaid Services (CMS) and can be found here: https://www.cms.gov/Medicare/Coding/place-of-servicecodes/Place_of_Service_Code_Set

Place of service 02 (Telehealth) will not be accepted on claims where Medicaid is the primary payer.

The exception to the POS 02 limitation is for home health claims. Home Health claims will still require the POS 02.
While FFS does not accept POS 02 and POS 10, MCOs may choose to allow these codes to identify telehealth services.

SOURCE: OH Department of Medicaid, Telehealth Services: Guidelines for Managed Care Entities, July 15, 2022, (Accessed Nov. 2024).

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, p. 4. (Accessed Nov. 2024).

FACILITY/TRANSMISSION FEE

No Reference Found

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Oklahoma

Last updated 11/26/2024

POLICY

SoonerCare (Oklahoma’s Medicaid program) reimburses providers for live video. …

POLICY

SoonerCare (Oklahoma’s Medicaid program) reimburses providers for live video. Providers must:

Be contracted with SoonerCare and appropriately licensed,
Bill for services using the appropriate modfier (GT, 95, FQ, or 93), 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.)

Additionally, out-of-state providers must comply with all laws and regulations of the provider’s location, including health care and telehealth requirements.

SOURCE: Health Care Authority, Providers, Telehealth, Modified Jun. 27, 2024. (Accessed Nov. 2024).

Oklahoma Health Care Authority issued letter regarding HIPAA Compliancy for Telehealth and Audio-Only Services.

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.

SOURCE: Health Care Authority, Providers, Telehealth, Modified Jun. 27, 2024. (Accessed Nov. 2024).

See Medical Codes allowed for telehealth post-PHE.

SOURCE: OK Health Care Authority, Medical Codes Allowed via telehealth after 5/11/23, Updated 7/18/23, (Accessed Nov. 2024).

See behavioral health codes allowed for telehealth post-PHE.

SOURCE: OK Health Care Authority, Behavioral Health Codes Allowed via telehealth after 5/11/23, Updated 5/24/23, (Accessed Nov. 2024).

The OHCA has discretion and the final authority to approve or deny any telehealth services based on agency and/or SoonerCare members’ needs.

SOURCE: OK Admin. Code Sec. 317:30-3-27(g) (Accessed Nov. 2024).

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(c)(11) &(12). (Accessed Nov. 2024).

Effective July 1, 2024, OHCA will add modifier 95 (synchronous telemedicine service rendered via real-time interactive audio and video telecommunications systems) as an allowed modifier to report services delivered via telehealth. More information about telehealth and services allowed to be delivered via telehealth can be found on the provider telehealth page.

SOURCE: OK Health Care Authority, Global Messages, 2024 Messages, 6/26/24, (Accessed Nov. 2024).

Physical, Occupational and Speech and Hearing Services

Even though physical therapy, occupational therapy, and/or speech and hearing services are not subject to the notification requirements of OAC 317:30-3-27(d)(2), said services must still comply with all other State and Federal Medicaid requirements, in order to be reimbursable by Medicaid. Accordingly, for those 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, including, but not limited to, 42 C.F.R. Â§ 440.110, OAC 317:30-5-291, 317:30-5-296, and 317:30-5-676.

SOURCE: OK Admin. Code Sec. 317:30-3-27(d). (Accessed Nov. 2024).

Psychiatric Services

Payment is made for procedure codes listed in the psychiatry section of the most recent edition of the American Medical Association Current Procedural Terminology (CPT) codebook. Check administrative rules for certain exceptions. 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(a) & (d) (Accessed Nov. 2024).

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 Nov. 2024).

Outpatient therapy services

The facility will directly provide outpatient mental health and substance use disorder services in accordance with 450:17-3 Part 7. In the event specialized services outside the expertise of the facility are required to meet the needs of the consumer, the facility will make them available through referral or other formal arrangement with other providers or, where necessary and appropriate, through the use of telemedicine services.

SOURCE: OK Admin. Code Sec. 450:17-5-185. (Accessed Nov. 2024).

Certified Community Behavioral Health Clinics

To the extent allowed by state law, facility will make services available via telemedicine in order to ensure consumers have access to all required services.

SOURCE: OK Admin. Code Sec. 450:17-5-176. (Accessed Nov. 2024).

Developmental Disabilities Services

Telehealth services do not expand services covered through Developmental Disabilities Services (DDS) Home and Community-Based Services (HCBS) waivers. Telehealth services are a delivery option for certain covered services. Telehealth services apply to contract professional services, including speech therapy, physical therapy, occupational therapy, audiology, psychology, nutrition, family training, family counseling, nursing, and dental care.

Telehealth services are billed with the appropriate modifier. See administration code for additional requirements.

SOURCE: OK Admin Code 340:100-3-41. (Accessed Nov. 2024).

Doula Services

Prenatal and postpartum visits can also be conducted via telehealth.

SOURCE: OK Health Care Authority, Provider Letter OHCA 2023-14, RE: Doula Services, July 1, 2023, (Accessed Nov. 2024).

Prenatal and postpartum visits may be conducted via telehealth.

Labor and delivery services may not be conducted via telehealth.

SOURCE: OK Admin Code 317:30-5-1217. (Accessed Nov. 2024).

Mobile Medication Units

Mobile medication units that provide appropriate privacy and adequate space may additionally provide the following services: …

Clinical services, such as therapy, provided in-person or when permissible through use of telehealth services.

SOURCE: OK Admin Code 450:70-6-10.1. (Accessed Nov. 2024).

Crisis Intervention

Onsite CIS is the provision of CIS to the member at the treatment facility, either in-person or via telehealth.

SOURCE: OK Admin Code 317:30-5-241.4. (Accessed Nov. 2024).

Human Immunodeficiency Virus (HIV) Counseling (OK SPA 23-0032)

The GT modifier (interactive audio and video telecommunications system) is allowed for Human Immunodeficiency Virus (HIV) counseling.

SOURCE: OK Health Care Authority, Provider Letter OHCA 2024-08, RE: Human Immunodeficiency Virus (HIV) Counseling (OK SPA 23-0032), May 7, 2024, (Accessed Nov. 2024).

Training requirements for community staff

Virtual training may be used as an alternative to both classroom and online training as referenced in this Section. Virtual training is an instructor-led, interactive, online learning experience with participants who are connected from geographically dispersed locations. This does not include telehealth services, webinars, webcasts, virtual meetings, or other similar platforms. Participants are expected to actively participate and engage with the trainer and the group during group discussions and activities. Refer to (c)(1) of this Section regarding reasons for dismissal from virtual training. See rule for additional requirements.

SOURCE: OK Admin Code 340-100-3-38 (Accessed Nov. 2024).

ELIGIBLE PROVIDERS

To participate, a provider must:

Be contracted with SoonerCare and appropriately licensed
Bill for services using the appropriate modfier (GT, 95, FQ, or 93), 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.)

Additionally, out-of-state providers must comply with all laws and regulations of the provider’s location, including health care and telehealth requirements.

SOURCE: Health Care Authority, Providers, Telehealth, Modified Jun. 27, 2024. (Accessed Nov. 2024).

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 Nov. 2024).

OHCA is expanding the use of telehealth to include certain occupational and physical therapy services. Effective May 12, 2023, OHCA began reimbursing for therapy services utilizing the following service codes delivered via telehealth: 97110, 97112, 97116, 97150, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 97530, 97535, and 97755.

OHCA asks that providers use modifier GT to denote services were performed utilizing telehealth. For providers unable to submit a claim with the GT modifier for an OHCA approved telehealth-rendered service, please utilize Place of Service (POS) code 02 to denote when telehealth is used.

SOURCE: Oklahoma Healthcare Authority, 2023 Global Messages, Telehealth expanded for OT/PT providers, 7/20/23, (Accessed Nov. 2024).

Indian Health Service/Tribal 638

An I/T/U encounter means a face to face, a telehealth contact, or an audio-only telecommunications contact between a health care professional and an Indian Health Services (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 twenty-four (24) 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 Nov. 2024).

Clinic Services

Teleheath and audio-only health service delivery requires either the provider or the member to be located at the freestanding clinic that is providing services pursuant to 42 Code of Federal Regulations (CFR) § 440.90. Refer to section Oklahoma Administrative Code (OAC) 317:30-3-27 for telehealth policy and OAC 317:30-3-27.1 for audio-only telecommunication policy.

SOURCE: OK Admin Code Sec. 317.30-5-575, (Accessed Nov. 2024).

Rural Health Center Services

RHC services are covered when medically necessary and furnished at the clinic or other outpatient setting, including the member’s place of residence, delivered via telehealth, or via audio-only telecommunications pursuant to Oklahoma Administrative Code (OAC) 317:30-3-27 and OAC 317:30-3-27.1.

SOURCE: OK Admin Code Sec. 317.30-5-355.2, (Accessed Nov. 2024).

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, per OAC 317:30-3-89 through 317:30-3-91.

SOURCE: OK Admin. Code Sec. 317:30-3-27(c)(3). (Accessed Nov. 2024).

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.

Accordingly, for those 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, including, but not limited to, 42 C.F.R. § 440.110, OAC 317:30-5-291, 317:30-5-296, and 317:30-5-676.

SOURCE: OK Admin. Code Sec. 317:30-3-27. (Accessed Nov. 2024).

Clinic Services

SOURCE: OK Admin Code Sec. 317.30-5-575, (Accessed Nov. 2024).

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 Nov 2024).

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Oregon

Last updated 12/12/2024

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 Dec. 2024).

“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.

SOURCE: OAR 410-141-3566, Health Systems Division: Medical Assistance, Oregon Health Plan, Telehealth Service and Reimbursement Requirements & OAR 410-120-1990 Health Systems Division: Medical Assistance Programs, Telehealth. (Accessed Dec. 2024).

Communications may be between providers, or between one or more providers and one or more members, family members /caregivers /guardians.

SOURCE: OAR 410-141-3566, Health Systems Division: Medical Assistance, Oregon Health Plan, Telehealth Service and Reimbursement Requirements, (Accessed Dec. 2024).

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 Dec. 2024).

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 950-050-0010 for interpretation services provided using 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. Administrative rules and CCO Direct Agreements do not supersede 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 Dec. 2023).

The Authority shall provide reimbursement for telemedicine or telehealth services at the same reimbursement rate as if it were provided in person. As a condition of reimbursement, providers shall agree to reimburse Certified and Qualified Health Care Interpreters (HCIs) for interpretation services provided using telemedicine or telehealth at the same rate as if interpretation services were provided in-person, per OARs 410-141-3515(12) and 410-141-3860(12).

Providers shall ensure Oregon Health Plan (OHP) clients or members are offered a choice of how services are received, including services offered using telemedicine or telehealth modalities and in-person services, except where the Authority issues explicit guidance during a declared state of emergency or if a facility has implemented its facility disaster plan.

Providers unable to offer in-person services shall offer local provider options to a client or member when an in-person visit is clinically indicated or when the client or member requests in-person services. This may include but is not limited to care coordination or completing referral paperwork.

SOURCE: OAR 410-120-1990 Health Systems Division: Medical Assistance Programs, Telehealth. (Accessed Dec. 2024).

The Oregon Health Authority (OHA) will submit a Medicaid State Plan Amendment to the Centers for Medicare & Medicaid Services (CMS) to change from the flat telehealth rates used during the COVID-19 Public Health Emergency (PHE) to rates based on Relative Value Units (RVUs) multiplied by the Oregon conversion factor. See memo for a table that lists the current PHE rate and the proposed RVU-based rate for covered telehealth codes.

SOURCE: Oregon Health Authority, Notice of intent – OHA will amend the Medicaid State Plan to increase rates for telehealth services. Public Notice, May 18, 2023, (Accessed Dec. 2024).

ELIGIBLE SERVICES/SPECIALTIES

Providers billing for covered telemedicine or telehealth services are responsible for:

Complying with HIPAA and the Authority’s Privacy and Confidentiality Rules and security protections for the member in connection with the telemedicine or telehealth communication and related records requirements (OAR chapter 943 division 14 and 120, OAR 410-120-1360 and 1380, 42 CFR Part 2, if applicable, and ORS 646A.600 to 646A.628 (Oregon Consumer Identity Theft Protection Act) except as noted in section (19) of this rule.
Obtaining and maintaining technology used in telemedicine or telehealth communication that is compliant with privacy and security standards in HIPAA and the Authority’s Privacy and Confidentiality Rules described in subsection (A) except as noted in section (19) of this rule.
Developing and maintaining policies and procedures to prevent a breach in privacy or exposure of client or member health information or records (whether oral or recorded in any form or medium) to unauthorized persons and timely breach reporting as described in OAR 943-014-0440.
Maintaining clinical and financial documentation related to telemedicine or telehealth services as required in OAR 410-120-1360 and any program specific rules in OAR Ch 309 and Ch 410.
Complying with all federal and state statutes as required in OAR 410-120-1380.

Providers shall develop and maintain care coordination policies and procedures to offer local provider options to clients or members when in-person services are clinically indicated or requested by the client or member and the provider does not offer these services.

The Authority shall only pay for telemedicine or telehealth services meeting all of the following requirements:

Services provided shall be medically and clinically appropriate for covered conditions within the Health Evidence Review Commission’s (HERC) prioritized list and in compliance with relevant guideline notes;
The Authority shall provide reimbursement for telemedicine or telehealth services at the same reimbursement rate as if it were provided in person. As a condition of reimbursement, providers shall agree to reimburse Certified and Qualified Health Care Interpreters (HCIs) for interpretation services provided using telemedicine or telehealth at the same rate as if interpretation services were provided in-person, per OARs 410-141-3515(12) and 410-141-3860(12).
When allowed by individual certification or licensing board’s scope of practice standards, telemedicine or telehealth delivered services for covered conditions are covered:
- When an established relationship exists between a provider and client or member defined as a client or member who has received in-person professional services from the physician or other qualified health care professional within the same practice within the past three years; and
- For establishing a client or member-provider relationship.
All physical and behavioral telemedicine or telehealth, and oral teledentristy services except School Based Health Services (SBHS) shall include Place of Service code 02 when the client or member is located in a place other than their home. When the client or member is located in their home, the claim shall include Place of Service code 10.
All claim types except Dental services, shall include modifier 95 when the telemedicine or telehealth delivered service utilizes a real-time interactive audio and video telecommunication system. When provision of the same service utilizes a real-time interactive audio only, the claim should include modifier 93.

SOURCE: OAR 410-120-1990, Health Systems Division: Medical Assistance Programs, Telehealth. (Accessed Dec. 2024).

Teledentistry

All billing requirements stated in this rule apply to all delivery modalities referenced in section (5) of this rule (live video, store and forward, remote patient monitoring and mobile communication devices).

As stated in ORS 679.543 and this rule, 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 also documents these services using the traditional CDT codes. This provider also reports the teledentistry event using D9995 or D9996 as appropriate. See the Dental Billing Instructions for details at: www.oregon.gov/oha/HSD/OHP/Pages/Policy-Dental.aspx;

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 shall meet all criteria of the CDT code billed.

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 Dec. 2024).

Behavioral Health

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 Dec. 2024).

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:

Screening must be conducted by PSS, CRM, PWS or other addiction professional. Screening service must be available 24 hours a day, seven days a week, every calendar day of the year. Screening must be made available to each individual immediately upon first contact. At least one organization within each BHRN within each county or region must meet this requirement: …
- 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 Dec. 2024).

Behavioral Rehabilitation Services Program

To utilize telehealth for services required by the BRS program, the BRS contractor and BRS providers shall:

Comply with Telehealth for Behavioral Health requirements described in OAR 410-172-0850;
Comply with prioritized list of health services guidelines for telephone and e-mail consultation described in OAR 410-141-3830; and
Comply with agency specific BRSTelehealth program rules and policies.

The BRS contractor and BRS providers shall develop written telehealth policy that complies with section (4)(a)(A-C) of this rule. At minimum, the policy shall describe:

The circumstances the provider may provide BRS services via telehealth;
The telecommunication technologies the BRS contractor or BRS provider has implemented to deliver services via telehealth; and
The process to obtain an individual’s informed consent in accordance with ORS 107.154, 179.505, 179.507, 192.515, including a sample form.

The BRS contractor and BRS providers may utilize telehealth for services that require a face-to-face setting when there is a documented barrier to providing in-person services, as follows:

Services via telehealth shall be provided by a qualified program staff within their scope of position;
Service notes for phone, individual or group counseling shall follow the same criteria as face-to-face counseling and identify the session was conducted by telehealth and the reason for the use of telehealth; and
Individual or group counseling via telehealth shall meet HIPAA and 42 CFR Part 2 standards for privacy.

School Based Health Services

The Authority may reimburse school medical providers for covered School-Based Health Services (SBHS) delivered via telehealth that meet the following criteria:

The covered telehealth service is provided to a child or young adult to the same extent that the service may be covered if it were provided in person;
The school medical provider meets the following privacy and security standards (see regulation)

The Authority shall provide reimbursement for a Medicaid-covered school-based telehealth service at the same reimbursement rate as if the service were provided in person.

For school-based telehealth service claims:

A service provided using synchronous audio and video must include modifier GT;
A service provided using synchronous audio, without video, (e.g., telephone) must include modifier 93.

In the event of a national or state declaration of emergency or in a prolonged school closure due to crisis, pandemic, or disaster, the Authority may modify the requirements for telehealth services to facilitate delivery of medically necessary service delivery. Modifications include, but are not limited to:

Recognizing that exceptional circumstances may affect how all educational and related services and supports are provided, the Authority shall, to the extent possible based on the exceptional circumstance, follow guidance from the US Department of Health and Human Services (HHS), Office for Civil Rights (OCR), Office of Special Education Programs (OSEP) in the Department of Education, and Office of Special Education and Rehabilitative Services (OSERS) and may allow enforcement discretion related to encryption requirements; and
The Authority may reimburse a SBHS delivered using a telehealth platform if:
- The telehealth service is medically necessary and appropriate;
- The delivery of the telehealth service reasonably approximates an in-person service; and
- Access to the telehealth service shall reduce barriers in the delivery of the health care service to accommodate the child or young adult’s Individual Plan of Care (IPOC).

SOURCE: OR OAR 410-133-0070, Health Systems Division: Medical Assistance Programs, School-Based Health Services, Telehealth (Accessed Dec. 2024).

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 Dec. 2024).

Linguistic and Cultural Access

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;

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 950-050-0040. 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.

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 OAR 410-141-3500.

See full list of CCO requirements in regulation.

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 Dec. 2024).

Health benefit plans must reimburse at the case rate for newborn nurse home visiting services conducted via telemedicine pursuant to OAR 333-006-0120 and ORS 743A.058.

SOURCE: OAR 333-006-0190, Health Systems Division: Public Health Division, Universally Offered Newborn Nurse Home Program, (Accessed Dec. 2024).

1915(i) Home and Community Based Services State Plan Option

“Face-to-Face” means a personal interaction where both words can be heard and facial expressions can be seen, either in person or through telehealth services where there is a live streaming audio and video, if medically appropriate and necessary. Face-to-face could include communication methods such as telehealth/telemedicine, in lieu of in-person visits, in accordance with HIPAA, as directed by OHA and as chosen by the Individual. Medically appropriate and necessary accommodations shall be made for Individuals with disabilities including those with hearing or sight impairments. For telehealth the following conditions must be met:

The agent performing the assessment is independent and qualified as defined in 42 CFR 441.730 and meets the provider qualifications defined by the State, including any additional qualifications or training requirements for the operation of required information technology.
The Individual receives appropriate support during the assessment, including the use of any necessary on-site support-staff.
The Individual provides informed consent for this type of assessment.

Eligibility for 1915(i) HCBS is established through a diagnostic and face-to-face needs-based assessment by an external IQA who meets the requirements of a QMHP:

Telehealth is considered face-to-face and it is the Individuals choice to conduct the assessment in- person or via telehealth;
In-Person or telehealth options are based on the choice and preference of the Individual accessing HCBS;
Individuals who choose telehealth assessment options must schedule an in-person follow up meeting within ninety (90) days of the functional needs assessment.

See regulation for additional requirements.

SOURCE: OAR 410-173-0005 & 410-173-0010, Oregon Health Authority, Health Systems Division: Medical Assistance Programs, 1915(i) Home and Community Based Services State Plan Option (Accessed Dec. 2024).

Durable Medical Equipment

For initial ordering of DME items identified in section (9) of this rule, an in-person or telehealth face-to-face encounter that is related to the primary reason the client requires the medical equipment or supplies must occur no more than six months prior to the start of services.

Telehealth encounters used to satisfy the face-to-face encounter requirement for a DMEPOS item must meet the requirements outlined in the HERC Ancillary Guideline note A5.

SOURCE: 410-122-0090, Oregon Health Authority, Health Systems Division: Medical Assistance Programs, Durable Medical Equipment Program Rules (Accessed Dec. 2024).

Assertive Community Treatment (ACT)

Community-Based” means services and supports that must be provided in a participant’s home and/or surrounding community. This can include but not limited to virtual telehealth, or wherever within the community the participant feels most comfortable. This is person-centered and will be tailored to the participants discretion.

“Face to Face” means that a personal interaction where communication between at least two-person(s) can be had either in-person or virtually through telehealth services where there is a secured HIPAA approved live streaming audio and video per OAR 410-120-1990 rule set. Virtual Telehealth meetings for Face-to-Face fidelity measurement purposes will be a last resort option if in-person is not safely available or feasible.

SOURCE: 309-019-0225, Oregon Health Authority, Health Systems Division: Behavioral Health Services, DACT Model (Accessed Dec. 2024).

Behavioral Health Services – IPS

“Face to Face” means that a personal interaction where communication between at least two-person(s) can be had. This will include any interactions through telehealth services where there is secured Health Insurance Portability and Accountability (HIPAA) approved live streaming audio and video. Virtual Telehealth meetings for Face-to-Face fidelity measurement purposes will be a last resort option if in-person is not safely available or feasible.

SOURCE: 309-019-0270, Oregon Health Authority, Health Systems Division: Behavioral Health Services, (Accessed Dec. 2024).

Hospital Services

Caring contacts may be conducted in person, via telemedicine or by phone.

SOURCE: OAR 333-520-0070 Oregon Health Authority, Health Systems Division, Public Health Division, Emergency Department and Emergency Services. (Accessed Dec. 2024).

ELIGIBLE PROVIDERS

Providers who offer telemedicine or telehealth delivery of services shall meet the following requirements:

Shall hold an unencumbered Oregon license;
Shall be enrolled with the Authority as an Oregon Health Plan (OHP) provider, per OAR 410-120-1260;
Shall provide services using telemedicine or telehealth that are within their respective certification or licensing board’s scope of practice and comply with telemedicine or 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.
- Providers billing for covered telemedicine or telehealth services are responsible for:
  - Complying with HIPAA and the Authority’s Privacy and Confidentiality Rules and security protections for the member in connection with the telemedicine or telehealth communication and related records requirements (OAR chapter 943 division 14 and 120, OAR 410-120-1360 and 1380, 42 CFR Part 2, if applicable, and ORS 646A.600 to 646A.628 (Oregon Consumer Identity Theft Protection Act) except as noted in section (19) of this rule.
  - Obtaining and maintaining technology used in telemedicine or telehealth communication that is compliant with privacy and security standards in HIPAA and the Authority’s Privacy and Confidentiality Rules described in subsection (A) except as noted in section (19) of this rule.
  - Developing and maintaining policies and procedures to prevent a breach in privacy or exposure of client or member health information or records (whether oral or recorded in any form or medium) to unauthorized persons and timely breach reporting as described in OAR 943-014-0440.
  - Maintaining clinical and financial documentation related to telemedicine or telehealth services as required in OAR 410-120-1360 and any program specific rules in OAR Ch 309 and Ch 410.
  - Complying with all federal and state statutes as required in OAR 410-120-1380.

The Authority shall only pay for telemedicine or telehealth services meeting all of the following requirements:

Services provided shall be medically and clinically appropriate for covered conditions within the Health Evidence Review Commission’s (HERC) prioritized list and in compliance with relevant guideline notes;
The Authority shall provide reimbursement for telemedicine or telehealth services at the same reimbursement rate as if it were provided in person. As a condition of reimbursement, providers shall agree to reimburse Certified and Qualified Health Care Interpreters (HCIs) for interpretation services provided using telemedicine or telehealth at the same rate as if interpretation services were provided in-person, per OARs 410-141-3515(12) and 410-141-3860(12).
When allowed by individual certification or licensing board’s scope of practice standards, telemedicine or telehealth delivered services for covered conditions are covered:
- When an established relationship exists between a provider and client or member defined as a client or member who has received in-person professional services from the physician or other qualified health care professional within the same practice within the past three years; and
- For establishing a client or member-provider relationship.
All physical and behavioral telemedicine or telehealth, and oral teledentristy services except School Based Health Services (SBHS) shall include Place of Service code 02 when the client or member is located in a place other than their home. When the client or member is located in their home, the claim shall include Place of Service code 10.
All claim types except Dental services, shall include modifier 95 when the telemedicine or telehealth delivered service utilizes a real-time interactive audio and video telecommunication system. When provision of the same service utilizes a real-time interactive audio only, the claim should include modifier 93.

SOURCE: OAR 410-120-1990, Health Systems Division: Medical Assistance Programs, Telehealth. (Accessed Dec. 2024).

“Meaningful access” means client or member-centered access reflecting the following statute and standards: Pursuant to Title VI of the Civil Rights Act of 1964, Section 1557 of the Affordable Care Act and the corresponding Federal Regulation at 45 CFR Part 92 and The Americans with Disabilities Act (ADA), providers’ telemedicine or telehealth services shall accommodate the needs of individuals who have difficulty communicating due to a medical condition, who need accommodation due to a disability, advanced age or who have Limited English Proficiency (LEP) including providing access to auxiliary aids and services as described in 45 CFR Part 92;

National Culturally and Linguistically Appropriate Services (CLAS) Standards at https://thinkculturalhealth.hhs.gov/clas/standards; and
As applicable to the client or member, Tribal based practice standards: https://www.oregon.gov/OHA/HSD/AMH/Pages/EBP.aspx;
“Synchronous” means an interaction between a provider and a client or member that occurs at the same time using an interactive technology. This may include audio only, video only, or audio with video and may include remote monitoring.

SOURCE: OR OAR 140-120-0000, Medical Assistance Program: Acronyms and Definitions & OAR 410-120-1990, Health Systems Division: Medical Assistance Programs, Telehealth. (Accessed Dec. 2024).

Dentists providing Medicaid services shall be licensed to practice dentistry within the State of Oregon or within the contiguous area of Oregon and shall 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.

SOURCE: OR OAR 410-123-1265, Health Systems Division: Medical Assistance Programs, Oregon Health Plan, Teledentistry. (Accessed Dec. 2024).

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 Dec. 2024).

School Based Health Services

The Authority may reimburse school medical providers for covered School-Based Health Services (SBHS) delivered via telehealth that meet the following criteria:

The covered telehealth service is provided to a child or young adult to the same extent that the service may be covered if it were provided in person;
The school medical provider meets the following privacy and security standards (see regulation)

The Authority shall provide reimbursement for a Medicaid-covered school-based telehealth service at the same reimbursement rate as if the service were provided in person.

For school-based telehealth service claims:

A service provided using synchronous audio and video must include modifier GT;
A service provided using synchronous audio, without video, (e.g., telephone) must include modifier 93

SOURCE: OR OAR 410-133-0070, Health Systems Division: Medical Assistance Programs, School-Based Health Services, Telehealth (Accessed Dec. 2024).

CCOs shall ensure that member choice and accommodation for telemedicine or telehealth shall encompass the following standards and services:

CCOs shall ensure that providers unable to offer in-person services have access to the CCO Provider Directory.
CCOs shall ensure that providers unable to offer in-person services inform the CCO upon referring a member to another provider in accordance with the requirements set forth in OAR 410-120-1990 so the CCO can provide any care coordination services necessary to support the member in accessing care.
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;
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.

…

CCOs shall provide reimbursement for telemedicine or telehealth services and reimburse Certified and Qualified Health Care Interpreters (HCIs) as defined in OAR 950-050-0010 for interpretation services provided using 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. Administrative rules and CCO Direct Agreements do not supersede 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 Dec. 2024).

Dental Care Benefits for Pregnant Individuals

Pregnant members shall be seen, treated in person or via teledentistry for an OHP-covered service within the following time frames:

For emergency dental care: within 24 hours;
For urgent dental care: within one week.
For routine dental care: within four weeks, unless there is a documented special clinical reason that would make access longer than four weeks appropriate;
For initial dental screening or examination: four weeks.

Additional Dental Services are available to pregnant members if authorized as medically/Dentally Necessary due to the pregnancy. See regulation for more details.

SOURCE: OAR 410-123-1510, Health Systems Division: Medical Assistance Programs, Dental/Denturist Services. (Accessed Dec. 2024).

Behavioral Health Treatment Intake, Assessment and Service Planning

All providers shall develop and implement written service delivery policies and specific procedures for office- based, community-based and telehealth services and supports compliant with these rules, to be made available to individuals and family members upon request (see rule for minimum requirements).

SOURCE: OAR 309-019-0110, Health Systems Division: Medical Assistance Programs, Outpatient Behavioral Health Services. (Accessed Dec. 2024).

ELIGIBLE SITES

There is no limitation on the location of the client or member;

Providers may be located in any location where privacy can be ensured;

Persons providing interpretive services and supports shall be in any location where member privacy and confidentiality can be ensured.

[slight variation between sections cited below.]

The Authority shall only pay for telemedicine or telehealth services meeting all of the following requirements:

Services provided shall be medically and clinically appropriate for covered conditions within the Health Evidence Review Commission’s (HERC) prioritized list and in compliance with relevant guideline notes;
The Authority shall provide reimbursement for telemedicine or telehealth services at the same reimbursement rate as if it were provided in person. As a condition of reimbursement, providers shall agree to reimburse Certified and Qualified Health Care Interpreters (HCIs) for interpretation services provided using telemedicine or telehealth at the same rate as if interpretation services were provided in-person, per OARs 410-141-3515(12) and 410-141-3860(12).
When allowed by individual certification or licensing board’s scope of practice standards, telemedicine or telehealth delivered services for covered conditions are covered:
- When an established relationship exists between a provider and client or member defined as a client or member who has received in-person professional services from the physician or other qualified health care professional within the same practice within the past three years; and
- For establishing a client or member-provider relationship.
All physical and behavioral telemedicine or telehealth, and oral teledentristy services except School Based Health Services (SBHS) shall include Place of Service code 02 when the client or member is located in a place other than their home. When the client or member is located in their home, the claim shall include Place of Service code 10.
All claim types except Dental services, shall include modifier 95 when the telemedicine or telehealth delivered service utilizes a real-time interactive audio and video telecommunication system. When provision of the same service utilizes a real-time interactive audio only, the claim should include modifier 93.

SOURCE: OAR 410-120-1990, Health Systems Division: Medical Assistance Programs, Telehealth. (Accessed Dec. 2024).

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. 414.723, (Accessed Dec. 2024).

School-Based Health Services required by the Individuals Disabilities Education Act (IDEA), Section 504 Plan, under the Rehabilitation Act of 1973, or any other documented individualized health or behavioral health plan or as otherwise determined medically necessary provided in school programs and settings provided to eligible children in their education program settings by public education enrolled providers billing for these services to Medicaid are exempt from the following sections of this rule. See Chapter 410, Division 133 for School-Based Health Services Oregon Administrative Rules.

SOURCE: OAR 410-120-1990, Health Systems Division: Medical Assistance Programs, Telehealth. (Accessed Dec. 2024).

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 Dec. 2024).

GEOGRAPHIC LIMITS

Medical Assistance Benefits: Out of State Services

The division may not provide any payments for items or services to any financial institution or entity located outside of the United States pursuant to 1902(a)(80) of the Social Security Act.

This provision also prohibits payments to telemedicine providers and pharmacies located outside of the United States.

SOURCE: OR OAR 410-120-1180 Health Systems Division: Medical Assistance Programs Chapter 10. (Accessed Dec. 2024).

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 Oct. 1, 2024 Prioritized List of Health Services, p. AD-2. (11/19/24). (Accessed Dec. 2024).

Costs for telehealth technologies used to provide SBHS are included in the cost for each service discipline and are not billed separately.

SOURCE: OR OAR 410-133-0245 Health Systems Division: Medical Assistance Program – Chapter 410. (Accessed Dec. 2024).

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Pennsylvania

Last updated 09/10/2024

POLICY

MA or CHIP managed care plan payments shall be …

POLICY

MA or CHIP managed care plan payments shall be made on behalf of enrollees for medically necessary health care services provided through telemedicine, if all of the following apply:

The health care service would be covered through an in-person encounter.
The provision of the health care service through telemedicine is consistent with Federal law and regulations, the laws of this Commonwealth, applicable regulations and guidance.
Federal approval, if necessary for the provision of the health care service through telemedicine, has been received by the Department of Human Services.

The MA or CHIP managed care plan shall pay a participating network provider for covered health care services delivered through telemedicine in accordance with the terms and conditions of both:

the contract negotiated between the MA or CHIP managed care plan and the participating network provider; and
the agreement with the Department of Human Services.

Subsection (a) does not apply if the telemedicine-enabling device, technology or service fails to comply with the Health Insurance Portability and Accountability Act of 1996, the Health Information Technology for Economic and Clinical Health Act or other applicable statute, regulation or guidance from the Federal Government or the Department of Human Services.

This section shall apply to MA and CHIP managed care plans beginning on or after January 1, 2026.

This section may not be construed to:

Prohibit a MA or CHIP managed care plan from making payments on behalf of enrollees to other health care providers for covered health care services provided through telemedicine.
Require a MA or CHIP managed care plan to pay for a health care service if the delivery of the health care service through telemedicine would be inconsistent with the standard of care.

SOURCE: Senate Bill 739, (2024 Session), PA Statute Sec. 4804-4805, (Accessed Sept. 2024).

Services rendered via telehealth, including those delivered using audio-only telecommunication technology, must use technology that is two-way, real-time, and interactive between beneficiary and provider.

SOURCE: PA Department of Human Services, Medical Assistance Bulletin 99-23-08 (Aug. 2, 2023), p. 3. (Accessed Sept. 2024).

Behavioral Health

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. 2024).

In response to CMS’s change in policy, the Department is providing coverage and payment for interprofessional consultation services in the MA Program. Allowing direct payments for interprofessional consultations between providers enrolled in the MA Program improves access to specialty care, supports patient-centered care, and maximizes the capacity of the existing workforce by supporting the focus of medical practice towards managing a beneficiary’s chronic conditions. Services must be directly relevant to the beneficiary’s diagnosis and treatment, and the consulting practitioner must have specialized expertise in the particular health concerns of the beneficiary. Interprofessional consultation services are intended to expand access to specialty care and foster interdisciplinary input on beneficiary care. They are not intended to be a replacement for direct specialty care when such care is clinically indicated.

Technology used for interprofessional consultation services must be real-time interactive telecommunication technology. Asynchronous communication and applications, such as store and forward, may be utilized as a part of the synchronous interprofessional consultation, but by themselves do not meet the requirements for interprofessional consultations. Providers must remain informed on federal and state statutes, regulations, and guidance regarding use of technology to render services.

SOURCE: PA Department of Human Services, Medical Assistance Bulletin Interprofessional Consultation Services, (Dec. 27, 2023) (Accessed Sept. 2024).

ELIGIBLE SERVICES/SPECIALTIES

MA services in the FFS delivery system rendered via telehealth will be paid the same rate as if the services were rendered in person. MA managed care organizations (MCO) may, but are not required to, allow for the use of telehealth. MA MCOs may negotiate payment for services rendered via telehealth. The MA Program will continue to pay for MA covered services rendered to beneficiaries via telehealth when clinically appropriate. Services rendered via telehealth must be provided according to the same standard of care as if delivered in-person.

SOURCE: PA Department of Human Services, Medical Assistance Bulletin 99-23-08 (Aug. 2, 2023), p. 3. (Accessed Sept. 2024).

The Department is adding POS 10 (Telehealth Provided in a Patient’s Home) for the following procedure codes and procedure code and modifier combinations for all PT/Spec combinations as the Department determined telehealth is appropriate for the performance of these services. These procedure codes may include modifiers FP, GN (speech pathology), HD (pregnant/parenting women’s program), HQ (group therapy), TC, TJ (Childhood Nutrition Weight Management Services), TM (School-Based ACCESS Program), UA (audiology), UB (pricing), U3 (pricing), U4 (pricing), U5 (pricing), U6 (pricing), U7, U8 (pricing), U9 (pricing), 24 (unrelated E&M service by the same physician or other qualified health care professional during a postoperative period), 25 (significant, separate identifiable E&M service by the same physician or other qualified health care professional on the same day of the procedure or other service), 26, 27(multiple outpatient hospital E&M encounters on the same date), 57 (decision for surgery).

SOURCE: PA Department of Human Services, Medical Assistance Bulletin 99-23-09, 2023 Healthcare Common Procedure Coding System (HCPCS) Updates, Fee Adjustments, and Other Procedure Code Changes (Aug. 31, 2023), (Accessed Sept. 2024).

The Department added POS 10 (Telehealth Provided in a Patient’s Home) to procedure 96160 with the FP modifier for the following PT/Spec combinations as the Department determined telehealth is appropriate for the performance of these services

SOURCE: PA Department of Human Services, Medical Assistance Bulletin, Updates to the Family Planning Services Program Fee Schedule (Sept. 1, 2023), (Accessed Sept. 2024).

The Department added Place of Service (POS) 10 (Telehealth Provided in a Patient’s Home) to the following procedure codes (see bulletin) as the Department determined telehealth was appropriate for the performance of services.

SOURCE: PA Department of Human Services, 2023 Medical Assistance Program Dental Fee Schedule Update and Dental Provider Handbook Update (Sept. 5, 2023), (Accessed Sept. 2024).

Additionally, the MA Program now utilizes two Place of Service (POS) codes to identify when services are rendered via telehealth – POS 02 (Telehealth Provided Other than in a Patient’s Home) and POS 10 (Telehealth Provided in a Patient’s Home). As a result of revisions announced in the 2023 HCPCS Update bulletin, the Department added POS 10 to all CNWMS-related procedure codes on the MA Program Fee Schedule. In conjunction with these updates, the GT Modifier was removed from procedure code T1015. Therefore, the chart attached to this bulletin has been updated to reflect the POS code changes for CNWMS rendered via telehealth.

SOURCE: PA Department of Human Services, 2023 Updates to Childhood Nutrition and Weight Management Services (Sept. 5, 2023), (Accessed Sept. 2024).

For FQHCs & RHCs

Telemedicine encounters must be provided according to the same standard of care as if delivered in-person. FQHCs/RHCs providing physical health services are to refer to MA Bulletin 99-23-08, titled “Updates to Guidelines for the Delivery of Physical Health Services via Telehealth,” or the current MA Bulletin or Department guidance, for more information. (https://www.dhs.pa.gov/docs/Publications/Documents/FORMS%20AND%20PUBS%20OMAP/MAB2023080201.pdf).

Telehealth encounters must be provided according to the same standard of care as if delivered in-person. FQHCs/RHCs providing behavioral health services licensed by OMHSAS are to refer to OMHSAS Bulletin OMHSAS-22-02, titled “Revised Guidelines for the Delivery of Behavioral Health Services Through Telehealth,” or the current OMHSAS Bulletin or Department guidance, for more information (https://www.dhs.pa.gov/docs/Documents/OMHSAS/Bulletin%20OMHSAS-22-02%20%20Revised%20Guidelines%20for%20Delivery%20of%20BH%20Services%20Through%20Telehealth%207.1.22.pdf)

Some dental services can be provided using teledentistry. FQHCs/RHCs are to refer to MA Bulletin 08-22-13, titled “Teledentistry Guidelines and Dental Fee Schedule Updates,” or the current MA Bulletin, for more information (https://www.dhs.pa.gov/docs/Publications/Documents/FORMS%20AND%20PUBS%20OMAP/MAB2022061301.pdf).

SOURCE: PA Department of Human Services, Medical Assistance Bulletin, Updates to The PROMISe™ Provider Handbook 837 Professional/CMS-1500 Claim Form, Appendix E – FQHC/RHC Handbook, March 1, 2024, Number 08-24-04, & PA PROMISe, 837 Professional/CMS-1500 Claim Form, Provider Handbook, Appendix E – FQHC/RHC. p. 10 (Revised Mar. 1, 2024) (Accessed Sept. 2024).

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 telehealth (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 99-23-08 (Aug. 2, 2023), p. 3-4 & [slight variation] PA Department of Human Services, Office of Mental Health and Substance Abuse Services Bulletin OMHSAS-22-02, p. 6, July 1, 2022, (Accessed May 2024).

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. 2024).

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), p. 2-3. (Accessed Sept. 2024).

Additionally, vaccine counseling only visits may be provided via telemedicine with the use of Place of Service (POS) 02 (Telehealth Provided Other than in Patient’s Home) or POS 10 (Telehealth Provided in Patient’s Home).

SOURCE: PA Department of Human Services, Medical Assistance Bulletin, Vaccine Counseling Only Visits for Beneficiaries Under 21 (May 30, 2023). (Accessed Sept. 2024).

I am a licensed, Medical Assistance (MA) enrolled provider – will I continue to be reimbursed for physical health and behavioral services delivered via telemedicine after October 31, 2022, when the suspended regulations expire?

The MA program will continue to reimburse both physical health and behavioral services delivered via telemedicine after October 31, 2022

Act 98 of 2022 permanently abrogated the two DHS regulations that prohibited payment specifically for audio-only telehealth service delivery—outpatient psychiatric clinics (which includes Mobile Mental Health Treatment and Partial Hospitalization Outpatient Services) under 55 Pa. Code § 1153.14(1), and Outpatient Drug & Alcohol Clinic Services under 55 Pa. Code § 1223.14(2).

Will there be a change in MA reimbursements for physical health or behavioral health services provided via telemedicine after May 11, 2023, or will I continue to be reimbursed at the same level for services provided regardless of how they are delivered?

DHS will continue to reimburse services delivered via telemedicine at the same rates as in-person delivered services for the MA Fee-for-Service (FFS) Program.

MA MCOs may negotiate payment for services rendered via telemedicine in the MA HealthChoices managed care program. To date, all MCOs are reimbursing for services delivered via telemedicine. DHS cannot require the MCOs to have payment parity for services delivered via telemedicine without a CMS approved directed payment, as MCOs are allowed to negotiate rates.

SOURCE: PA Dept. of State, Professional Licensing, Telemedicine FAQs. (Accessed Sept. 2024).

School-Based ACCESS Program Provider Handbook Mid-Year Update

Delivery Method: While DHS has historically expressed its intent for MA services to be rendered to MA beneficiaries in person, some services may be delivered using telemedicine. Telemedicine is the use of telecommunications technologies to deliver services when the provider and the student are not in the same place at the same time. As outlined within this section by provider type, services rendered via telemedicine must be provided according to the same standard of care as if delivered in person. MA coverage and payment for services provided via telemedicine is separate and apart from authorization to engage in telemedicine from a licensing standpoint. All providers using telemedicine are advised to remain informed on all federal and state statutes, regulations and guidance regarding telemedicine.

SOURCE: PA Department of Human Services, School-Based ACCESS Program Provider Handbook Mid-Year Update, May 2, 2022, (Accessed Sept. 2024).

The MA Program will pay for interprofessional consultation services provided on behalf of a beneficiary between licensed and enrolled MA providers when clinically appropriate. Interprofessional consultations occur between an initiating treating provider and a consulting provider to benefit the treatment of the beneficiary but without the beneficiary present. See bulletins for codes eligible for interprofessional consultation services.

The treating provider enrolled in the MA Program who participates in an interprofessional consultation performed at the same time as an office visit is to bill using office visit procedure codes. The treating provider is to bill using procedure code 99452 when participating in a medical consultative discussion outside of an evaluation and management service, which can only be billed once every 14 days.

Consulting providers enrolled in the MA Program are to bill using procedure codes 99446, 99447, 99448, 99449, and 99451 when participating in a medical consultative discussion as the consulting provider. Consulting providers are not to bill for interprofessional consultation services if they have seen the beneficiary in the previous 14 days or if they plan to see the beneficiary in the next 14 days.

Providers who participate in an interprofessional consultation should bill with the POS codes identified in the attachment. Providers should not bill with POS 02 (telehealth provided other than in patient’s home) or POS 10 (telehealth provided in patient’s home) because these POS codes can only be utilized when the MA beneficiary is present.

SOURCE: PA Department of Human Services, Medical Assistance Bulletin Interprofessional Consultation Services, (Dec. 27, 2023) (Accessed Sept. 2024).

Effective for dates of services on or after March 1, 2024, the Department added POS 02 (Telehealth Provided Other than in a Patient’s Home) and POS 10 (Telehealth Provided in a Patient’s Home) for PT/Spec 10 (Mid-Level Practitioner)/247 (Pharmacist) for certain procedure codes based upon clinical review. See fee schedule.

SOURCE: PA Department of Human Services, Medical Assistance Bulletin 99-24-07 (Sept. 9, 2024), p. 3. (Accessed Sept. 2024).

The Department added procedure code G0136 with the FP (family planning) modifier for the following Provider Type (PT)/Specialty (Spec) combinations, based on clinical review, in Place of Service (POS) 02 (Telehealth Provided Other than in a Patient’s Home), 10 (Telehealth Provided in a Patient’s Home), 11 (Office), 12 (Home), 22 (Outpatient Hospital), 27 (Outreach Site/Street), and/or 49 (Independent Clinic) certain procedure codes based upon clinical review. See fee schedule.

SOURCE: PA Department of Human Services, Medical Assistance Bulletin 01-24-06, 08-24-07, 09-24-06, 10-24-06, 24-24-04, 25-24-02, 28-24-01, 31-24-07, 33-24-06 (May 28, 2024), p. 2. (Accessed Sept. 2024).

Certified Nurse Midwife Services: The Department is adding POS 99 (Special Treatment Room) for PT/Spec 33 (Certified Nurse Midwife)/370 (Tobacco Cessation) to procedure code 99407. Additionally, the Department is adding the FP (Family Planning) modifier to procedure code 99407 for PT/Spec combination 33/370 for POS 02 (Telehealth Provided Other than in a Patient’s Home), 10 (Telehealth Provided in a Patient’s Home), 11 (Office), 27 (Outreach Site/Street), and 99.

SOURCE: PA Department of Human Services, Medical Assistance Bulletin 99-24-02 (April 29, 2024), p. 2. (Accessed Sept. 2024).

ELIGIBLE PROVIDERS

Does the Department of Human Services allow Medical Assistance (MA) enrolled providers to bill for services delivered using telemedicine?

Yes. The Department of Human Services (DHS) has allowed services to be provided via telemedicine since 2007 and has allowed MA-enrolled providers to bill MA for these services. MA-enrolled providers should consult the Office of Medical Assistance Programs (OMAP) and Office of Mental Health and Substance Abuse Services (OMHSAS) telemedicine bulletins for more information on service delivery and billing (see question 7 below). DHS will continue allowing physical health and behavioral health services to be provided via telemedicine delivery and will continue to reimburse at the same rate as services delivered in person in the fee-for-service program. Managed Care Organizations (MCOs) may, but are not required to, allow for the use of telemedicine. MA MCOs may negotiate payment for services rendered via telemedicine.

SOURCE: PA Dept. of State, Professional Licensing, Telemedicine FAQs. (Accessed Sept. 2024).

Licensed Practitioners

MA coverage and payment for services provided via telehealth is separate and apart from authorization to engage in telehealth from a professional licensing standpoint. Providers using telehealth must remain informed on federal and state statutes, regulations, and guidance regarding telehealth. Practitioners should exercise sound clinical judgement and should not provide services through telehealth when it is not clinically 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.

See out of state providers section for more info for out of state providers.

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. 2024).

The Department is opening Provider Type (PT)/Specialty (Spec) combination 08 (Clinic)/110 (Psychiatric Outpatient Clinic) in Place of Service (POS) 02 (Telemedicine), 10 (Telehealth provided in the home of the individual being served) and 49 (Independent Clinic) and PT/Spec combination 08/184 (Outpatient Drug and Alcohol Clinic) in POS 02, 10, 12 (Home) and 57 (Non-Residential Substance Abuse Treatment Facility) for the following outpatient and other office evaluation and management procedure codes as a result of clinical review.

SOURCE: PA Department of Human Services, Medical Assistance Bulletin, Addition of Behavioral Health Providers to Certain Procedure Codes and other Procedure Code Changes (Aug. 2, 2022). (Accessed Sept. 2024).

SOURCE: PA Department of Human Services, Medical Assistance Bulletin 99-24-07 (Sept. 9, 2024), p. 3. (Accessed Sept. 2024).

SOURCE: PA Department of Human Services, Medical Assistance Bulletin 99-24-02 (April 29, 2024), p. 2. (Accessed Sept. 2024).

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.

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. 2024).

School-Based ACCESS Program Provider Handbook Mid-Year Update

The provider services log must indicate whether the service type is Direct: Telemedicine or Direct: In Person when documenting the service and how it was provided. The “Description of Service” section of the provider service paper log should be used to record details about the service provided, including verification consent was obtained prior to the start of any telemedicine session, whether any service disruptions or connectivity issues occurred during the service delivery and whether the service was delivered using telephone-only.

SOURCE: PA Department of Human Services, School-Based ACCESS Program Provider Handbook Mid-Year Update, May 2, 2022, (Accessed Sept. 2024).

FQHC/RHC

Telemedicine encounters must be provided according to the same standard of care as if delivered in-person. FQHCs/RHCs providing physical health services are to refer to MA Bulletin 99-23-08, titled “Updates to Guidelines for the Delivery of Physical Health Services via Telehealth,” or the current MA Bulletin or Department guidance, for more information (https://www.dhs.pa.gov/docs/Publications/Documents/FORMS%20AND%20PUBS%20OMAP/MAB2023080201.pdf).

ELIGIBLE SITES

The originating site is where the beneficiary is located at the time the MA covered service is rendered to them via telehealth. 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 telehealth equipment and available to provide in-person clinical intervention, if needed. Providers should obtain the location of the beneficiary at the time each service is rendered via telehealth should there be a need for emergency medical services.

Providers are to use POS 02 when billing for services provided via telehealth technology to beneficiaries located in a location other than their home. Providers are to use POS 10 to identify when services via telehealth technology are provided in the home of the individual being served.

SOURCE: PA Department of Human Services, Medical Assistance Bulletin 99-23-08 (Aug. 2, 2023), p. 4. (Accessed Sept. 2024).

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. 2024).

SOURCE: PA Department of Human Services, Medical Assistance Bulletin 99-24-07 (Sept. 9, 2024), p. 3. (Accessed Sept. 2024).

SOURCE: PA Department of Human Services, Medical Assistance Bulletin 99-24-02 (April 29, 2024), p. 2. (Accessed Sept. 2024).

SOURCE: PA Department of Human Services, Medical Assistance Bulletin, Vaccine Counseling Only Visits for Beneficiaries Under 21 (May 30, 2023). (Accessed Sept. 2024).

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.

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. 2024).

School-Based ACCESS Program Provider Handbook Mid-Year Update

POS 02 is to be used when services are rendered via telemedicine for certain services (see bulletin).

Nursing Services/Personal Care Services: Services delivered through telemedicine are NOT compensable.

SOURCE: PA Department of Human Services, School-Based ACCESS Program Provider Handbook Mid-Year Update, May 2, 2022, (Accessed Sept. 2024).

GEOGRAPHIC LIMITS

Services may be provided using telehealth to Pennsylvania residents who are temporarily out of the state as long as the individual continues to meet eligibility for the Pennsylvania MA Program, and the provider or licensed practitioner has received authorization to practice in the state or territory where the individual will be temporarily located.

SOURCE: PA Department of Human Services, Medical Assistance Bulletin 99-23-08 (Aug. 2, 2023), p. 5. (Accessed Sept. 2024).

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. 2024).

FACILITY/TRANSMISSION FEE

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. The MA fee for Q3014 is $15.72. MA Providers may not bill procedure code Q3014 if another MA covered service is provided at the originating site. Providers may access the online version of the MA Program Fee Schedule at the Department’s website at: https://www.dhs.pa.gov/providers/Providers/Pages/Health%20Care%20for%20Providers/MAFee-Schedule.aspx.

SOURCE: PA Department of Human Services, Medical Assistance Bulletin 99-23-08 (Aug. 2, 2023), p. 5. (Accessed Sept. 2024).

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Puerto Rico

Last updated 09/04/2024

Policy

Any professional certified to offer their services through Telehealth …

Policy

Any professional certified to offer their services through Telehealth (Cybertherapy) will be able to bill health insurance companies and the Insurance Administration of Health (ASES) for the services provided, and they will be obliged to pay the same with the same rate established in the contract, as if it were a service provided in person. For these purposes, insurance companies of health and ASES, will have to provide the professionals who request it with the corresponding codes for billing for the services provided through Telehealth.

SOURCE: Departmento De Salud, Reglamento Para El USO De La Telesalud En Puerto Rico, Numero 9518 (Dec. 1, 2023), Article 7., Departamento de Salud, Reglamento Para Regular La Ciberterapia en Puerto Rico, Numero 9517 (Dec. 2023), Article 7. (Accessed Sept. 2024).

The Puerto Rico Medicaid delivery system is a subset of the larger public government healthcare delivery system for most of the island’s population. The Puerto Rico Department of Health is the single state agency, and they have a cooperative agreement with the Puerto Rico Health Insurance Administration (PRHIA) also known as Administracion de Seguros Salud de Puerto Rico (ASES) which implements and administers island-wide health insurance system. Approximately half of Puerto Rico’s 3.5 million residents have low incomes and depend upon the public health system for their medical care.

https://www.medicaid.gov/state-overviews/puerto-rico.html

The practice of Telemedicine must take into consideration those aspects as defined by the “Center for Medicare Services” (CMS), for the purposes of the “Act for the Use of Telemedicine and Telehealth in Puerto Rico ” [Law 168-2018, as amended] Rev. November 19, 2020, the consultations made may be considered for reimbursement by “Medicare”, “Medicaid” other medical plans.

Synchronous teleconsultations are carried out in real time (term most used in the international arena), involving the participation of both patients and health professionals in sending information, sometimes using sophisticated telecommunication technologies.

Telecare – Refers to equipment in the home that allows independent living and issues data and alerts to caregivers. Telecare is a monitoring system for the elderly or dependents. The innovative service consists of a wearable device hidden under the guise of a simple watch, connected 24×7 to a central control unit, which receives the user’s vital signs, location and signals. If an emergency situation is detected, we contact the user, family members and emergency care agencies if necessary.

Teleconsultation- Remote communication between patient and provider. It is a system that uses computers and telecommunications for the purpose of providing health care at the hands of specialized personnel.

SOURCE: Telesalud. Departamento de Salud. (Accessed Sept. 2024).

Synchronous: Synchronous Teleconsultation (face to face) is carried out in real time between the health professional and the patient requesting the service.

Source: Telemedicina Y Telesalud. Departamento de Salud. (Accessed Sept. 2024).

Eligible Services/Specialties

Any professional licensed and certified to offer their services through Cybertherapy, may bill health insurance companies and the Health Insurance Administration (ASES) for the services provided, and these they will be obliged to pay them as if it were a service provided in person. For these purposes, the health insurance companies and ASES, They will have to provide the professionals who request it with the corresponding codes for billing for services provided through Cybertherapy.

SOURCE: Departamento de Salud, Reglamento Para Regular La Ciberterapia en Puerto Rico, Numero 9517 (Dec. 2023), Article 7. (Accessed Sept. 2024).

Eligible Providers

The provisions of this Regulation apply to the following health professionals duly authorized to exercise their specialty who are interested in obtaining a certification for offer services using Telehealth:

Audiologists
Chiropractors
Dentists
Health Educators and Pharmacists
Veterinary Doctors
Podiatrists
Doctors in Naturopathy and Naturopaths
Nutritionists and Dietitians
Optics
Optometrists
Those categories of nursing included in the Law No. 254 of December 31, 2015.

SOURCE: Departmento De Salud, Reglamento Para El USO De La Telesalud En Puerto Rico, Numero 9518 (Dec. 1, 2023), Article 1, Section 1.5. (Accessed Sept. 2024).

Cybertherapy

The provisions of this Regulation apply to all health professional duly authorized to practice practice of physical therapy, occupational therapy, speech-language therapy, psychology, professional counseling and counseling in rehabilitation, who is interested in obtaining a certification for offer services using Cybertherapy.

This regulation is promulgated with the purpose of promoting, facilitate and incorporate into our jurisdiction the advances technologies in the practice of physiotherapy, therapy occupational, speech-language therapy, psychology, counseling professional and rehabilitation counseling, in addition to having that every professional duly licensed and authorized to practice the practices described above, can invoice the services provided using Cybertherapy, as established in Law No. 48-2020, to health insurance companies and to the Health Insurance Administration (ASES).

SOURCE: Departamento de Salud, Reglamento Para Regular La Ciberterapia en Puerto Rico, Numero 9517 (Dec. 2023), Article 1, Section 1.3 & 1.5 (Accessed Sept. 2024).

Eligible Sites

No reference found.

Geographic Limits

No reference found.

Facility/Transmission Fee

No reference found.

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Rhode Island

Last updated 10/17/2024

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 Oct. 2024).

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 Oct. 2024).

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 [search ‘telehealth’ in description area]. (Accessed Oct. 2024).

Community Health Worker Services

Health System Navigation and Resource Coordination Services that prevent disease, disability, and other health conditions or their progression; prolong life; and/or promote physical and mental health and efficiency.

The following are examples of health system navigation and resource coordination services:

Helping a beneficiary with a telehealth appointment and/or educating a member on the use of telehealth technology.

Collateral Services: Service time billed must be for either direct contact with a beneficiary (in-person or through telehealth) or for collateral services on an individual basis. Collateral services are those delivered on behalf of an individual beneficiary but that are not delivered in that beneficiary’s presence/directly to the beneficiary.

SOURCE: RI Executive Office of Health and Human Services Medicaid Program, Community Health Workers Provider Manual, pg. 8 & 11 (Feb. 2024). (Accessed Oct. 2024).

Teledentistry Policy

Teledentistry is not a specific service but a mode of accomplishing a particular service. Teledentistry may include communication from one dental provider to another. Providers are asked to bill nonpaying codes D9995 (Synchronous teledentistry) and D9996 (Asynchronous teledentistry) for documentation but should use applicable D codes. Frequency limitations for service codes apply. Dentists billing for exams completed by dentistry acknowledge they have received and reviewed essential information to make a diagnosis, comparable to what would be used in an in-person visit.

SOURCE: RI Executive Office of Health and Human Services Medicaid Program, Dental Manual, pg. 11. (Aug. 2024). (Accessed Oct. 2024).

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 Oct. 2024).

An encounter must include a face-to-face or telemedicine (telephone-only and tele video services) visit with a physician (including optometrists and psychiatrists), physician assistant, nurse practitioner (advanced practice registered nurses), clinical social worker, clinical psychologist, certified nurse midwife, clinical nurse specialist, licensed mental health counselor, licensed marriage and family therapist, dentist or registered dental hygienist.

SOURCE: RI Executive Office of Health and Human Services, Principles of Reimbursement for FQHCs, Aug. 2022, pg. 5-6, (Accessed Oct. 2024).

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 Oct. 2024).

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, Mar. 2023 . (Accessed Oct. 2024).

GEOGRAPHIC LIMITS

No Reference Found

TRANSMISSION FEE

No Reference Found

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South Carolina

Last updated 08/26/2024

POLICY

Children and adult beneficiaries are eligible to receive services …

POLICY

Children and adult beneficiaries are eligible to receive services via telehealth modality under the State Plan benefit (authority).

South Carolina Medicaid 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.
The medical care can be safely furnished.
No equally effective, more conservative or less costly treatment is available Statewide

The following conditions apply to all services rendered via telehealth.

The beneficiary must be present and participating in the telehealth visit. Any exemptions to this condition (such as inter professional consultation services) will be otherwise listed under the exempted service section of the Physician Services Provider Manual respectively).
The referring provider must provide pertinent medical information and/or records to the consulting provider via a secure transmission.
Interactive audio and video telecommunication must be used, permitting encrypted communication between the distant site physician or practitioner and the Medicaid beneficiary. The telecommunication service must be secure and adequate to protect the confidentiality and integrity of the telehealth information transmitted.
The telehealth equipment and transmission speed and image resolution must be technically sufficient to support the service billed. Any staff involved in the telehealth visit must be trained in the use of the telehealth equipment and competent in its operation.
A trained healthcare professional at the referring site (patient site presenter) is required to present the beneficiary to the provider at the consulting site and remain available as clinically appropriate (this condition is waived when the referring site is the patient home).
If the beneficiary is a minor (under 18 years old), a parent and/or guardian must present the minor for telehealth service unless otherwise exempted by State or Federal law. The parent and/or guardian need not attend the telehealth session unless attendance is therapeutically appropriate.
The beneficiary retains the right to withdraw from the telehealth visit at any time.
All telehealth activities must comply with the requirements of HIPAA: Standards for Privacy of individually identifiable health information and all other applicable State and Federal Laws and regulations.
The beneficiary has access to all transmitted medical information, except for live interactive video, as there is often no stored data in such encounters.
The provider at the distant site must obtain prior approval for service when services require prior approval, based on service type or diagnosis.

Reimbursement to the health professional delivering the medical service is the same as the current fee schedule amount for the service provided. Consulting site physicians and practitioners submit claims for telehealth or telepsychiatry services using the appropriate CPT code for the professional service along with the telehealth modifier GT, “via interactive audio and video telecommunications system”. By coding and billing the “GT” modifier with a covered telehealth procedure code, the consulting site physician and/or practitioner certifies that the beneficiary was present at the referring site when the telehealth service was furnished. Fee schedules are located on the SCDHHS website at http://www.scdhhs.gov.

SOURCE: SC Health and Human Svcs. Dept. Physicians Provider Manual, p. 32-35, 193. (Sept. 2024). (Accessed Aug. 2024).

Telepsychiatry

To qualify for reimbursement, interactive audio and video equipment that permits two-way real-time or near real-time communication between the beneficiary, 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. 31. (Mar. 2024). (Accessed Aug. 2024).

Rehabilitative Therapy

SCDHHS provides coverage for the delivery of certain rehabilitative therapy services via telehealth from a consultant site to a referring site within the limitations described below:

The consultant site (distant site) is the physical location where a specialty physician or practitioner providing medical care is located at the time the service is provided via telehealth. The provider performing the medical care must have a valid, active license in South Carolina.
The referring site (patient site) is the location of a Medicaid beneficiary at the time the service is being furnished.

The following conditions apply to all rehabilitative therapy services rendered via telehealth:

The beneficiary must be present and participating in the telehealth visit.
Interactive audio and video telecommunication must allow encrypted communication between the distant site practitioner and the Medicaid beneficiary. The telecommunication system must be secure and adequate to protect the confidentiality and integrity of the telehealth information transmitted.
The telehealth equipment and transmission speed and image resolution must be technically sufficient to support the service billed. Any staff involved in the telehealth visit must be trained in the use of the telehealth equipment and competent in its operation.
A trained healthcare professional at the referring site (patient site presenter) is required to present the beneficiary to the practitioner at the consulting site and remain available as clinically appropriate (this condition is waived when the referring site is the beneficiary’s home).
If the beneficiary is a minor (under 18 years), a parent and/or guardian must present the minor for telehealth service unless otherwise exempted by State or Federal law. The parent and/or guardian need not attend the telehealth session unless attendance is therapeutically appropriate.
The beneficiary retains the right to withdraw from the telehealth visit at any time.
All telehealth activities must comply with the requirements of HIPAA: Standards for Privacy of individually identifiable health information and all other applicable State and Federal Laws and regulations.
The beneficiary has access to all transmitted medical information, except for live interactive video, as there is often no stored data in such encounters.
The provider at the distant site must obtain prior approval for service when services require prior approval, based on service type or diagnosis.

Rehabilitative therapy services delivered via telehealth are a continuation of the therapy services provided in an office or outpatient setting. Quality of health care must be maintained regardless of the mode of delivery.

See Rehabilitative Therapy manual for procedure codes allowed via telehealth.

SOURCE: SC Health and Human Svcs. Dept. Rehabilitative Therapy and Audiological Services Provider Manual, p. 8-9 (Jul. 2024). (Accessed Aug. 2024).

Federally Qualified Health Center/Rural Health Center Services

Telehealth substitutes for an in-person visit, and generally involves two-way, interactive technology that permits communication between the practitioner and patient. FQHCs/RHCs can provide telehealth to extend care when a patient is in a different location.

SOURCE: SC Health and Human Svcs. Dept. Federally Qualified Health Center Provider Manual, p. 20. (Sept. 2024) & SC Health and Human Svcs. Dept. Rural Health Clinic Provider Manual, p. 19. (Sept. 2024). (Accessed Sept. 2024).

ELIGIBLE SERVICES/SPECIALTIES

Telehealth services are not an expansion of Medicaid-covered services but an option for the delivery of certain covered services. Quality of health care must be maintained regardless of the mode of delivery. Telehealth includes consultation, diagnostic and treatment services.

Services that are eligible for reimbursement include consultation, office visits, individual psychotherapy, pharmacologic management, and psychiatric diagnostic interview examinations and testing, delivered via a telecommunication system.

A list of Medicaid telehealth services can be found in the Procedure Codes section of this manual.

Office and OP visits that are conducted via telehealth are counted towards the applicable benefit limits for these services.

Well-care visits conducted via telehealth must be billed with the appropriate EPSDT code and a GT modifier.

Services provided by allied health professionals are not covered.

SOURCE: SC Health and Human Svcs. Dept. Physicians Provider Manual, p. 32, 34, 145, 204 (Sept. 2024). (Accessed Aug. 2024).

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. 22. (Jan. 2023). (Accessed Aug. 2024).

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 Manual, p. 31 (Jul. 2024). (Accessed Aug. 2024).

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 (Mar. 2024). (Accessed Aug. 2024).

Applied Behavior Analysis

SCDHHS will continue to reimburse providers for the ABA services described in the bulletin referenced in the source below when rendered through telehealth for one year beyond the end date of the current federal PHE.* These flexibilities will be extended for remote supervision of registered behavior technicians (RBTs) who provide service in a face-to-face setting and consultation of parent-directed activities via telehealth for the CPT codes listed as described in Medicaid bulletin 20-011. These flexibilities will be extended for encounters that include both audio and visual components.

*On March 21, 2024 SCDHHS issued Medicaid bulletin 24-010 to announce that flexibilities continued for one year after the expiration of the federal PHE are now extended by SCDHHS through Dec. 31, 2024. This extension aligns with a similar policy announced by the Centers for Medicare and Medicaid Services that extended telehealth flexibilities issued during the COVID-19 federal PHE for Medicare providers through Dec. 31, 2024.

SOURCE: SC Dept. of Health and Human Services. Medicaid Bulletin 22-005. (May 2023); SC Dept. of Health and Human Services. Medicaid Bulletin 24-010. (Mar. 2024). (Accessed Aug. 2024).

Authorized synchronous audio/visual supervision of RBTs and other therapists is available using telehealth for established patients. Services provided via telehealth are to be reimbursed in lieu of, not in addition to, those provided face-to-face and reimbursed in a manner consistent with the authorities and limitations detailed in the State Plan and this provider manual. Use of a GT modifier will be required for any telehealth visits in addition to any other modifier(s) required for the service. The GT modifier will be listed in the secondary modifier position, with any other required modifier listed in the primary modifier position.

If in-person interaction with an RBT or other therapist is not feasible, services below may be provided via telehealth for consultation by providers authorized to practice independently, when provided through a parent or family member.

SOURCE: SC Health and Human Svcs. Autism Spectrum Disorder Provider Manual, p. 19 (Jul. 2024). (Accessed Aug. 2024).

Behavioral Health

Prior to the COVID-19 PHE, SCDHHS’ Medicaid program covered a broad array of behavioral health services that were eligible for reimbursement when delivered using audio and visual interactions to ensure access to services in a variety of settings. SCDHHS will continue to augment the state’s existing behavioral health telehealth benefit and extend the flexibilities included below for one year beyond the end date of the current federal PHE.* Services described within the bulletin referenced in the source below are eligible for reimbursement when delivered by LIPs and associate-level licensed practitioners as described in Medicaid bulletins 20-009, 20-014 and 20-016. Services rendered through an FQHC or RHC for the CPT codes listed will be reimbursed. Services described will also be continued for this period for mental health professional master’s level personnel employed by other state agencies.

Developmental Evaluation Center (DEC) Screenings

SCDHHS will continue to reimburse DECs for services rendered through telehealth for one year beyond the end date of the current federal PHE.* These flexibilities will be extended for encounters that include both audio and visual components. As specified in the SCDHHS memo issued April 16, 2020, services rendered by a physician, NP, PA or psychologist for the below Healthcare Common Procedure Coding System (HCPCS) codes will be reimbursed subject to the same duration requirements and service limits as services delivered face-to-face.

Addiction and Recovery-related Services

SCDHHS will continue to reimburse for management of medication-assisted treatment (MAT) services and services rendered by Act 301 local alcohol and drug abuse authorities (local authorities) delivered through telehealth for one year beyond the end date of the current federal PHE.* These continued flexibilities apply to the procedure codes listed below for the services and provider types described in the memo SCDHHS issued April 17, 2020, and Medicaid bulletin 20-017 with the exception of audio-only telephonic coverage of MAT services, which will sunset with the end of the current federal PHE.

Telehealth Services for BabyNet-enrolled Children

SCDHHS will continue to reimburse providers for early intervention services and development of individualized family service plans (IFSPs) rendered through telehealth. These flexibilities will be extended for one year beyond the end date of the current federal PHE.* Services for the procedure codes listed below will continue to be reimbursed when rendered as described in Medicaid bulletin 20-010 and the Medicaid alert dated July 9, 2020. Interpretation services as described in Medicaid bulletin 20-010 will also continue for one year beyond the end date of the current federal PHE.* Additional billing guidance for these services is available in the memo issued by SCDHHS on April 30, 2020.

In addition to the physical and speech therapy services described above, providers can also continue to be reimbursed for occupational therapy rendered through telehealth for children enrolled in the BabyNet program as described in Medicaid bulletin 20-008.

Child Well-care and Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Visits

SCDHHS will continue to reimburse providers for child well-care and EPSDT visits rendered through telehealth. These continued flexibilities apply to the policy changes described in Medicaid bulletin 20-015 for encounters that include both audio and visual components.

Physical and Speech Therapy Services

SCDHHS will continue to reimburse for physical and speech therapy services that include both audio and visual components for one year beyond the end date of the current federal PHE.* These continued flexibilities apply to physical and speech therapy services rendered by the provider types and procedure codes listed below for services described in Medicaid bulletins 20-008 and 20-016, with the exception of services provided as audio-only telephonic services, which will no longer be reimbursable upon expiration of the current federal PHE.

SOURCE: SC Dept. of Health and Human Services. Medicaid Bulletin 22-005. (May 2023); SC Dept. of Health and Human Services. Medicaid Bulletin 24-010. (Mar. 2024). (Accessed Aug. 2024).

Occupational Therapy

Occupational therapy services described in Medicaid bulletins 20-008 and 20-016 will continue to be eligible for reimbursement when delivered via telehealth that includes both audio and visual components for one year beyond the end date of the current federal PHE.* Initial evaluations still must be performed in a face-to-face encounter to be eligible for reimbursement.

SOURCE: SC Dept. of Health and Human Services. Medicaid Bulletin Update on Occupational Therapy Telehealth Flexibilities. (Oct. 2022); SC Dept. of Health and Human Services. Medicaid Bulletin 24-010. (Mar. 2024). (Accessed Aug. 2024).

Nutritional Counseling Services

Nutritional counseling services are allowed to be performed via telehealth. A telehealth encounter must be billed with GT modifier, and it counts towards the twelve (12) hours of combined medical nutrition therapy services provided to a patient per fiscal year. Services delivered in-person or via telehealth by the same provider type will be reimbursed at the same rate.

For Federally Qualified Health Center Services, medical nutrition therapy is billable under the encounter rate. If the beneficiary is seen by a physician or mid-level provider and dietitian on the same day, one encounter can be billed for the services received that day.

For Rural Health Center Services, nutritional counseling services are also allowed to be performed via telehealth. However, medical nutrition therapy is not allowed to be billed using the encounter rate. All providers and dietitians are required to bill the appropriate CPT codes with a primary diagnosis code. The provider can either schedule the patient for an independent visit or may bill the initial medical nutrition therapy visit on the same day as a routine physical exam or E&M service. The subsequent individual or group nutrition therapy must be scheduled as independent visits. Medical nutrition therapy services performed in a RHC must be billed under the performing provider’s group NPI, not allowed to be billed under the RHC NPI.

SOURCE: SC Health and Human Svcs. Dept. Medicaid Bulletin 23-060, Dec. 2023 & SC Health and Human Svcs. Dept. Physicians Provider Manual, p. 212, 254, 257. (Aug. 2024). (Accessed Aug. 2024).

Interprofessional Consultation

SCDHHS will reimburse providers for interprofessional consultation services as distinct services under the Medicaid physician fee schedule.

Interprofessional consultation is defined as a situation in which the patient’s treating physician or other qualified health care practitioner (hereafter referred to as the treating practitioner) requests the opinion and/or treatment advice of a physician or other qualified health care practitioner with specific specialty expertise (hereafter referred to as the consulting practitioner) to assist the treating practitioner with the patient’s care.

Interprofessional consultation is intended to expand access to specialty care and foster interdisciplinary input on patient care. It is not intended to be a replacement for direct specialty care when such care is clinically indicated. Reimbursement of interprofessional consultation is permissible, even when the beneficiary is not present, as long as the consultation is for the direct benefit of the beneficiary. The consulting provider must be an enrolled Medicaid provider. Interprofessional consultation services may be provided via telehealth and reimbursed with the use of the appropriate modifier.

SOURCE: SC Health and Human Svcs. Dept. Medicaid Bulletin 23-063, Dec. 2023 & SC Health and Human Svcs. Dept. Physicians Provider Manual, p. 85-86. (Sept. 2024). (Accessed Aug. 2024).

Federally Qualified Health Center/Rural Health Center Services

FQHC/RHC providers are eligible to serve as referring site or consulting site providers for telehealth services.

When billing valid encounters provided by telehealth, FQHC/RHC providers must use POS code 02 with the encounter code T1015 as well as the procedure codes for the specific allowable services provided during the telemedicine encounter. Modifier GT is also required for all services provided via telehealth and must be recorded secondary to any other applicable modifiers.

See page 21 of manual for PHE limited telehealth codes.

SOURCE: SC Health and Human Svcs. Dept. Federally Qualified Health Center Provider Manual, p. 9, 16, 21. (Sept. 2024); SC Health and Human Svcs. Dept. Rural Health Clinic Provider Manual, p. 7, 13, 21. (Sept. 2024). (Accessed Sept. 2024).

ELIGIBLE PROVIDERS

Providers who meet the Medicaid credentialing requirements and are currently enrolled with the South Carolina Medicaid program are eligible to bill for telehealth and telepsychiatry when the service is within the scope of their practice. The referring provider is the provider who has evaluated the beneficiary, determined the need for a consultation, and has arranged the services of the consulting provider for the purpose of consultation, diagnosis and/or treatment. The consulting provider is the provider who evaluates the beneficiary via telehealth mode of delivery upon the recommendation of the referring provider. In situations where a referral is not needed, the provider will not need to be confined to the definitions above.

Practitioners at the distant site who may furnish and receive payment of covered telehealth services are:

Physicians
NPs
PAs
Licensed Independent Practitioners (and associates)
Physical, occupational, and speech therapists

A licensed physician, NP, PA, licensed psychologist, licensed professional counselor, licensed independent social worker, and licensed marriage and family counselor may provider telepsychiatry services.

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 telehealth. The health professional providing the medical care must be currently and appropriately licensed in South Carolina. FQHC and RHC providers are eligible to serve as consulting site providers for telehealth services.

Consulting site physicians and practitioners submit claims for telehealth or telepsychiatry services using the appropriate CPT code for the professional service along with the telehealth modifier GT, “via interactive audio and video telecommunications system”. By coding and billing the “GT” modifier with a covered telehealth procedure code, the consulting site physician and/or practitioner certifies that the beneficiary was present at originating site when the telehealth service was furnished.

SOURCE: SC Health and Human Svcs. Dept. Physicians Provider Manual, p. 33-34, 193. (Sept. 2024) (Accessed Aug. 2024).

SCDHHS will continue to reimburse FQHCs and RHCs for services rendered through telehealth. This extension applies to the flexibilities announced in Medicaid bulletin 20-007 and to the services described within the bulletin referenced in the source below.

SOURCE: SC Dept. of Health and Human Services. Medicaid Bulletin 22-005. (May 2023); SC Dept. of Health and Human Services. Medicaid Bulletin 24-010. (Mar. 2024). (Accessed Aug. 2024).

Federally Qualified Health Center/Rural Health Center Services

FQHC/RHC providers are eligible to serve as referring site or consulting site providers for telehealth services.

FQHCs/RHCs 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. For a limited time during the Public Health Emergency period, visits rendered via telehealth may be billed separately, in lieu of an encounter, under the FQHC/RHC provider NPI. Refer to the Special Clinic Services section of this manual.

SOURCE: SC Health and Human Svcs. Dept. Federally Qualified Health Center Provider Manual, p. 7, 20. (Sept. 2024); SC Health and Human Svcs. Dept. Rural Health Clinic Provider Manual, p. 7, 22. (Sept. 2024). (Accessed Sept. 2024).

ELIGIBLE SITES

Eligible originating (referring) sites:

Practitioner offices (physician, NP, CNM, PA or LIP);
Hospitals (inpatient and outpatient);
Rural Health Clinics;
Federally Qualified Health Centers;
Community Mental Health Centers;
Public Schools;
Act 301 Behavioral Health Centers
Patient home

A referring site (also known as an originating site) is the location of an eligible Medicaid beneficiary at the time the service being furnished via a telecommunication system occurs. Medicaid beneficiaries are eligible for telehealth services only if they are presented from a referring site located in the SCMSA. Referring site presenters may be required to facilitate the delivery of this service. Referring site presenters should be a person knowledgeable in how the equipment works and able to provide clinical support if needed during a session.

A trained 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 (this condition is waived when the referring site is the patient home).

SOURCE: SC Health and Human Svcs. Dept., Physicians Provider Manual, p. 33, 35 (Sept. 2024). (Accessed Aug. 2024).

Local Education Agency Manual refers providers to the Physician Manual Policy.

SOURCE: SC Health and Human Svcs. Dept., Local Education Manual, p. 22. (Jan. 2023). (Accessed Aug. 2024).

SCDHHS will waive referring site restrictions that existed prior to the COVID-19 PHE, which will allow providers to be reimbursed for services delivered via telehealth to Healthy Connections Medicaid members regardless of the members’ location as described in Medicaid bulletin 20-005. This flexibility applies to the evaluation and management (E/M) Current Procedural Terminology (CPT) codes listed in the bulletin referenced in the source below for services rendered by a physician, nurse practitioner, or physician assistant. This flexibility will be made permanent for evaluation and management encounters that include both audio and visual components.

SOURCE: SC Dept. of Health and Human Services. Medicaid Bulletin 22-005. (May 2023). (Accessed Aug. 2024).

Federally Qualified Health Center/Rural Health Center Services

FQHC services are allowed to be performed in the following settings: …

Telehealth or Telehealth at Home

SOURCE: SC Health and Human Svcs. Dept. Federally Qualified Health Center Provider Manual, p.13. (Sept. 2024). (Accessed Sept. 2024).

RHC services are allowed to be performed in the following settings:

Telehealth

SOURCE: SC Health and Human Svcs. Dept. Rural Health Clinic Provider Manual, p. 13. (Sept. 2024). (Accessed Sept. 2024).

GEOGRAPHIC LIMITS

A consultant site (also called the distant site) is the site at which the provider is located at the time the telehealth service. The provider performing the medical care must be currently and appropriately licensed in South Carolina. FQHC and RHC providers are eligible to serve as consulting site providers for telehealth services.

A referring site (also called the patient site) is the location of an eligible Medicaid beneficiary at the time the telehealth service is being furnished. Medicaid beneficiaries are eligible for telehealth services only if they are presented from a referring site located in the SCMSA.

SOURCE: SC Health and Human Svcs. Dept. Physicians Provider Manual, p. 33. (Sept. 2024). (Accessed Aug. 2024).

FACILITY/TRANSMISSION FEE

The referring site, also known as the originating site, is only eligible to receive a facility fee for telehealth services. Claims must be submitted with an appropriate HCPCS code (telehealth originating site facility fee). If a provider from the referring site performs a separately identifiable service for the beneficiary on the same day as telehealth, documentation for both services must be clearly and separately identified in the beneficiary’s medical record, and both services are eligible for full reimbursement.

Hospital providers are eligible to receive reimbursement for a facility fee for telehealth when operating as the referring site. Claims must be submitted with the appropriate telehealth revenue code. There is no separate reimbursement for telehealth services when performed during an inpatient stay, OP clinic or ER visit, or OP surgery, as these are all-inclusive payments.

SOURCE: SC Health and Human Svcs. Dept., Physicians Provider Manual, p. 193 (Sept. 2024). (Accessed Aug. 2024).

Federally Qualified Health Center/Rural Health Center Services

FQHCs/RHCs are eligible to receive reimbursement for a facility fee for the telehealth services when operating as the referring site. Claims must be submitted with the HCPCS code for telehealth referring site facility fee. When serving as the referring site, the FQHC/RHCs cannot bill the encounter code if these are the only services rendered.

SOURCE: SC Health and Human Svcs. Dept. Federally Qualified Health Center Provider Manual, p. 22. (Sept. 2024), & SC Health and Human Svcs. Dept. Rural Health Clinic Provider Manual, p. 20. (Sept. 2024). (Accessed Sept. 2024).

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South Dakota

Last updated 12/11/2024

POLICY

Providers should refer to the General Coverage Principles manual …

POLICY

Providers should refer to the General Coverage Principles manual for basic coverage requirements all services must meet. These coverage requirements include:

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.

Services provided via telemedicine are subject to the same service requirements and limitations as in person services. Providers must have and utilize appropriate equipment to provide a service via telemedicine. Telemedicine services always involve an originating site and a distant site.

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 reimbursement for distant site services is listed on the applicable fee schedule. The maximum allowable amount for services provided via telemedicine is the same as services provided in-person. Facility related charges for distant site telemedicine providers are not reimbursable.

SOURCE: SD Medicaid Billing and Policy Manual: Telemedicine, p. 3 & 12 (Nov. 2024) (Accessed Dec. 2024).

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 adult and children 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.

Services provided via teledentistry should include the following additional documentation in addition to the standard of service documentation:

If synchronistic, the name of the platform used to complete the visit; and
Detailed clinical notes of the visit including the name and credentials of individuals involved in the teledentistry visit and their role in the visit.

SOURCE: South Dakota Medicaid Billing and Policy Manual, Teledentistry Services, pg. 3 (Jun. 2023) (Accessed Dec. 2024).

ELIGIBLE SERVICES/SPECIALTIES

Only certain procedure codes may be provided via telemedicine. Refer to the Appendix for a list of procedure codes allowed to be provided via telemedicine.

Applied Behavioral Analysis (ABA) Services – ABA services may be provided via telemedicine. The service must be provided by means of “real-time” interactive telecommunications system and the provider must have a face-to-face visit within the first 30 days and every 90 days thereafter. Please refer to the Applied Behavioral Analysis (ABA) Services manual for additional coverage information.

Audiology Services – Limited fitting and programming audiology services may be provided via telemedicine. The service must be provided by means of “real-time” interactive telecommunications system and the provider must have a face-to-face visit within the first 30 days and every 90 days thereafter. The following services may be performed when the patient is in any setting, including the patient’s home:

Cochlear Implant Follow-Up/Reprogramming (CPT codes 92601-92604);
Hearing Aid Checks (CPT codes 92592-92593), and
Auditory Function Evaluation (CPT codes 92620, 92621, 92626, and 92627).

In addition, the following services can be provided via telemedicine when the patient is located in a clinic or other setting with a qualified health professional present:

Tympanometry (CPT code 92550 and 92567); and
Evoked Auditory Tests (CPT codes 92585-92588).

Please refer to the Audiology Services manual for additional coverage information.

Diabetes Self-Management Training (DSMT) – When applicable, the distant site practitioner must confirm that the recipient has received or will receive 1 hour of in-person DSMT services for purposes of injection training when it is indicated during the year following the initial DSMT service or any calendar year’s 2 hours of follow-up training.

Please refer to the Diabetes Self-Management Training Services manual for additional coverage information.

End-Stage Renal Disease (ESRD) Services – ESRD services must include at least 1 visit per month be furnished face-to-face “hands on” to examine the vascular access site by a physician other licensed practitioner. Telemedicine may be used for providing additional visits

Emergency Department or Initial Inpatient Consultation – The intent of an inpatient or emergency department telemedicine consultation service is that a physician or other licensed practitioner or other appropriate source is asking another physician or other licensed practitioner for advice, opinion, a recommendation, suggestion, direction, or counsel, etc. in evaluating or treating a patient because that individual has expertise in a specific medical area beyond the requesting professional’s knowledge.

A request for an inpatient or emergency department telemedicine consultation from an appropriate source and the need for an inpatient or emergency department telemedicine consultation (i.e., the reason for a consultation service) shall be documented by the consultant in the patient’s medical record and included in the requesting physician or other licensed practitioner plan of care in the patient’s medical record.

Inpatient and Nursing Facility Telemedicine – Inpatient telemedicine consultations furnished to recipients in hospitals or skilled nursing facilities via telemedicine must be at the request of the physician of record, the attending physician, or another appropriate source. The physician or practitioner who furnishes the initial inpatient consultation via telemedicine cannot be the physician or practitioner of record or the attending physician or practitioner, and the initial inpatient telemedicine consultation would be distinct from the care provided by the physician or practitioner of record or the attending physician or practitioner. Counseling and coordination of care with other providers or agencies is included as well, consistent with the nature of the problem(s) and the patient’s needs.

Teledentistry Services – Please refer to the Teledentistry Services manual for information regarding coverage of teledentistry services.

Therapy Services – Physical therapy, occupational therapy, and speech language therapy services may be provided via telemedicine. The service must be provided by means of “real-time” interactive telecommunications system and the provider must have a face-to-face visit within the first 30 days and every 90 days thereafter.

Telemedicine service for electric stimulation attended, code 97032, is limited to one unit. Providers must document any treatment modifications used to support delivering services via telemedicine. Please refer to the Therapy Services manual for additional coverage information.

School District Services – School district providers may provide physical and occupational therapy via telemedicine using CPT code 97799 for physical therapy and CPT code 97139 for occupational therapy. Speech-language pathology services continue to be allowed when provided via telemedicine and should be billed using CPT code 92507. The service must be provided by means of “real-time” interactive telecommunications system and the provider must have a face-to-face visit within the first 30 days and every 90 days thereafter.

Psychology services may also be provided via telemedicine or real time, two-way audio-only using CPT code 90899. Audio-only services must be provided in accordance with the independent mental health practitioner coverage criteria stated in this manual.

Please refer to the School District Services manual for additional coverage information.

Services not specifically listed as covered in the procedure code table in the Appendix are considered non-covered. Claims submitted by a non-eligible originating site will be denied. Birth to Three services do not qualify for an originating site reimbursement unless provided at an eligible originating site location. Distant sites located outside of the United States are not covered.

SOURCE: SD Medicaid Billing and Policy Manual: Telemedicine, (Nov. 2024). (Accessed Dec. 2024).

Can ABA services be provided via telemedicine? Yes, South Dakota Medicaid allows ABA services to be provided via telemedicine. Refer to the Telemedicine manual for coverage details.

SOURCE: SD Medicaid Billing and Policy Manual: Applied Behavior Analysis, p. 7 (Oct. 2023). (Accessed Nov. 2024).

Can speech therapy be provided via telemedicine? Yes, 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. 8, (Dec. 2023), (Accessed Dec. 2024).

Speech language pathologist services can be provided via telemedicine if it meets the requirements in the in the Telemedicine manual. The service must be provided by means of “real-time” interactive telecommunications system. To ensure that a patient’s care needs are assessed by a health care provider in person and the provider must have a face-to-face visit within the first 30 days and every 90 days thereafter.

SOURCE: SD Medicaid Billing and Policy Manual: Birth to Three Non-School District Providers, p. 3, (Oct. 2022), (Accessed Dec. 2024).

Refer to the Telemedicine manual regarding speech language pathology, occupational therapy, physical therapy, and psychology services that may be provided via telemedicine.

SOURCE: SD Medicaid and Policy Manual: School Districts, pg. 5, (Aug. 2024), (Accessed Dec. 2024).

See manual for list of codes.

SOURCE: SD Medicaid Billing and Policy Manual, Teledentistry Services, p. 2, (Jun. 2023), (Accessed Dec. 2024).

CHW Services must be related to an intervention outlined in the individual’s CHW Service Plan. Service may be provided face-to-face, via telemedicine, or via two-way audio-only when the recipient does not have access to audio/visual telemedicine technology. The limitation necessitating audio-only services must be documented in the recipient’s record. Up to five (5) units of individual services may be performed in a clinic setting in a plan year to allow for the initial establishment of CHW/recipient relationship after which services are only allowed to be provided in a home or community setting. A CHW may attend medical appointments with a recipient. Group services may take place in a meeting room of a medical setting. The CHW Service Plan must be finalized prior to CHW services being rendered.

Covered services include:

Health system navigation and resource coordination
Health promotion and coaching
Health education

Services may be provided to the parent or legal guardian of a recipient 18 or younger if the service is for the direct benefit of the recipient, in accordance with the recipient’s needs and CHW Service Plan objectives, and for the purpose of addressing the diagnosis identified in the CHW Service Plan

SOURCE: SD Medicaid Billing and Policy Manual: Community Health Worker, pg. 4-5, (Oct. 2024). (Accessed Dec. 2024).

Non-covered service

Mental health treatment provided without the recipient physically present in a face-to-face or telehealth session with the mental health provider except for telehealth treatment and collateral contacts.

Mental health services provided after the third face-to-face or telehealth session with the recipient without a supporting treatment plan meeting the above requirements of this section are non-covered services.

A provider may not submit a claim for mental health services provided after the third face-to-face or telehealth session with a recipient and before the effective date of the treatment plan

“Psychotherapy,” the face-to-face or telehealth treatment of a recipient through a psychological or psychiatric method. The treatment is a planned, structured program based on a primary diagnosis of mental disorder and is directed to influence and produce a response for a mental disorder and to accomplish measurable goals and objectives specified in the recipient’s individual treatment plan;

May psychotherapy be provided via telehealth? Does telehealth meet the definition of face-to-face?

Yes, telehealth services are considered face-to-face. Psychotherapy is allowed to be provided via telehealth. Please review the telehealth chapter for more information about telehealth requirements.

SOURCE: SD Medicaid Billing and Policy Manual: Independent Mental Health Practitioners (Apr. 2024), (Accessed Dec. 2024).

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. Jun. 2024. (Accessed Dec. 2024).

A face-to-face encounter for physician recertification for hospice may occur via telemedicine.

SOURCE: SD Medicaid Billing and Policy Manual: Hospice, p. 2 (Sept. 2024), (Accessed Dec. 2024).

Telemedicine consultation services are covered as outpatient hospital services.

SOURCE: SD Medicaid Billing and Policy Manual: Outpatient Hospital Services, p. 2 (Jun. 2024), (Accessed Dec. 2024).

“Visit,” a face-to-face or telehealth encounter between a federally qualified health center or rural health clinic patient and a physician, physician assistant, nurse practitioner, nurse midwife, visiting nurse, mental health provider listed in ARSD 67:16:41:03, dentist, or an accredited substance use disorder provider.

SOURCE: SD Medicaid Billing and Policy Manual: FQHC and RHC Services, pg. 7, (Jun. 2024), (Accessed Dec. 2024).

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 telemedicine. The encounter must occur within the 90 days before or 30 days after the start of the services.

SOURCE: SD Medicaid Billing and Policy Manual: Home Health Agency Services, p. 2 (Feb. 2024). (Accessed Dec. 2024).

Physician Administered Drugs – Pediatric Vaccination Counseling

A total of six counseling sessions (three for each code) per recipient, per calendar, year are reimbursable. Counseling may be provided via telemedicine. Counseling may also be provided via audio only if the visit was initiated by the recipient and the recipient does not have access to face-to-face audio/visual telemedicine technology. Telemedicine and audio only services must be billed in accordance with the Telemedicine Services billing manual.

SOURCE: SD Medicaid Billing and Policy Manual: Physician Administered Drugs, p. 5 (Oct. 2024). (Accessed Dec. 2024).

Diabetes Self-Management Training

Refer to the Telemedicine manual for guidance regarding providing services via telemedicine.

SOURCE: SD Medicaid Billing and Policy Manual: Diabetes Self-Management Training, pg. 2, (Jan. 2024), (Accessed Dec. 2024).

CHOICES Waiver

Supported living services are reimbursed at a 15-minute unit rate. Please refer to the CHOICES Fee Schedule for detailed rates.

A portion of this service can be delivered virtually, which includes but is not limited to:

The use of telephonic/virtual supports through FaceTime, Zoom, Echo or other means of telecommunication to provide verbal prompting for a participant and/or their support person to provide personal care supports to perform activities of daily living.
The use of telephonic/virtual supports through FaceTime, Zoom, or Echo other means of telecommunication to continue to support participants with medication management.
Check-in phone calls are considered a case management function and would not be considered telephonic/virtual habilitative supports.

Remote Day Services are reserved for outstanding circumstances that restrict a participant’s access to Facility and/or Community Support Day Services. The following examples are types of virtual day services:

The use of telephonic/virtual supports through Facetime, Zoom, Echo, or means of telecommunication to promote socialization that aligns with ISP goals. CSPs can use technology to promote and support social interaction through “virtual hangouts” for participants to engage with their friends and other natural supports.
Utilizing technology to support individuals to access community events that they previously engaged in. Examples of this may include supporting participants to access online church services, remote book clubs, etc.

SOURCE: SD Medicaid Billing and Policy Manual, CHOICES Waiver, p. 10, (Feb. 2024), (Accessed Dec. 2024).

ELIGIBLE PROVIDERS

In order to receive payment, all eligible servicing and billing provider’s National Provider Identifiers (NPI) must be enrolled with South Dakota Medicaid. Servicing providers acting as a locum tenens provider must enroll in South Dakota Medicaid and be listed on the claim form. Please refer to the provider enrollment chart for additional details on enrollment eligibility and supporting documentation requirements.

South Dakota Medicaid has a streamlined enrollment process for eligible ordering, referring, and attending providers that may require no action on the part of the provider as submission of claims constitutes agreement to the South Dakota Medicaid Provider Agreement.

Distant site locations must be in the United States. The physician or practitioner at the distant site must be licensed to provide the service in both the state of the originating site and state of the distant site. Services should be provided at a location consistent with any applicable laws or regulations regarding where services may be provided. The distant site and the originating site cannot be the same clinic/facility location. 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.

The following providers can provide services via telemedicine at a distant site:

Audiologists
Behavior Analyst
Board-Certified Assistant Behavior Analyst (BCaBA)
Certified Nurse Anesthetist
Certified Social Worker – PIP
Certified Social Worker – PIP Candidate
Clinical Nurse Specialists
Community Health Worker (CHW)
Community Mental Health Centers
Dentists
Diabetes Education Program
Dieticians
Federally Qualified Health Center (FQHC)
Indian Health Services (IHS) Clinics
Licensed Marriage and Family Therapist
Licensed Professional Counselor – MH
Licensed Professional Counselor – working toward MH designation
Nurse-midwife
Nurse Practitioners
Nutritionists
Occupational Therapists
Physical Therapists
Physicians
Physician Assistants
Podiatrists
Psychologist
Radiologist
Registered Behavior Technician (RBT)
Rural Health Clinic (RHC)
Speech Language Pathologists
Substance Use Disorder Agencies
Tribal 638 facilities

Telemedicine provided at a distant site must be billed with the GT modifier in the first modifier position to indicate the service was provided via telemedicine/audio-only. Failure to comply with this requirement may lead to payment recoupment or other action as decided by South Dakota Medicaid.

SOURCE: SD Medicaid Billing and Policy Manual: Telemedicine, p. 3,-4, 13 (Nov. 2024). (Accessed Dec. 2024).

Indian Health Services and Tribal 638 Providers

IHS clinics are eligible to serve as an originating site for telemedicine services. IHS/Tribal 638s 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.

Telemedicine Services Outside the Four Walls: Per a CMS temporary exception to the “Four Walls” requirement, home-to-home telemedicine services are permitted. This exception is in place until February 11, 2025. Under this exception, the IHS servicing provider and the recipient may be outside the four walls of a clinic. In order to bill for distant site telemedicine services at the encounter rate after February 11, 2025, the practitioner must be located at the IHS/Tribal 638 clinic (within the four walls).

Please refer to the Telemedicine Manual for additional information regarding telemedicine services.

IHS is 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.

Please refer to the Telemedicine manual for additional information.

Any services rendered by a 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.

Telemedicine Distant Site Claim – If IHS or a Tribal 638 is providing distant site telemedicine services, the services should be billed on the applicable claim form for the service. For services billed on a CMS 1500 or 837P, the provider should include the GT modifier. For claims billed on a UB-04 or 837I, the following information should be entered in the applicable locator on a UB-04 claim or its equivalent on an electronic claim:

Locator 42 – Enter appropriate Rev Code (example: 450 for outpatient)
Locator 43 – Enter the appropriate description of the Rev Code
Locator 44 – Enter one of the allowable HCPCS procedures codes listed in the Telemedicine

Services Manual and include the GT modifier.

SOURCE: SD Medicaid Billing and Policy Manual: IHS and Tribal 638 Providers, p. 5 & 12-13 & 14, (May 2024), (Accessed Dec. 2024).

FQHC/RHC

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. Please refer to the Telemedicine manual for additional information.

SOURCE: SD Medicaid Billing and Policy Manual: FQHC and RHC Services, pg. 7, (Jun. 2024), (Accessed Dec. 2024).

UB-04 Claim Instructions

Non-OPPC modifier that must be billed primary modifier on the claim: Claim procedure code modifier: GT must be used with telemedicine revenue code 780 for inpatient claims.

SOURCE: SD Medicaid Billing and Policy Manual: UB-04 Claim Instructions, pg. 8, (Mar. 2024), Third Party Claims (Jul. 2024), & UB-04 Crossover Claims (Jul. 2024), (Accessed Dec. 2024).

ELIGIBLE SITES

South Dakota Medicaid covers telemedicine services even if the recipient and the provider are located in the same community. The decision of whether it is appropriate to deliver the service via telemedicine should be determined by the provider and the recipient.

Telemedicine originating sites for services provided via telemedicine include any site in the U.S. where the patient is at the time of the telemedicine service, including a person’s home. Originating sites listed below 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 sites are not reimbursed for any additional costs associated with equipment, technicians, technology, or personnel utilized in the performance of the telemedicine service. 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.

Originating sites must be an enrolled provider to be reimbursed by South Dakota Medicaid. The following providers are eligible to be reimbursed a facility fee for serving as an originating site:

Office of a physician or practitioner;
Outpatient Hospital;
Inpatient Hospital
Critical Access Hospital;
Rural Health Clinic (RHC);
Federally Qualified Health Center (FQHC);
Indian Health Service Clinic;
A Hospital-Based or Critical Access Hospital-Based Renal Dialysis Center
Community Mental Health Center (CMHC);
Substance Use Disorder Agency;
Nursing Facilities; and
Schools

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.

[POS information listed in several provider manuals.]

SOURCE: SD Medicaid Billing and Policy Manual: Telemedicine, (Nov. 2024). (Accessed Dec. 2024).

02 and 10 telemedicine POS Codes listed in several Claims Instructions documents.

SOURCE: SD Medicaid, Provider Manuals, Claims Instructions, & CMS 1500 Claims Instructions, (Accessed Dec. 2024).

FQHC/RHCs

Reimbursement for the telemedicine facility fee is limited to the amount listed on the Physician Services fee schedule.

A claim for a telemedicine originating site fee should be billed under the FQHC/RHC’s NPI. As indicated above, payment is limited to the fee schedule amount.

SOURCE: SD Medicaid Billing and Policy Manual: FQHC and RHC Services, (Jun. 2024) (Accessed Dec. 2024).

Indian Health Services and Tribal 638 Providers

IHS is 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.

Please refer to the Telemedicine manual for additional information.

Any services rendered by a contracted provider are reimbursed through their contract with IHS and may not be billed directly to Medicaid.

If IHS is an originating site for a telemedicine service, the originating site fee should be billed on the applicable claim form for the service. For services billed on a CMS 1500 or 837P, IHS should bill for the originating site fee using HCPCS code Q3014. For claims billed on a UB-04 or 837I, the following information should be entered in the applicable locator or its equivalent on an electronic claim:

Locator 42 – Rev Code 780
Locator 43 – Telemedicine
Locator 44 – Q3014

SOURCE: SD Medicaid Billing and Policy Manual: IHS and Tribal 638 Providers, p. 5, 13 (May 2024), (Accessed Dec. 2024).

GEOGRAPHIC LIMITS

SOURCE: SD Medicaid Billing and Policy Manual: Telemedicine, p. 4 (Nov. 2024), (Accessed Dec. 2024).

FACILITY/TRANSMISSION FEE

Originating sites must be an enrolled provider to be reimbursed by South Dakota Medicaid. The following providers are eligible to be reimbursed a facility fee for serving as an originating site:

Office of a physician or practitioner;
Outpatient Hospital;
Critical Access Hospital;
Rural Health Clinic (RHC);
Federally Qualified Health Center (FQHC);
Indian Health Service Clinic;
Community Mental Health Center (CMHC);
Substance Use Disorder Agency;
Nursing Facilities; and
Schools

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 sites are not reimbursed for any additional costs associated with equipment, technicians, technology, or personnel utilized in the performance of the telemedicine service. 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.

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 including for providers paid at an encounter rate or other methodology. providers. There is no additional reimbursement for equipment, technicians, technology, or personnel utilized in the performance of telemedicine services. The originating site fee is not reimbursable for audio-only services and should not be billed for these services.

An originating site eligible for reimbursement must bill for the service using the HCPCS code Q3014 for CMS 1500 Claims or Revenue code 780 for UB-04 Claims. 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.

SOURCE: SD Medicaid Billing and Policy Manual: Telemedicine, (Nov. 2024). (Accessed Dec. 2024).

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. Refer to the Telemedicine manual for additional information regarding the telemedicine originating site fee.

SOURCE:SD Medicaid Billing and Policy Manual: Skilled Nursing Facility and Nursing Facility Services, p. 10-11, (Jul. 2024), (Accessed Dec. 2024).

Teledentistry

“Originating site”, physical location of the Medicaid recipient at the time the synchronous teledentistry service is provided.

An originating site is the physical location of the patient at the time a synchronous (live, two-way interaction between a patient and a provider using audiovisual telecommunications technology) teledentistry service is provided. A distant site is the physical location of the practitioner providing the service via synchronous 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.

The originating site must submit a CMS 1500 or 837P claim to South Dakota Medicaid. For more information on originating sites please refer to the Telemedicine manual. Originating site are not reimbursed for any additional costs associated with equipment, technicians, technology, or personnel utilized in the performance of the teledentistry service. For more information on originating sites please refer to the Telemedicine manual.

SOURCE: SD Medicaid Billing and Policy Manual, Teledentistry Services, p. 4-6, (Jun. 2023), (Accessed Dec. 2024).

FQHC/RHC

Reimbursement for the telemedicine facility fee is limited to the amount listed on the Physician Services fee schedule.

A claim for a telemedicine originating site fee should be billed under the FQHC/RHC’s NPI. As indicated above, payment is limited to the fee schedule amount.

SOURCE: SD Medicaid Billing and Policy Manual: FQHC and RHC Services, p. 8 & 10 (Jun. 2024). (Accessed Dec. 2023).

School District Services

Q3014: Telehealth Originating Site Fee – For OT, PT, SLP, and psychology telehealth services only.

The telehealth originating site fee (Q3014) is not a time-based code. Providers should refer to the Telemedicine manual for additional billing guidance.

SOURCE: SD Medicaid and Policy Manual: School Districts, pg. 4 & 7 (Aug. 2024), (Accessed Dec. 2024).

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Tennessee

Last updated 08/26/2024

POLICY

Telehealth Services

A health insurance entity shall provide coverage …

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 Aug. 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, Aug. 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.

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.

SOURCE: TN Code Annotated, Sec. 56-7-1003, (Accessed Aug. 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 Aug. 2024).

ELIGIBLE SERVICES/SPECIALTIES

This section does not require a health insurance entity to provide reimbursement [coverage] for healthcare services that are not medically necessary, unless the terms and conditions of an applicable health insurance policy provide that coverage.

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 Aug. 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.

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.

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.

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 Aug. 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 Aug. 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, (Apr. 2024) (Accessed Aug. 2024).

Lactation Consultation

Telehealth appointments are available for prenatal and postpartum lactation sessions and any consults with International Board-Certified Lactaation Consultants (IBCLCs).

SOURCE: TennCare, Lactation Consultant Benefit Update (Jul. 24, 2024) Powerpoint. (Accessed Sept. 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 Aug. 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 Aug. 2024).

Lactation Consultation

Telehealth appointments are available for prenatal and postpartum lactation sessions and any consults with International Board-Certified Lactaation Consultants (IBCLCs).

SOURCE: TennCare, Lactation Consultant Benefit Update (Jul. 24, 2024) Powerpoint. (Accessed Sept. 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 Aug. 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 Aug. 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 Aug. 2024).

School-Based Services

See manual for additional information.

SOURCE: TennCare Biling Manual: Tennessee School Districts (July 2023), p. 11. (Accessed Aug 2024).

Mental Health & Substance Abuse Services

All telehealth sites shall ensure that telehealth equipment is located in a space conducive to a clinical environment and provides adequate comfort and privacy for the individual being evaluated. Both visual and audio privacy are important and placement and selection of the rooms used for conducting telehealth assessments should consider this. Proper lighting is required to keep shadows off the faces of the participants.

SOURCE: TN Dept. of Mental Health and Substance Abuse Services. Office of Crisis Services and Suicide Prevention. Minimal Standards of Care. p. 52, (Apr. 2024) & TN Dept. of Mental Health and Substance Abuse Services. Office of Crisis Services Telecommunications Guidelines, p. 8, (2012) (Accessed Aug. 2024).

Lactation Consultation

Indicate the setting for the visit (office, telehealth, home visit, etc.) using the Place of Service Code on your claim.

Yes. Lactation consultation visits can occur in the outpatient office setting, at the patient’s home, or through telehealth. The setting of the visit should be indicated in the documentation of the visit and on the claim using the place of service code.

Lactation services are billable only in the outpatient setting. Lactation services provided inpatient are covered under the global maternity claim.

SOURCE: TennCare, Lactation Consultant Benefit Update (Jul. 24, 2024) Powerpoint. (Accessed Sept. 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.

SOURCE: TN Code Annotated, Title 56, Ch. 7, Part 1002, (Accessed Aug. 2024).

Provider-Based Telemedicine

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.

SOURCE: TN Code Annotated, Part 1003, (Accessed Aug. 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 Aug. 2024).

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Texas

Last updated 12/17/2024

POLICY

Synchronous audiovisual technology – An interactive, two-way audio and …

POLICY

Synchronous audiovisual technology – An interactive, two-way audio and video telecommunications platform that meets the privacy requirements of the Health Insurance Portability and Accountability Act.

Telemedicine/Telehealth Service Delivery: 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 …

SOURCE: TX Medicaid Telecommunication Services Handbook, p. 5 & 9 (Dec. 2024), (Accessed Dec. 2024).

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. [repealed eff. April 1, 2025], (Accessed Dec. 2024).

The executive commissioner by rule shall require each health and human services agency that administers a part of Medicaid to provide Medicaid reimbursement for a telemedicine medical service initiated or provided by a physician.

The commission shall ensure that reimbursement is provided only for a telemedicine medical service initiated or provided by a physician.

The commission shall ensure that 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.

The commission shall require reimbursement for a telemedicine medical service 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), [repealed eff. April 1, 2025 (Accessed Dec. 2024).

Texas Medicaid managed care organizations (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. 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).

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, Jan. 2024, p. 5, 7 and 8, (Aug. 2024) (Accessed Aug. 2024).

The following delivery methods may be used to provide telemedicine [telehealth] 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. 9, & 13-14, (Aug. 2024). (Accessed Aug. 2024).

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 Dec. 2024).

CSHCN Program

Authorization is not required for telemedicine or telehealth services, however prior authorization may be required for the individual procedure codes billed.

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.

Only those services that involve direct face-to-face interactive video communication between the client and the distant-site provider constitute a telemedicine or telehealth service. No separate reimbursement will be made for the cost of telemedicine and telehealth hardware or equipment, electronic documentation, and transmissions. Telephone conversations, chart reviews, electronic mail messages, and fax transmissions alone do not constitute a telemedicine or telehealth interactive video service and will not be reimbursed as telemedicine or telehealth services.

Telecommunication services may be reimbursed the lower of the billed amount or the amount allowed by Texas Medicaid.

SOURCE: TX Medicaid CSHCN Services Program Provider Manual: Telecommunication Services (Nov. 2024), p. 3., 13 (Accessed Dec. 2024).

ELIGIBLE SERVICES/SPECIALTIES

Telemedicine medical services and telehealth services are authorized service delivery methods for Texas Medicaid covered services as provided in this section. All telemedicine medical services and telehealth services are subject to the specifications, conditions, limitations, and requirements established by the Texas Health and Human Services Commission (HHSC) or its designee.

A client must not be required to receive a covered service as a telemedicine medical service or telehealth service except in the event of an active declaration of state of disaster and at the direction of HHSC.
In the event of a declaration of state of disaster, HHSC may issue direction to providers regarding the use of telemedicine medical services and telehealth services, including the use of an audio-only platform, to provide covered services to clients who reside in the area subject to the declaration of state of disaster.
HHSC considers the following criteria when determining whether a covered service may be delivered as telemedicine medical service or telehealth service, including via an audio-only platform:
- Clinical effectiveness;
- Cost effectiveness;
- Health and safety;
- Patient choice and access to care; and
- Other criteria specific to the service.

Conditions for reimbursement applicable to telemedicine medical services.

The provider must be enrolled in Texas Medicaid.
The covered services must be provided in compliance with Texas Occupations Code Chapter 111 and Title 22 Texas Administrative Code Chapter 174 (relating to Telemedicine).
A telemedicine medical service must be designated for reimbursement by HHSC. Telemedicine medical services designated for reimbursement are those that are clinically effective and cost-effective, as determined by HHSC and in accordance with paragraph (3) of this section. Covered services that HHSC has determined are clinically effective and cost-effective when provided as a telemedicine medical service can be found in the Texas Medicaid Provider Procedures Manual (TMPPM).

*See regulations for eligible sites topic for conditions for school-based settings.

Conditions for reimbursement applicable to telehealth services.

The provider must be enrolled in Texas Medicaid.
The covered services must be provided in compliance with Texas Occupations Code Chapter 111 and standards established by the respective licensing or certifying board of the professional providing the telehealth service.
Telehealth services must be designated for reimbursement by HHSC. Telehealth services designated for reimbursement are those that are clinically effective and cost-effective, as determined by HHSC and in accordance with paragraph (3) of this section. Covered services that HHSC has determined are clinically effective and cost-effective when provided as a telehealth service can be found in the TMPPM.

Conditions for reimbursement applicable to both telemedicine medical services and telehealth services.

Preventive health visits under Texas Health Steps (THSteps), also known as Early and Periodic Screening, Diagnosis and Treatment program, are not reimbursed if performed using telemedicine medical services or telehealth services. Health care or treatment provided using telemedicine medical services or telehealth services after a THSteps preventive health visit for conditions identified during a THSteps preventive health visit may be reimbursed.
Documentation in the patient’s medical record for a telemedicine medical service or a telehealth service must be the same as for a comparable in-person evaluation.
Providers of telemedicine medical services and telehealth services must maintain confidentiality of protected health information (PHI) as required by Title 42 Code of Federal Regulations (CFR) Part 2, 45 CFR Parts 160 and 164, Texas Occupations Code Chapters 111 and 159, and other applicable federal and state law.
Providers of telemedicine medical services and telehealth services must comply with the requirements for authorized disclosure of PHI relating to patients in state mental health facilities and residents in state supported living centers, which are included in, but not limited to, 42 CFR Part 2, 45 CFR Parts 160 and 164, Texas Health and Safety Code §611.004, and other applicable federal and state law.
Telemedicine medical services and telehealth services are reimbursed in accordance with Chapter 355 of this title (relating to Reimbursement Rates).

SOURCE: TX Admin Code Title 1, Sec. 354.1432, (Accessed Dec. 2024).

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, Dec. 2024, (Accessed Dec. 2024).

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.

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.

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/telehealth) delivery in the description do not need to be billed with the 95 modifier.

Behavioral health procedure codes that are reimbursed to distant site providers when billed with the FQ modifier (audio-only services) are included in the individual TMPPM handbooks. Procedure codes that indicate telephone or audio-only delivery in their description do not need to be billed with the FQ modifier.

See manual for codes MCOs must reimburse when delivered via telehealth.

SOURCE: TX Medicaid Telecommunication Services Handbook, p. 4, 7, 8-9 12 (Dec. 2024). (Accessed Dec. 2024).

Conditions for reimbursement applicable to telemedicine and telehealth provided using a synchronous audiovisual technology platform, or using store and forward technology in conjunction with synchronous audio-only are those that meet the following conditions:

Must be designated for reimbursement by HHSC.
Must be clinically effective and cost-effective, as determined and published in the benefit language by HHSC.
May not be denied solely because an in-person medical service between a provider and client did not occur.
May not be limited by requiring the provider to use a particular synchronous audiovisual technology platform to receive reimbursement for the service.

Other conditions for reimbursement applicable to services may vary by service type. Providers may refer to the appropriate TMPPM handbook for additional information on synchronous audiovisual technology platform coverage conditions.

Note: Telemedicine and telehealth services that HHSC has determined are clinically effective and cost-effective when provided via a synchronous audiovisual technology platform or using store and forward technology in conjunction with synchronous audio-only technology can be found in the appropriate TMPPM handbooks.

SOURCE: TX Medicaid Telecommunication Services Handbook, p. 6. (Dec. 2024). (Accessed Dec. 2024).

To the extent permitted by federal law and to the extent it is cost-effective and clinically effective, as determined by the commission, the commission shall ensure that Medicaid recipients, child health plan program enrollees, and other individuals receiving benefits under a public benefits program administered by the commission or a health and human services agency, regardless of whether receiving benefits through a managed care delivery model or another delivery model, have the option to receive services as telemedicine medical services, telehealth services, or otherwise using telecommunications or information technology, including the following services:

preventive health and wellness services;
case management services, including targeted case management services;
subject to Subsection (c), behavioral health services;
occupational, physical, and speech therapy services;
nutritional counseling services; and
assessment services, including nursing assessments under the following Section 1915(c) waiver programs:
- the community living assistance and support services (CLASS) waiver program;
- the deaf-blind with multiple disabilities (DBMD) waiver program;
- the home and community-based services (HCS) waiver program; and
- the Texas home living (TxHmL) waiver program.

SOURCE: TX Statute Sec. 531.02161, [repealed eff. April 1, 2025] (Accessed Dec. 2024).

Providers must defer to the needs of the person receiving services, allowing the mode of service delivery to be accessible, person- and family-centered, and primarily driven by the person’s choice and not provider convenience.

Providers must provide outpatient mental health services to Medicaid eligible persons in accordance with accepted medical community standards and standards that govern occupations, as explained in Title 1 Texas Administrative Code (TAC) §371.1659. In addition, providers must deliver, to include delivery by telemedicine or telehealth, outpatient mental health services in full accordance with all applicable licensure and certification requirements.

During a Declaration of State of Disaster, the Health and Human Services Commission (HHSC) may issue direction to providers regarding the use of a 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. A Declaration of State of Disaster is when an executive order or proclamation is issued by the governor declaring a state of disaster in accordance with Section 418.014 of the Texas Government Code.

Outpatient Mental Health Services

The following outpatient mental health services may be provided by synchronous audiovisual technology if clinically appropriate and safe, as determined by the billing provider, and agreed to by the person receiving services. Outpatient mental health services provided by synchronous audiovisual technology must be billed using modifier 95.

Psychiatric diagnostic evaluation services with and without medical services
Psychotherapy (individual, family, or group) services
Pharmacological management services (most appropriate E/M code with modifier UD) for psychiatric care only
Neurobehavioral services
Neuropsychological and psychological testing services if the following conditions are met:
- The psychometric test must be available in an online format, except for tests that are administered and responded to orally;
- The provider, or test administrator, must observe the person, in real-time, for the duration of the test; and
- The provider delivers the psychometric test in accordance with their licensing board and professional guidelines.

See manual for procedure codes and specific instructions.

Follow Up Visits

A follow-up visit may be completed in-person or through the use of synchronous audiovisual technology, or synchronous telephone (audio-only) technology. Follow-up visits completed using synchronous audiovisual technology or synchronous telephone (audio-only) technology should only be provided if agreed to by the client, parent, or legal guardian.

Intellectual and Developmental Disabilities Service Coordination

Supportive Encounter (Type B): A face-to-face, telephone, or telemedicine contact with a person or with a collateral on the person’s behalf to provide service coordination.

Mental Health Targeted Case Management (MHTCM) Services

MHTCM services may be provided by synchronous audiovisual technology if clinically appropriate and safe, as determined by the billing provider, and agreed to by the person receiving services or LAR. In addition, approval to deliver the services by synchronous audiovisual technology must be documented in the plan of care of the person receiving services. MHTCM services provided by synchronous audiovisual technology must be billed using modifier 95.

Intensive Case Management for Persons 20 Years of Age and Younger

Intensive case management services are primarily community-based, meaning that services are provided in whatever setting is clinically appropriate and person-centered, to include telehealth delivery.

Mental Health Rehabilitative Services

The following MHR services may be provided by synchronous audiovisual technology if clinically appropriate and safe, as determined by the billing provider, and agreed to by the person receiving services or LAR. In addition, except for crisis intervention services, approval to deliver the services by synchronous audiovisual technology must be documented in the plan of care of the person receiving services. MHR services provided by synchronous audiovisual technology must be billed using modifier 95.

Medication training and support
Skills training and development
Psychosocial rehabilitation services
Crisis intervention services
- Documented approval of the mode of delivery in the plan of care is not required prior to the delivery of crisis intervention services by synchronous audiovisual technology.

Peer Specialist Services

Peer specialist services may be provided by synchronous audiovisual technology if clinically appropriate and safe, as determined by the billing provider, and agreed to by the person receiving services. In addition, approval to deliver the services by synchronous audiovisual technology must be documented in the person-centered recovery plan of the person receiving services. Peer specialist services provided by synchronous audiovisual technology must be billed using modifier 95.

Screening, Brief Intervention, and Referral to Treatment (SBIRT)

SBIRT services may be provided by synchronous audiovisual technology if clinically appropriate and safe, as determined by the provider, and agreed to by the person receiving services. SBIRT services provided by synchronous audiovisual technology must be billed using modifier 95.

Substance Use Disorder

The following SUD services may be provided by synchronous audiovisual technology if clinically appropriate and safe, as determined by the billing provider, and agreed to by the person receiving services. SUD services provided by synchronous audiovisual technology must be billed using modifier 95.

Comprehensive assessment
Individual and group counseling
MAT services – Prescribing of certain MAT medications may be done via telemedicine presuming all other applicable state and federal laws and regulations are followed.

Case Management for Children and Pregnant Women (CPW)

CPW services may be provided using synchronous audiovisual technologies if clinically appropriate and safe, as determined by the provider, and agreed to by the client receiving services. Whenever possible, HHSC encourages face-to-face interaction, such as an in-person visit.

The Telecommunication Services Handbook (Vol. 2, Provider Handbooks) for information on policy restrictions for services delivered by synchronous telephone (audio-only) technologies. Services delivered using audio-only technologies must be billed using
the 93 modifier.

SOURCE: TX Medicaid Behavioral Health and Case Management Services Handbook, (Dec. 2024). (Accessed Dec. 2024).

Children’s Services

Telehealth services may be provided using synchronous audiovisual technologies if clinically appropriate and safe, as determined by the provider, and agreed to by the client receiving services. Whenever possible, HHSC encourages face-to-face interaction, such as an in-person visit, as well as the use of synchronous audiovisual technology over synchronous telephone (audio-only) technology of telehealth services.

Providers must defer to the needs of the client receiving services, allowing the mode of service delivery to be accessible, person- and family-centered, and primarily driven by the client in service’s choice and not provider convenience.

Services delivered by synchronous audiovisual technology will require participation of a parent or caregiver to assist with the treatment.

Therapy assistants may deliver services and receive supervision using synchronous audiovisual technology in accordance with each discipline’s rules. Providers should refer to state practice rules and national guidelines regarding supervision requirements for each discipline

The following procedure codes may be provided through telehealth delivery using synchronous audiovisual technology:

Specialized skills training (SST)
Targeted case management (TCM)
Physical therapy (PT) evaluations and reevaluations
Occupational therapy (OT) evaluations and reevaluations
PT and OT treatments

Speech therapy (ST) evaluations and reevaluations
ST treatments

Providers must use modifier 95 to indicate remote delivery. Providers are reminded to use the required modifiers GP, GO, and GN on all claims except evaluation and re-evaluation procedures for physical, occupational, or speech therapy treatment.

See manual for excluded services.

Applied Behavioral Analysis

Services must be provided in compliance with the Texas Health Step-Comprehensive Care Program, medical standards for telehealth, and these Medicaid Autism Services requirements, which may be more restrictive than general ABA practice.

Some service delivery to children or youth and to the parents or caregivers may be delivered remotely. It is the LBA’s responsibility to ensure that remotely delivered telehealth services are within scope of practice, are not contraindicated for the child or youth, family, or particular situation, are clinically appropriate and effective, and are in compliance with Texas licensure and standards for telehealth as well as follow all Medicaid, Texas Health Steps-CCP and the Medicaid Autism Services requirements.

ABA evaluation and treatment services may only be delivered via telehealth using synchronous audio-visual technology.

Health and Behavior Assessment and Intervention

HBAI services may be provided by synchronous audiovisual technology if clinically appropriate and safe, as determined by the provider, and agreed to by the person receiving services. HBAI services provided by synchronous audiovisual technology must be billed using modifier 95. See manual for eligible services.

Medical Nutrition Counseling Services (CCP)

Certain telehealth services may be provided for medical nutrition therapy and nutrition counseling services clients 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 interactions, such as an in-person visit, as well as the use of synchronous audiovisual technology over synchronous telephone (audio-only) technology of telehealth services. Therefore, providers must document in the person’s medical record the reason(s) that services were delivered by synchronous telephone (audio-only) technology. See chart in manual for services are authorized for telehealth delivery using synchronous audiovisual and synchronous telephone (audio-only) technologies.

The procedure codes in the table above may be delivered by synchronous telephone (audio-only) technology only during certain PHE or natural disasters.

Medical nutrition counseling services (procedure code S9470) are authorized for telehealth delivery using synchronous audiovisual and synchronous telephone (audio-only) technologies, when noted.

Medical nutrition counseling services (procedure code S9470) may be delivered by synchronous telephone (audio-only) technology only during certain PHE or natural disasters. Services provided by synchronous audio-visual technology must be billed using modifier 95. Services delivered using audio-only technologies must be billed using modifier 93. Documentation requirements for a telehealth service are the same as for an in-person visit and must accurately reflect the services rendered. Documentation must identify the means of delivery when provided.

During a Declaration of State of Disaster, the Texas Health and Human Services Commission (HHSC) may issue direction to providers regarding the use of 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. A Declaration of State of Disaster is when an executive order or proclamation is issued by the governor declaring a state of disaster in accordance with Section 418.014 of the Texas Government Code.

Refer to: The Telecommunication Services Handbook (Vol. 2, Provider Handbooks) for information on restrictions for services delivered by synchronous telephone (audio-only) technologies.

Medical Checkups During a Declaration of State Disaster

The following limitations apply to all THSteps preventive medical checkups and exception-to-periodicity checkups during a Declaration of State Disaster when HHSC issues direction regarding the use of synchronous audiovisual and synchronous telephone (audio-only) technologies:

Clients who are 2 years through 20 years of age may receive a THSteps medical checkup or exception-to-periodicity checkup using synchronous audiovisual or synchronous telephone (audio-only) technologies.
Clients from birth through 2 years of age may not receive a THSteps checkup or exception-to-periodicity checkup using synchronous audiovisual or synchronous telephone (audio-only) technologies.
Clients from birth through 24 months of age must receive in-person checkups.

A medical checkup provided using synchronous audiovisual or synchronous telephone (audio-only) technologies must be completed according to the age-specific checkup requirements listed on the THSteps Periodicity Schedule.

Synchronous audiovisual delivery for medical checkups is preferred over synchronous telephone (audio-only) delivery.

An in-person THSteps follow-up visit must be completed within six months of the synchronous audiovisual or synchronous telephone (audio-only) checkup in order for the checkup to be considered a complete THSteps checkup.

When HHSC issues direction, the following THSteps medical checkup services are authorized for delivery using synchronous audiovisual or synchronous telephone (audio-only) technologies during a Declaration of State Disaster (see manual).

Medical checkups and exception-to-periodicity checkups provided using synchronous audiovisual or synchronous telephone (audio-only) technologies are limited to checkups for clients who are over 24 months of age for the following procedure codes (see manual).

Medical checkups for clients who are 2 years of age or younger must be completed in-person and may not be completed using synchronous audiovisual or synchronous telephone (audio-only) technologies (procedure codes 99381, 99382, 99391 and 99392).

THSteps providers should use their clinical judgement regarding which checkup components may be appropriate for completion using synchronous audiovisual or synchronous telephone (audio-only) technologies.

THSteps providers are encouraged to ensure that clients receiving a medical checkup using synchronous audiovisual or synchronous telephone (audio-only) technologies receive age-appropriate vaccines and laboratory screenings in a timely manner.

Medical checkup services using synchronous audiovisual or synchronous telephone (audio-only) technologies should only be provided if agreed to by the client or parent/guardian.

See Children’s Services Handbook for additional information and a list of procedure codes.

SOURCE: TX Medicaid Children’s Services Handbook, (Dec. 2024), (Accessed Dec. 2024).

Telemedicine medical services used for the treatment of chronic pain with scheduled drugs via audio-only is prohibited, except in certain circumstances (see audio-only section for more info).

Treatment of a client for acute pain with scheduled drugs using telemedicine is permitted, as provided by 22 TAC §174.5(e). Acute pain is defined by 22 TAC §170.2(2).

All physicians must comply by 22 TAC §174.5 when issuing prescriptions through a telemedicine service.

SOURCE: TX Medicaid Telecommunication Services Handbook, p. 10, (Dec. 2024). (Accessed Dec. 2024).

LEAs that participate in the SHARS program may be reimbursed for telehealth and telemedicine services delivered to children in school-based settings, or while receiving remote instruction.

A school-based setting is defined in Texas Government Code §531.02171(b) as a school district or an open enrollment charter school.

Remote instruction is defined according to requirements set forth by TEA and includes technology based learning in home or community-based settings.

Providers may be reimbursed for telehealth and telemedicine services delivered to children in school based settings, or while learning remotely with the following criteria:

Reimbursement for providers is only available when the patient site is a school, home, or community-based setting.
- A patient site is the physical location of the student while the service is being rendered.
Reimbursement for providers is only available when the distant site is a school or office-based setting.
- A distant site is the physical location of the Texas Medicaid provider rendering the service.
A telehealth or telemedicine visit may not be conducted if the provider and student are both physically located at the same school at the time the services are rendered.
All medical necessity criteria for in-person services apply when services are delivered to children in school-based settings.

Providers must be able to defer to the needs of the student receiving services, allowing the mode of service delivery (synchronous audiovisual, synchronous telephone (audio-only), or in-person) to be accessible.

Providers should obtain informed consent for treatment from the student’s parent or legal guardian and the student prior to rendering a telehealth or telemedicine service. Verbal consent is permissible and should be documented in the student’s medical record.

Services delivered by synchronous audiovisual or synchronous telephone (audio-only) technology may require participation of a parent or caregiver to assist with the treatment.

During a Declaration of State of Disaster, HHSC may issue direction to providers regarding the use of a telemedicine or telehealth service 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.

A Declaration of State of Disaster is when an executive order or proclamation is issued by the governor declaring a state of disaster in accordance with Section 418.014 of the Texas Government Code.

Telehealth services are a benefit of Texas Medicaid and SHARS. Telehealth services has the meaning assigned by Texas Occupations Code (TOC) §111.001. Telehealth services are defined as healthcare 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 than the health professional using telecommunications or information technology.

Telehealth services must be provided in compliance with standards established by the respective licensing or certifying board of the professional providing the services.

LEAs that participate in the SHARS program may be reimbursed for telehealth occupational therapy (OT), physical therapy (PT), speech therapy (ST), counseling, and psychological services.

All other reimbursement and billing guidelines that are applicable to in-person services will also apply when OT, PT, ST, counseling, and psychological services are delivered as telehealth services.

OT, PT, ST, counseling, and psychological telehealth services provided by LEAs during school hours through SHARS may be delivered via synchronous audiovisual technologies.

Synchronous audiovisual technology is defined as an interactive, two-way audio and video telecommunications platform that meets the privacy requirements of HIPAA.

Synchronous Audiovisual Technology

The following procedure codes may be provided to children eligible through SHARS as telehealth services via synchronous audiovisual technology if clinically appropriate (as determined by the treating provider), safe and agreed to by the student receiving services.

The patient site must be a school, home, or community-based setting in order for the distant site provider to be eligible for reimbursement of these services.

All telehealth services provided by synchronous audiovisual technology must be billed using modifier 95.

The following procedure codes must be billed for telehealth services delivered via synchronous audiovisual technology:

See manual for additional details for synchronous audio visual technology and telemedicine services.

SOURCE: TX Medicaid School Health and Related Services (SHARS) Handbook, (Dec. 2024). (Accessed Dec. 2024).

In addition to the service requirements in this division, a child or adolescent must receive additional assessments, including a developmental assessment and history of trauma assessment, performed by an LPHA with appropriate training and experience in the assessment and treatment of children in a crisis setting. The assessments must:

be administered in person or through telehealth or telemedicine medical services; and
include the individual’s parents, LAR, or adult caregiver, as applicable and as clinically appropriate according to the child’s or adolescent’s age, functioning, and current living situation.

SOURCE: TX Admin Code, Title 26, Part 1 Ch. 306, Sec. 306.67, (Accessed Dec. 2024).

In providing covered benefits to a child with special health care needs, a health plan provider must permit benefits to be provided through telemedicine medical services, teledentistry dental services, and telehealth services in accordance with policies developed by the commission. See statute for additional requirements.

SOURCE: TX Statute 62.157 (Accessed Dec. 2024).

Federally Qualified Health Center Services Reimbursement

A visit is a face-to-face, telemedicine, or telehealth encounter between an FQHC patient and a physician, physician assistant, nurse practitioner, certified nurse-midwife, visiting nurse, a qualified clinical psychologist, clinical social worker, other health professional for mental health services, dentist, dental hygienist, or an optometrist. Encounters with more than one health professional and multiple encounters with the same health professional that take place on the same day and at a single location constitute a single visit, except where one of the following conditions exist:

after the first encounter, the patient suffers illness or injury requiring additional diagnosis or treatment; or
the FQHC patient has a medical visit and an “other” health visit, as defined in paragraph (13) of this subsection.

A medical visit is a face-to-face, telemedicine, or telehealth encounter between an FQHC patient and a physician, physician assistant, nurse practitioner, certified nurse midwife, or visiting nurse. An “other” health visit includes, but is not limited to, a face-to-face, telemedicine, or telehealth encounter between an FQHC patient and a qualified clinical psychologist, clinical social worker, other health professional for mental health services, a dentist, a dental hygienist, an optometrist, or a Texas Health Steps Medical Screen.

SOURCE: TX Admin Code, Title 1, Part 15, Ch. 355 Subchapter J, 355. 8261. (Accessed Dec. 2024).

Physical Therapy, Occupational Therapy, and Speech Therapy

Providers must defer to the needs of the person receiving services, allowing the mode of service delivery (synchronous audiovisual or in-person) to be accessible, person- and family-centered, and primarily driven by the person’s choice and not provider convenience.

Evaluation, reevaluation, and treatment of some PT, OT, and ST services may be provided by synchronous audiovisual technology.

Telehealth services for OT, PT or ST by synchronous audiovisual technology are allowed for specific procedure codes if clinically appropriate as determined by the practitioner, per standard of care, safe, agreed to by the person receiving services or by the legally authorized representative (LAR), and in compliance with each discipline’s rules.

The following procedure codes may be provided by synchronous audiovisual technology:

Physical Therapy Evaluations- Low, Moderate, and High Complexity and re-evaluation
Occupational Therapy Evaluation– Low, Moderate, and High Complexity and re-evaluation
PT or OT Services (individual or group)
Community reintegration (procedure code 97537) may be provided if the person receiving services is currently receiving other therapeutic procedure codes and may not be billed separately.
Speech Evaluations and re-evaluations
ST (individual or group) services
The provider should obtain informed consent for treatment from the patient, patient’s parent, or the patient’s legal guardian prior to rendering a telehealth service. Verbal consent is permissible and should be documented in the client’s medical record.
Services delivered by synchronous audiovisual technology may require participation of a caregiver or parent to assist with the treatment.
Therapy assistants may deliver services and receive supervision by synchronous audio- visual technology within limits outlined in each discipline’s rules. Providers should refer to state practice rules and national guidelines regarding supervision requirements for each discipline.
Providers must use modifier 95 to indicate remote delivery. Providers are reminded to use the required modifiers GP, GO, and GN on all claims for physical, occupational, or speech therapy treatment

See section 4.5 in the manual for a list of telehealth service procedure codes and section 4.8.1 for a list of in-person procedure codes.

SOURCE: TX Medicaid Physical Therapy, Occupational Therapy, and Speech Therapy Services Handbook pg. 9-10 (Dec. 2024). (Accessed Dec. 2024).

Physical Therapy, Occupational Therapy, and Speech and Language Pathology as a Telehealth Service.

Except as described in subsection (c) of this section, a service provider of physical therapy, occupational therapy, or speech and language pathology may provide physical therapy, occupational therapy, or speech and language pathology to an individual as a telehealth service.

If a service provider of physical therapy, occupational therapy, or speech and language pathology provides physical therapy, occupational therapy, or speech and language pathology to an individual as a telehealth service, a program provider must ensure that the service provider:

uses a synchronous audio-visual platform to interact with the individual, supplemented with or without asynchronous store and forward technology;
does not use an audio-only platform to provide the service; and
before providing the telehealth service:
- obtains the written informed consent of the individual or LAR to provide the service; or
- obtains the individual or LAR’s oral consent to receive the telehealth service and documents the oral consent in the individual’s record.

A program provider must ensure that a service provider of physical therapy, occupational therapy, or speech and language pathology performs certain services in person, as required by the Texas Medicaid Provider Procedures Manual. See regulation for list.

SOURCE: 26 TAC Sec. 262.9, (Accessed Dec. 2024).

Providers must provide the services to Medicaid eligible clients in accordance with accepted medical community standards and standards that govern occupations, as explained in Title 1 Texas Administrative Code (TAC) §371.1659. In addition, providers must deliver, to include delivery by telemedicine or telehealth, services in full accordance with all applicable licensure and certification requirements.

During a Declaration of State of Disaster, the Health and Human Services Commission (HHSC) may issue direction to providers regarding the use of a telemedicine or telehealth service 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. A Declaration of State of Disaster is when an executive order or proclamation is issued by the governor declaring a state of disaster in accordance with Section 418.014 of the Texas Government Code.

The following office and other outpatient services may be provided by synchronous audiovisual technology if clinically appropriate and safe, as determined by the provider, and agreed to by the client receiving services. New and established patient services provided by synchronous audiovisual technology must be billed with modifier 95.

See manual for procedure codes that can be reimbursed for telemedicine (physician-delivered) evaluation and management to new and established clients.

SOURCE: TX Medicaid Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, (Dec. 2024), pg. 181 (Accessed Dec. 2024).

Other Family Planning Office or Outpatient Visits

New and established patient E/M services for general family planning visits (procedure codes 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, and 99215) may be provided via a telemedicine service delivered using synchronous audiovisual technology 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.

New and established patient E/M services delivered using synchronous audiovisual technology must be billed using the 95 modifier.

Documentation requirements for a telemedicine service are the same as for an in-person visit and must accurately reflect the services rendered. Documentation must identify the service delivery method when provided via telemedicine.

During a Declaration of State of Disaster, HHSC may issue direction to providers regarding the use of a 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. A Declaration of State of Disaster is when an executive order or proclamation by the governor declaring a state of disaster in accordance with Section 418.014 of the Texas Government Code.

SOURCE: TX Medicaid Gynecological, Obstetrics, and Family Planning Title XIX Services Handbook pg. 9-10, (Dec. 2024). (Accessed Dec. 2024).

Healthy Texas Women Program/HTW Plus

Certain telemedicine and telehealth services may be provided for HTW clients 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 interactions, such as an in-person visit, as well as the use of synchronous audio-visual technology over synchronous telephone (audio-only) technology of telemedicine and telehealth services. Therefore, providers must document in the person’s medical record the reason(s) for why services were delivered by synchronous telephone (audio-only) technology. The following HTW services are authorized for telemedicine delivery using synchronous audiovisual and synchronous telephone (audio-only), when noted, technologies. See manual for codes.

New patient and established client services provided by synchronous audiovisual technology must be billed using modifier 95. See manual for procedure codes are for new and established client services.

Established client service (procedure code 99211) is only during certain public health emergencies. Procedure codes that indicate remote (telemedicine medical and telehealth services) delivery in the description do not need to be billed with the 95 modifier.

FQHCs and RHCs may be reimbursed for telemedicine and telehealth in the following manner:

The distant site provider fee is reimbursable as a prospective payment system (PPS), alternative prospective payment system (APPS), or AIR (All Inclusive Rate) PPS.
The facility fee (procedure code Q3014) is an add-on procedure code that should not be included in any cost reporting that is used to calculate a FQHC PPS, APPS, or the RHC AIR (All Inclusive Rate) PPS per visit encounter rate.

See manual for non-behavioral health services that can be delivered by telemedicine and telehealth services.

SOURCE: TX Medicaid Healthy Texas Women Program Handbook, (Dec. 2024), pg. 12-13 (Accessed Dec. 2024).

Notwithstanding §263.8(a) of this chapter (relating to Comprehensive Nursing Assessment), the comprehensive nursing assessment completed by an RN is not required to be completed in person for an individual who resides in the disaster area, if the RN conducts the assessment as a telehealth service or by telephone.

SOURCE: 26 TAC Sec. 263.1000, (Accessed Dec. 2024).

An assessment of an individual may be performed as a telemedicine medical service or a telehealth service, including via an audio-only platform, in accordance with the requirements and limitations of Subchapter A, Division 33 of this chapter (relating to Advanced Telecommunications Services).

A service described in this subsection may be delivered as a telemedicine medical service or a telehealth service, including via an audio-only platform, in accordance with the requirements and limitations of Subchapter A, Division 33 of this chapter. The comprehensive provider agency and staff members must implement procedures to ensure that each individual is provided mental health services based on:

the assessment conducted under subsection (a) of this section;
medical necessity as determined by an LPHA; and
when available, physical health care needs as determined by a physician, physician assistant, or advanced practice registered nurse.

SOURCE: TX Admin Code Title 1, Sec. 354.2607, (Accessed Dec. 2024).

Mental Health Recovery Treatment Planning, Mental Health Targeted Case Management, Crisis Intervention Services, Medication Training and Support Services, Psychosocial Rehabilitative Services, Skills Training and Development Services

The aforementioned may be delivered as a telemedicine medical service or a telehealth service, including via an audio-only platform, in accordance with the requirements and limitations of Subchapter A, Division 33 of this chapter (relating to Advanced Telecommunications Services). See applicable Administrative Code section for more details.

SOURCE: TX Admin Code Title 1, Sec. 354.2609, TX Admin Code Title 1, Sec. 354.2655, TX Admin Code Title 1, Sec. 354.2707, TX Admin Code Title 1, Sec. 354.2709, TX Admin Code Title 1, Sec. 354.2711, TX Admin Code Title 1, Sec. 354.2713, (Accessed Dec. 2024).

Ongoing Evaluation and Management of Chronic Pain and Chronic Pain Management (CPM)

The first time that procedure code G3002 is billed, the physician or qualified health practitioner must see the client in person. After the initial visit, any of the CPM in-person components included in procedure codes G3002 and G3003 may be provided through telehealth, as clinically appropriate, to increase access to care for Medicaid clients.

SOURCE: TX Medicaid Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, (Dec. 2024), pg. 175 (Accessed Dec. 2024).

Managed Care

MCOs may offer to STAR+PLUS members a choice of audio-visual communication in place of in-person change in condition assessments, as long as the assessment does not require or potentially require a change in the RUG level.

During a declared state of disaster, HHSC may issue direction to STAR+PLUS [STAR Kids and STAR Health] MCOs regarding whether initial, annual renewal, or change in condition assessments may be conducted through audio-visual or audio-only communication for STAR+PLUS members who reside in the area subject to the declared state of disaster.

For limited circumstances, STAR+PLUS [STAR Kids and STAR Health] MCOs may submit, in a manner and format prescribed by HHSC, an exceptions policy for required in-person assessments for approval by HHSC. The policy must be developed by the MCO’s clinical staff, such as the Chief Medical Director or the Director’s designee.

See rules Sec. 1604-1506 for additional requirements for each program.

SOURCE: Title 1, Part 15, Sec. 353.1503, (Accessed Dec. 2024).

Ambulance Services

Emergency Triage, Treat, Transport (ET3) permits emergency transportation (ground ambulance) providers to: … Initiate and facilitate appropriate TIP through telemedicine or telehealth.

Treatment on scene may also be performed, when medically necessary, via a telemedicine or telehealth visit performed in accordance with telemedicine and telehealth services requirements outlined in the Telecommunication Services Handbook (Vol. 2, Provider Handbooks).

When billing for TIP via telemedicine or telehealth, providers must bill using the most clinically appropriate emergency transport code (A0427 or A0429), the ET modifier, the W destination modifier to indicate TIP, and procedure code Q3014. Procedure code Q3014 will be informational only and used by Medicaid to identify TIP through telemedicine or telehealth services.

SOURCE: TX Medicaid Ambulance Services, (Dec. 2024). (Accessed Dec. 2024).

Emergency triage, treat and transport (ET3) services. HHSC may reimburse a Medicaid-enrolled ambulance provider responding to a call initiated by an emergency response system and upon arrival at the scene the ambulance provider determines the recipient’s needs are nonemergent, but medically necessary. ET3 services may be reimbursed for: …

initiating and facilitating treatment in place via telemedicine or telehealth.

SOURCE: TX Admin Code Sec. 354.1115, (Accessed Dec. 2024).

CSHCN Program

Emergency room care, critical care, home care, preventive care, newborn care, and care provided in a nursing home, skilled nursing facility, or client’s home, are not approved telemedicine or telehealth services. Consultative, but not routine, inpatient care, is included as a telemedicine or telehealth service.

Telemedicine is provided for the purpose of the following:

Client assessment by a health professional
Diagnosis, consultation, or treatment by a physician
Transfer of medical data that requires the use of advanced telecommunications technology, other than telephone or facsimile technology, including the following:
- Compressed digital interactive video, audio, or data transmission.
- Clinical data transmission using computer imaging by way of still-image capture and store-and-forward.
- Other technology that facilitates access to health-care services or medical specialty expertise.

See manual for specific codes.

SOURCE: TX Medicaid CSHCN Services Program Provider Manual: Telecommunication Services (Nov. 2024), p. 3-4. (Accessed Dec. 2024).

Inpatient Outpatient Hospital – Radiation Therapy

Teletherapy is covered by Texas Medicaid once per day in an outpatient hospital setting.

SOURCE: TX Medicaid Inpatient and Outpatient Hospital Services Handbook, p. 61 (Dec. 2024). (Accessed Dec. 2024).

Emergency Triage, Treat, and Transport (ET3)

Emergency Triage, Treat, and Transport (ET3) services are designed to allow greater flexibility for Medicaid-enrolled ambulance providers to address clients’ health-care needs following a 9-1-1 call, fire, police, or other locally established system for emergency calls. ET3 permits emergency transportation (ground ambulance) providers to: …

Initiate and facilitate appropriate TIP through telemedicine or telehealth.

Treatment in Place

Treatment on scene may also be performed, when medically necessary, through a telemedicine or telehealth visit performed in accordance with telemedicine and telehealth services requirements outlined in the Telecommunication Services Handbook (Vol. 2, Provider Handbooks).

Note: Similar section contained in CSHCN Ambulance Provider Manual.

SOURCE: TX Medicaid Ambulance Services Handbook, p. 7-8 (Dec. 2024). (Accessed Dec. 2024).

Preventive care medical checkups are not a benefit of a telemedicine or telehealth service.

SOURCE: TX Medicaid CSHCN Services Program Manual – Physician, (Nov. 2024), (Accessed Dec. 2024).

Home Dialysis

Certain telemedicine and telehealth services may be provided for ESRD clients 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 interactions, such as an in-person visit.

Documentation requirements for a telehealth service are the same as for an in-person visit and must accurately reflect the services rendered. Documentation must identify the means of delivery when provided.

See manual for ESRD dialysis services are authorized for telemedicine and telehealth delivery using synchronous audiovisual technology.

Services provided by synchronous audio-visual technology must be billed using modifier 95.

During a Declaration of State of Disaster, the Texas Health and Human Services Commission (HHSC) may issue direction to providers regarding the use of a 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. A Declaration of State of Disaster is when an executive order or proclamation is issued by the governor declaring a state of disaster in accordance with Section 418.014 of the Texas Government Code.

The Telecommunication Services Handbook (Vol. 2, Provider Handbooks) for more information about telemedicine and telehealth documentation requirements including requirements for informed consent.

SOURCE: TX Medicaid Clinic and Other Outpatient Facility Services Handbook, p. 26 (Dec. 2024). (Accessed Dec. 2024).

ELIGIBLE PROVIDERS

The information in this handbook is intended for home health agencies, hospitals, nurse practitioners (NP), clinical nurse specialists (CNS), certified nurse midwives (CNM), licensed professional counselors (LPC), licensed marriage and family therapists (LMFT), licensed clinical social workers (LCSW), physicians, physician assistants (PA), psychologists, licensed psychological associates, provisionally licensed psychologists, and licensed dieticians.

Providers may provide telecommunication services for Texas Medicaid clients under the provider’s National Provider Identifier (NPI). No additional enrollment is required to provide telemedicine medical service or telehealth services.

Telemedicine Services

A distant site is the location of the provider rendering the service. Distant-site telemedicine benefits include services that are performed by the following providers, who must be enrolled as a Texas Medicaid provider:

Physician
Clinical Nurse Specialist (CNS)
Nurse Practitioner (NP)
Physician Assistant (PA)
Certified Nurse Midwife (CNM)
Federally Qualified Health Center (FQHC) (in manual only)

A distant site provider is the physician, or PA, NP, CNM, FQHC, Rural Health Clinic (RHC), or CNS who is supervised by and has delegated authority from a licensed Texas physician, who uses telemedicine to provide health-care services to a client in Texas.

Distant site providers must be licensed in Texas.

An out-of-state physician who is a distant site provider may provide episodic telemedicine without a Texas medical license as outlined in Texas Occupations Code §151.056 and Title 22 Texas Administrative Code (TAC) §172.2(g)(4) and 172.12(f).

Distant site providers that provide mental health services must be appropriately licensed or certified in Texas, or be a qualified mental health professional-community services (QMHP-CS), as defined in 26 TAC §301.303(48).

School Based Services: Telemedicine services provided in a school-based setting are also a benefit if the physician delegates provision of services to a nurse practitioner, clinical nurse specialist, or physician assistant, as long as the nurse practitioner, clinical nurse specialist, or physician assistant is working within the scope of their professional license and within the scope of their delegation agreement with the physician.

SOURCE: TX Medicaid Telecommunication Services Handbook, p. 7-8, 10 (Dec. 2024) (Accessed Dec. 2024).

Telehealth Services

A distant site is the location of the provider rendering the service. A distant site provider is the health professional licensed, certified, or otherwise entitled to practice in Texas who uses telehealth services to provide health care services to a patient in Texas.

Licensed psychological associates (LPAs), provisionally licensed psychologists (PLPs), post-doctoral psychology fellows, and pre-doctoral psychology interns under psychologist supervision may also deliver telehealth services. All requirements outlined in the Outpatient Mental Health Services benefit language must be met.

Distant site providers who provide mental health services must be appropriately licensed or certified in Texas or be a QMHP-CS as defined in 26 Texas Administrative Code §301.303(48).

A distant-site provider that is located outside of state lines while rendering services is considered an out-of-state provider.

The distant site provider must obtain informed consent to treatment from the patient, patient’s parent or the patient’s legal guardian prior to rendering a telehealth service.

Distant site providers should meet all other telehealth service requirements specified in Texas Occupations Code §111.

SOURCE: TX Medicaid Telecommunication Services Handbook, p. 12 (Dec. 2024) (Accessed Dec. 2024).

The executive commissioner by rule shall ensure that a rural health clinic as defined by 42 U.S.C. Section 1396d(l)(1) and a federally-qualified health center as defined by 42 U.S.C. Section 1396d(l)(2)(B) may be reimbursed for the originating site facility fee or the distant site practitioner fee or both, as appropriate, for a covered telemedicine medical service, teledentistry dental service, or telehealth service delivered by a health care provider to a Medicaid recipient. The commission is required to implement this subsection only if the legislature appropriates money specifically for that purpose. If the legislature does not appropriate money specifically for that purpose, the commission may, but is not required to, implement this subsection using other money available to the commission for that purpose.

SOURCE: TX Statute Sec. 531.0216, [repealed eff. April 1, 2025], (Accessed Dec. 2024).

The Health and Human Services Commission (HHSC) reimburses eligible distant site professionals providing telemedicine medical services as follows:

Physicians
Physician assistants
Advanced Practice Registered Nurses (APRNs)
Certified nurse midwives

HHSC reimburses eligible distant site professionals providing telehealth services as follows:

Licensed professional counselors, including licensed marriage and family therapists, and licensed clinical social workers (including Comprehensive Care Program social workers) are reimbursed for their Medicaid telehealth services in the same manner as their other professional services in accordance with §355.8091 of this title (relating to Reimbursement to Licensed Professional Counselors, Licensed Clinical Social Workers, and Licensed Marriage and Family Therapists).
Licensed psychologists (including licensed psychological associates) and psychology groups are reimbursed for their Medicaid telehealth services in the same manner as their other professional services in accordance with §355.8085 of this title.
Durable medical equipment suppliers are reimbursed for their Medicaid telehealth services in the same manner as their other professional services in accordance with §355.8023 of this title (relating to Reimbursement Methodology for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS)).

Telemedicine medical services provided in a school-based setting by a physician, even if the physician is not the patient’s primary care physician, will be reimbursed in accordance with the applicable methodologies described in subsection (b)(1) of this section and §355.8443 of this title (relating to Reimbursement Methodology for School Health and Related Services (SHARS)) if the following conditions are met:

the physician is an authorized health care provider under Medicaid;
the patient is a child who receives the service in a primary or secondary school-based setting;
the parent or legal guardian of the patient provides consent before the service is provided; and
a health professional as defined by Government Code §531.0217(a)(1) is present with the patient during the treatment.

Fees for telemedicine, telehealth, and home telemonitoring services are adjusted within available funding as described in §355.201 of this title (relating to Establishment and Adjustment of Reimbursement Rates by the Health and Human Services Commission).

SOURCE: TX Admin Code. Title 1, Sec. 355.7001 (Accessed Dec. 2024).

School Health and Related Services (SHARS)

LEAs that participate in the SHARS program may be reimbursed for telehealth and telemedicine services delivered to children in school-based settings, or while receiving remote instruction.

See manual for specific requirements.

LEAs that participate in the SHARS program may be reimbursed for telehealth occupational therapy (OT), physical therapy (PT), speech therapy (ST), counseling, and psychological services.

All other reimbursement and billing guidelines that are applicable to in-person services will also apply when OT, PT, ST, counseling, and psychological services are delivered as telehealth services.

See manual for procedure codes and requirements that may be provided to children eligible through SHARS as telehealth services via synchronous audiovisual technology if clinically appropriate (as determined by the treating provider), safe and agreed to by the student receiving services.

SOURCE: TX Medicaid School Health and Related Services (SHARS) Handbook, (Dec. 2024). (Accessed Dec. 2024).

School-based telemedicine medical services. If a telemedicine medical service provided by an out-of-network physician to a member in a primary or secondary school-based setting meets the conditions for reimbursement in § 354.1432 of this title (relating to Telemedicine and Telehealth Benefits and Limitations), a health care MCO must reimburse the out-of-network physician without prior authorization, even if the physician is not the member’s primary care provider. The MCO must use the reasonable reimbursement methodology described in subsection (f)(2) of this section to reimburse an out-of-network physician.

SOURCE: TX Admin Code Title 1, Sec. 353.4, (Accessed Dec. 2024).

FQHCS

FQHCs may be reimbursed the distant-site provider fee for telemedicine services at the Prospective Payment System (PPS) rate or Alternative Prospective Payment System (APPS) rate.

FQHC practitioners may be employees of the FQHC or contracted with the FQHC.

SOURCE: TX Medicaid Telecommunication Services Handbook, p. 10 & 12 (Dec. 2024). (Accessed Dec. 2024).

SOURCE: TX Statute Sec. 531.0216, [repealed eff. Apr. 1, 2025], (Accessed Dec. 2024).

After the first encounter, the patient suffers illness or injury requiring additional diagnosis or treatment; or
The FQHC patient has a medical visit and an “other” health visit, as defined in paragraph (13) of this subsection.

SOURCE: Texas Admin Code Title 1, Sec. 355.8261, (Accessed Dec. 2024).

The commission by rule shall require each health and human services agency that administers a part of the Medicaid program to provide Medicaid reimbursement for teledentistry dental services provided by a dentist licensed to practice dentistry in this state.

The commission shall require reimbursement for a teledentistry dental service at the same rate as the Medicaid program reimburses for the same in-person dental service. A request for reimbursement may not be denied solely because an in-person dental service between a dentist and a patient did not occur. The commission may not limit a dentist’s choice of platform for providing a teledentistry dental service by requiring that the dentist use a particular platform to receive reimbursement for the service.

SOURCE: TX Govt. Code Sec. 531.02172, [repealed Apr. 1, 2025], (Accessed Dec. 2024)

Rural Health Clinics

RHCs may be reimbursed the distant-site provider fee for telemedicine services at the PPS rate. RHC practitioners may be employees of the RHC or contracted with the RHC.

The facility fee (procedure code Q3014) may be reimbursed as an add-on procedure code that should not be included in any cost reporting that is used to calculate the RHC AIR (All Inclusive Rate) PPS per visit encounter rate.

To receive reimbursement for more than one facility fee for the same client on the same date of service, an RHC must submit documentation of medical necessity that the client needed multiple distant-site provider consultations. An RHC can use a signed letter from the client’s treating health care provider at the RHC documenting that the client suffered an illness or injury requiring additional diagnosis or treatment by a distant site provider. This will suffice to document the client’s medical need for purposes of receiving additional facility fee payments for the same client on the same date of service. The letter must state that the client suffered an illness or injury that required additional diagnosis or treatment by a distant-site provider.

If an RHC is eligible for payment of both an encounter fee and a facility fee for the same client on the same date of service, the RHC must submit a claim for the facility fee separate from the claim submitted for the encounter.

The facility fee should not be included in any cost reporting that is used to calculate the RHC All Inclusive Rate (AIR) prospective payment system (PPS) per-visit encounter rate.

Note: Telemedicine and telehealth services must be billed with modifier 95. Procedure codes that indicate remote delivery (telemedicine medical services or telehealth services) in the description do not need to be billed with modifier 95.

SOURCE: TX Medicaid Telecommunication Services Handbook, p. 11 (Dec. 2024). (Accessed Dec. 2024).

A medical visit is a face-to-face or telemedicine medical service encounter between an RHC patient and a physician, physician assistant, advanced nurse practitioner, certified nurse-midwife, visiting nurse, or clinical nurse practitioner. Encounters with more than one health professional and multiple encounters with the same health professional that take place on the same day and at a single location constitute a single visit, except where one of the following conditions exists:

after the first encounter, the patient suffers illness or injury requiring additional diagnosis or treatment; or
the RHC patient has a medical visit and an “other” health visit as defined in subsection (n) of this section.

An “other” health visit includes, but is not limited to, a face-to-face or telehealth service encounter between an RHC patient and a clinical social worker.

SOURCE: 15 TAC Sec. 355.8101. (Accessed Dec. 2024).

Physical Therapy, Occupational Therapy, and Speech and Language Pathology as a Telehealth Service.

SOURCE: 26 TAC Sec. 263.6, (Accessed Dec. 2024).

CSHCN Program

A distant site is the location of the provider rendering the service. Distant-site benefits include services that are performed by the following providers, who must be enrolled as a CSHCN Services Program provider:

Telemedicine Services

Physician
Advanced Practice Registered Nurse (APRN)
Physician assistant (PA)

Telehealth Services

Licensed professional counselor
Licensed marriage and family therapist
Licensed clinical social worker
Psychologist
Licensed dietician

See manual for other specific requirements.

SOURCE: TX Medicaid CSHCN Services Program Provider Manual (Nov. 2024), p. 5 & 8. (Dec. 2024).

School-Based Services

The commission shall ensure that Medicaid reimbursement is provided to a school district or open-enrollment charter school for telehealth services provided through the school district or charter school by a health professional, even if the health professional is not the patient’s primary care provider, if:

the school district or charter school is an authorized health care provider under Medicaid; and
the parent or legal guardian of the patient provides consent before the service is provided.

A health professional is defined as:

Licensed, registered, certified, or otherwise authorized by this state to practice as a social worker, occupational therapist, or speech-language pathologist;
Licensed professional counselor
Licensed marriage and family therapist; or
Licensed specialist in school psychology.

SOURCE: TX Government Code Sec. 531.02171, [repealed eff. Apr. 1, 2025] (Accessed Dec. 2024).

ELIGIBLE SITES

The physical environments of the client and the distant site provider must ensure that the client’s protected health information remains confidential. A parent or legal guardian may be physically located in the patient site or distant site environment during a telehealth or telemedicine service with a child.

A patient site is the place where the client is physically located. A client’s home may be the patient site for telemedicine.

A patient site is the place where the client is physically located while the service is rendered. Patient-site providers that are enrolled in Texas Medicaid may only be reimbursed for the facility fee using procedure code Q3014. Charges for other services that are performed at the patient site may be submitted separately.

A client’s home may be the patient site for telehealth. Procedure code Q3014 is not a benefit if the patient site is the client’s home.

SOURCE: TX Medicaid Telecommunication Services Handbook, pg. 4, 10, 13-13 (Dec. 2024), (Accessed Dec. 2024).

School-Based Setting

Conditions for telemedicine medical services provided in a primary or secondary school-based setting.

For a child receiving telemedicine medical services in a primary or secondary school-based setting, advance parent or legal guardian consent for a telemedicine medical service must be obtained.
The patient’s primary care physician or provider must be notified of a telemedicine medical service, unless the patient does not have a primary care physician or provider. (i) The patient receiving the telemedicine medical service, or the patient’s parent or legal guardian, must consent to the notification. (ii) For a telemedicine medical service provided to a child in a primary or secondary school-based setting, the notification must include a summary of the service, including:
- Exam findings;
- Prescribed or administered medications; and
- Patient instructions.

See Administrative Code Section for more details.

SOURCE: TX Admin Code Title 1, Sec. 354.1432, (Accessed Dec. 2024).

Telemedicine provided in a school-based setting by a physician, even if the physician is not the client’s primary care physician or provider, are benefits if all of the following criteria are met:

The physician is an authorized health-care provider enrolled in Texas 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.

Telemedicine services provided in a school-based setting are also a benefit if the physician delegates provision of services to a nurse practitioner, clinical nurse specialist, or physician assistant, as long as the nurse practitioner, clinical nurse specialist, or physician assistant is working within the scope of their professional license and within the scope of their delegation agreement with the physician.

SOURCE: TX Medicaid Telecommunication Services Handbook, p. 10 (Dec. 2024), (Accessed Dec. 2024).

The physician is an authorized health care provider under Medicaid;
The patient is a child who receives the service in a primary or secondary school-based setting;
the parent or legal guardian of the patient provides consent before the service is provided; and
a health professional as defined by Government Code §531.0217(a)(1) is present with the patient during the treatment.

SOURCE: TX Admin. Code, Title 1, Sec. 355.7001(f). (Accessed Dec. 2024).

School Health and Related Services (SHARS)

LEAs that participate in the SHARS program may be reimbursed for telehealth and telemedicine services delivered to children in school-based settings, or while receiving remote instruction.

OT, PT, ST, counseling, and psychological telehealth services provided by LEAs during school hours through SHARS may be delivered via synchronous audiovisual technologies.

SOURCE: TX Medicaid School Health and Related Services (SHARS) Handbook, (Dec. 2024). (Accessed Dec. 2024).

CSHCN Program

A patient site is where the client is physically located while the service is rendered. The patient-site must be one of the following:

Established medical site – A location where clients will present to seek medical care. There must be a patient-site presenter and sufficient technology and medical equipment to allow for an adequate physical evaluation, as appropriate for the client’s presenting complaint. A defined physician-client relationship is required. A client’s private home is not considered an established medical site.
Established health site – A location where clients will present to seek a health service. There must be a patient-site presenter and sufficient technology and medical equipment to allow for an adequate physical evaluation or assessment, as appropriate for the client’s presenting complaint. A defined health provider-client relationship is required. A client’s private home is not considered an established health site.

SOURCE: TX Medicaid CSHCN Services Program Provider Manual (Nov. 2024), p. 6, 8-9. (Dec. 2024).

GEOGRAPHIC LIMITS

No Reference Found

FACILITY/TRANSMISSION FEE

Patient-site providers that are enrolled in Texas Medicaid may only be reimbursed for the facility fee using procedure code Q3014. Procedure code Q3014 is payable to NP, CNS, PA, physicians, and outpatient hospital providers. Charges for other services that are performed at the patient site may be submitted separately. Procedure code Q3014 is not a benefit if the patient site is the client’s home.

Telemedicine Services for FQHCs

FQHCs may be reimbursed the facility fee (procedure code Q3014) as an add-on procedure code that should not be included in any cost reporting that is used to calculate a PPS or APPS per visit encounter rate.

To receive reimbursement for more than one facility fee for the same client on the same date of service, an FQHC must submit documentation of medical necessity that indicates that the client needed multiple distant-site provider consultations. An FQHC can use a signed letter from the client’s treating health- care provider at the FQHC to document the client’s medical need for receiving multiple distant-site provider consultations on the same date of service. The letter must state that the client suffered an illness or injury that required additional diagnosis or treatment by a distant-site provider.

If an FQHC is eligible for payment of both an encounter fee and a facility fee for the same client on the same date of service, the FQHC must submit a claim for the facility fee separate from the claim that was submitted for the encounter.

Telemedicine Services for RHCs

The facility fee should not be included in any cost reporting that is used to calculate the RHC All Inclusive Rate (AIR) prospective payment system (PPS) per-visit encounter rate.

Distant-Site Telehealth Services for FQHCs

The facility fee (procedure code Q3014) may be reimbursed as an add-on procedure code and should not be included in any cost reporting that is used to calculate a PPS or APPS per visit encounter rate.

To receive reimbursement for more than one facility fee for the same client on the same date of service, an FQHC must submit documentation of medical necessity indicating that the client needed multiple distant site provider consultations.

An FQHC can use a signed letter from the client’s treating health care provider at the FQHC documenting that the client suffered an illness or injury requiring additional diagnosis or treatment by a distant site provider. This will suffice to document the client’s medical need for purposes of receiving additional facility fee payments for the same client on the same date of service.

If an FQHC is eligible for payment of both an encounter and a facility fee for the same client on the same date of service, the FQHC must submit claims for the facility fee separate from claims submitted for the encounter.

Distant-Site Telehealth Services for RHCs

RHCs may be reimbursed the distant-site provider fee for telehealth services at the PPS rate.

RHC practitioners may be employees of the RHC or contracted with the RHC.

To receive reimbursement for more than one facility fee for the same client on the same date of service, an RHC must submit documentation of medical necessity indicating that the client needed multiple distant site provider consultations.

A signed letter from the client’s treating health care provider at the RHC documenting that the client suffered an illness or injury requiring additional diagnosis or treatment by a distant site provider will suffice to document the client’s medical need for purposes of receiving additional facility fee payments for the same client on the same date of service.

If an RHC is eligible for payment of both an encounter and a facility fee for the same client on the same date of service, the RHC must submit claims for the facility fee separate from claims submitted for the encounter.

SOURCE: TX Medicaid Telecommunication Services Handbook, (Dec. 2024). (Accessed Dec. 2024).

Telemedicine and telehealth patient site locations, as defined in §354.1430 and §354.1432 of this title, are reimbursed a facility fee determined by HHSC.

SOURCE: TX Admin. Code, Title 1 Sec. 355.7001(d), (Accessed Dec. 2024).

Healthy Texas Women Program

FQHCs and RHCs may be reimbursed for telemedicine and telehealth in the following manner: …

The facility fee (procedure code Q3014) is an add-on procedure code that should not be included in any cost reporting that is used to calculate a FQHC PPS, APPS, or the RHC AIR (All Inclusive Rate) PPS per visit encounter rate.

SOURCE: TX Medicaid Healthy Texas Women Program Handbook, (Dec. 2024), pg. 13, (Accessed Dec. 2024).

CSHCN Program

Patient-site providers enrolled in the CSHCN Services Program may only be reimbursed for the facility fee using procedure code Q3014. Procedure code Q3014 is payable to advanced practice registered nurses, physician assistants, and physicians in the office and outpatient hospital settings and to hospitals in the outpatient hospital setting. Charges for other services that are performed at the patient site may be submitted separately.

Procedure code Q3014 is not a benefit if the patient site is the client’s home.

The facility fee (procedure code Q3014) is not a benefit for telehealth services. Charges for other services that are performed at the patient site may be submitted separately.

SOURCE: TX Medicaid CSHCN Services Program Provider Manual (Nov. 2024), p. 6, 7, 9. (Dec. 2024).

Treatment in Place

SOURCE: TX Medicaid Ambulance Services Handbook, p. 7-8 (Dec. 2024). (Accessed Dec. 2024).

READ LESS

Utah

Last updated 11/25/2024

POLICY

Communication by telemedicine is considered face-to-face contact between a …

POLICY

Communication by telemedicine is considered face-to-face contact between a health care provider and a patient under the state’s medical assistance program if:

the communication by telemedicine meets the requirements of administrative rules adopted in accordance with Subsection (3); and
the health care services are eligible for reimbursement under the state’s medical assistance program.

This Subsection (1) applies to any managed care organization that contracts with the state’s medical assistance program.

The reimbursement rate for telemedicine services approved under this section:

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.

The department shall adopt administrative rules in accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act, 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 designated under Subsection (3)(a).

SOURCE: UT Code Annotated Sec. 26B-3-122. (Accessed Nov. 2024).

Telehealth services seek to improve an individual’s health by permitting two-way communication between members and their providers and may be performed for a variety of medically necessary services. This communication often requires the use of interactive telecommunications equipment that can include both audio and video components but may also be conducted via audio-only.

Telecommunication technologies that support synchronous care include:

Live video two-way, face-to-face interaction between the member and the provider using audiovisual communication, including E-visits through an online patient portal.
Audio only visits by means of telephone or other forms of communication without video.

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.

Services not otherwise covered by Utah Medicaid are not covered when delivered via telehealth.

SOURCE: Utah Medicaid Provider Manual: Section I: General Information (July 2024). (Accessed Nov. 2024).

Telehealth services are an additional method of delivering health care to patients. Refer to Section I: General Information, Chapter 8-4.2, Telehealth.

SOURCE: Utah Medicaid Provider Manual: Physician Services (July 2024). (Accessed Nov. 2024).

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.

Telehealth services must comply with privacy and security measures set forth under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the Health Information Technology for Economic and Clinical Health (HITECH) Act, Pub. L. No. 111-5, 123 Stat. 226, 467, to ensure that all patient communications and records, including recordings of telehealth encounters, are secure and remain confidential. 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 may 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, -4, -5 (Accessed Nov. 2024).

ELIGIBLE SPECIALTIES/SERVICES

“Telemedicine services” means telehealth services including:

clinical care;
health education;
health administration;
home health;
facilitation of self-managed care and caregiver support; or
remote patient monitoring occurring incidentally to general supervision; and

provided by a provider to a patient through a method of communication that:

uses asynchronous store and forward transfer or synchronous interaction; and
meets industry security and privacy standards, including compliance with the federal Health Insurance Portability and Accountability Act of 1996 and the federal Health Information Technology for Economic and Clinical Health Act.

SOURCE: UT Code Sec. 26B-4-704, (Accessed Nov. 2024).

The utilization of telehealth services is dependent upon the member and their situation. As such, providers must determine the clinical appropriateness and medical necessity of the services being delivered through clinical-based decision making. Some examples of when telehealth may be appropriate are:

Diagnostic review and discussion of results
Evaluation and management services
Management of chronic conditions
Medication management
Mental health, behavioral health, and substance use disorder services
Telepsychiatric consultation
Teledentistry
Treatment counselling
Wellness checks

Providers are responsible for determining the applicable CPT and HCPCS codes associated with each of the above-listed services and ensure the codes are covered. Reporting requirements for services provided via telehealth are the same as those provided for services performed in-person.

When psychiatrists consult with a physician regarding a member’s possible need for telepsychiatry, they must report the following CPT codes to receive payment for services:

99446 Interprofessional telephone/Internet assessment and management service provided by a consultative physician including a verbal and written report to the patient’s treating/requesting physician or other qualified health care professional; 5-10 minutes of medical consultative discussion and review
99447 11-20 minutes of medical consultative discussion and review
99448 21-30 minutes of medical consultative discussion and review
99449 31 minutes or more of medical consultative discussion and review

The treating physician, consulting with the psychiatrist, reports CPT code 99358- Prolonged evaluation and management service before and/or after direct patient care

Teledentistry services are covered for eligible members statewide.

Providers must report one of the following CPT codes to receive reimbursement for services:

D0140 –Limited oral evaluation – problem focused; An evaluation limited to a specific oral health problem or complaint. This may require interpretation of information acquired through additional diagnostic procedures. Report additional diagnostic procedures separately. Definitive procedures may be required on the same date as the evaluation. Typically, patients receiving this type of evaluation present with a specific problem and/or dental emergencies, trauma, acute infections, etc.
D0170 – Re-evaluation – limited, problem focused (established patient; not post-operative visit); Assessing the status of a previously existing condition. For example: – a traumatic injury where no treatment was rendered but patient needs follow-up monitoring; – evaluation for undiagnosed continuing pain; – soft tissue lesion requiring follow-up evaluation.
D0171 – Re-evaluation – post-operative office visit.

The dentist, to receive reimbursement, must reports CPT code D9995- teledentistry – synchronous; real-time encounter; Reported in addition to other procedures (e.g., diagnostic) delivered to the patient on the date of service to denote that services were rendered via teledentistry. Rates for approved teledentistry are the same as rates for in-person dental services.

SOURCE: Utah Medicaid Provider Manual: Section I: General Information (July 2024). (Accessed Nov. 2024).

The Medicaid program shall reimburse for telemedicine services at the same rate that the Medicaid program reimburses for other health care services.

The Medicaid program shall reimburse for audio-only telehealth services as specified by division rule.

The Medicaid program shall reimburse for telepsychiatric consultations at a rate set by the Medicaid program.

SOURCE: UT Code 26B-3-123 (Accessed Nov. 2024).

Rehabilitative Mental Health and Substance Use Disorder

Services may be provided via telemedicine when clinically appropriate.

For dates of service prior to April 1, 2022, when services are provided by telemedicine, providers must specify place of service ‘02’ in the place of service field on the claim. For dates of service on or after April 1, 2022, providers must specify the place of service as follows:

’02’ (Telehealth Provided Other than in Patient’s Home)
’10’ (Telehealth Provided in Patient’s Home)

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
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) and Assertive Community Outreach Treatment (ACOT)
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. (Sept. 2024) (Accessed Nov. 2024).

Autism Spectrum Disorder

When clinically appropriate, supervision of an assistant behavior analyst or behavior technician may occur via remote access technology.

Parent training services via remote technology are covered when it is clinically appropriate, per Utah Administrative Rule R414-42.

Documentation must substantiate the clinical appropriateness of telehealth services.

The provider may deliver services or supervise only one member or one group session at a time. Medicaid coverage requires synchronous delivery of services. This is comprised of real-time videoconferencing that occurs via two-way video and audio interactions.

The following services not covered when performed via telehealth:

Adaptive behavior treatment administered by a technician
Group adaptive behavior treatment administered by a technician
Group adaptive behavior treatment with protocol modification administered by a QHP

SOURCE: Utah Medicaid Provider Manual: Autism Spectrum Disorder (Sept. 2024). (Accessed Nov. 2024).

Supervision and parent training may be performed by a behavior therapist via telehealth regardless of geographic location. These services are reported with CPT codes 97151, 97155, 97156, and 97157. Remote access technology may not be used for other ABA services.

SOURCE: UT Medicaid Information Bulletin, Jan. 2023, (accessed Nov. 2024).

Utah Medicaid has allowed home health and hospice interventions to be delivered by telehealth when home visits have been restricted by quarantine or self-isolation or not allowed due to restrictions on facility/community access.

Continuing – The following changes will remain:

Telehealth visits for home health and hospice services provided to members living in facilities will remain permitted when the facility is closed due to infection control measures.
Home Health and Hospice agencies that are CLIA certified can perform COVID-19 testing in patients’ homes and receive reimbursement for these services.

Utah Medicaid has allowed flexibility for Applied Behavior Analysis (ABA) services during the PHE. Please refer to the Autism Spectrum Disorder Services provider manual for additional information.

Continuing – The following changes related to ABA will remain at the end of the PHE. Including:

Telehealth services without geographic restriction for supervision and parent training by a psychologist or behavioral analyst
Telehealth services for CPT code 97151 and 97153 in limited circumstances; such as, issues with access to care
Use of additional autism diagnostic tools
Telehealth services for ABA therapy may only be delivered to one patient at a time

SOURCE: UT Department of Health and Human Services, COVID-19 and the Public Health Emergency, (April 2023), (Accessed Nov. 2024).

School Based Skills Development Services

Utah Medicaid covers medically necessary, non-experimental, and cost-effective services provided via telehealth. Telehealth is a two-way, real-time interactive communication to facilitate contact directly between a student and a provider. This electronic communication uses interactive telecommunications equipment that includes, at a minimum, audio and video equipment that complies with HIPAA and UHIN privacy and security standards for telehealth.

Covered telehealth services include but are not limited to the following:

Consultation services
Evaluation and management services
Mental health services

Reporting requirements for provided telehealth services are the same as those provided when the student is present (in person).

SOURCE: Utah Medicaid Provider Manual: School Based Skills Development Services (Sept. 2024). (Accessed Nov. 2024).

ELIGIBLE PROVIDERS

Distant site (hub site) – is where the provider delivering the service is located at the time the service is provided via telecommunications system

Distant providers:

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) was 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 (July 2024). (Accessed Nov. 2024).

ELIGIBLE SITES

There are no geographic restrictions surrounding the use of telehealth services. Medicaid covers telehealth services when performed via synchronous care. Telecommunication technologies that support synchronous care include:

Live video two-way, face-to-face interaction between the member and the provider using audiovisual communication, including E-visits through an online patient portal.
Audio only visits by means of telephone or other forms of communication without video.

SOURCE: Utah Medicaid Provider Manual: Section I: General Information (July 2024). (Accessed Nov. 2024).

Rehabilitative Mental Health and Substance Use Disorder

’02’ (Telehealth Provided Other than in Patient’s Home)
’10’ (Telehealth Provided in Patient’s Home)

SOURCE: Utah Medicaid Provider Manual: Rehabilitative Mental Health and Substance Use Disorder Services. (Sept. 2024) (Accessed Nov. 2024).

Autism Spectrum Disorder

When reporting services delivered via remote access technology, the CMS 1500 claim form must include “Place of Service 02” to identify the service as delivered via telehealth.

SOURCE: Utah Medicaid Provider Manual: Autism Spectrum Disorder (July 2023). (Accessed Nov. 2024).

School Based Skills Development Services

There are no geographic restrictions for telehealth services.

SOURCE: Utah Medicaid Provider Manual: School Based Skills Development Services (Sept. 2024). (Accessed Nov. 2024).

GEOGRAPHIC LIMITS

Live video two-way, face-to-face interaction between the member and the provider using audiovisual communication, including E-visits through an online patient portal.
Audio only visits by means of telephone or other forms of communication without video.

SOURCE: Utah Medicaid Provider Manual: Section I: General Information (July 2024). (Accessed Nov. 2024).

School Based Skills Development Services

There are no geographic restrictions for telehealth services.

SOURCE: Utah Medicaid Provider Manual: School Based Skills Development Services (Sept. 2024). (Accessed Nov. 2024).

FACILITY/TRANSMISSION FEE

The provider, if the member is in a facility i.e. the originating site, receives no additional reimbursement for the use of telehealth services.

SOURCE: Utah Medicaid Provider Manual: Section I: General Information (Jul 2024), (Accessed Nov. 2024).

The originating site receives no reimbursement for the use of telehealth services.

SOURCE: Utah Admin Code, R414-42-4.(3). (Accessed Nov. 2024).

School Based Skills Development Services

Providers at the originating site receive no additional reimbursement for the use of telehealth services.

SOURCE: Utah Medicaid Provider Manual: School Based Skills Development Services (Sept. 2024). (Accessed Nov. 2024).

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Vermont

Last updated 11/27/2024

POLICY

All health insurance plans in this State shall provide …

POLICY

All health insurance plans in this State shall provide coverage for health care services and dental services delivered through telemedicine by a health care provider at a distant site to a patient at an originating site to the same extent that the plan would cover the services if they were provided through in-person consultation.

[Subdivision (a)(2) repealed effective January 1, 2026.]

A health insurance plan shall provide the same reimbursement rate for services billed using equivalent procedure codes and modifiers, subject to the terms of the health insurance plan and provider contract, regardless of whether the service was provided through an in-person visit with the health care provider or through telemedicine.

The provisions of subdivision (A) of this subdivision (2) shall not apply:

to services provided pursuant to the health insurance plan’s contract with a third-party telemedicine vendor to provide health care or dental services; or
in the event that a health insurer and health care provider enter into a value-based contract for health care services that include care delivered through telemedicine or by store-and-forward means.

A health insurance plan may charge a deductible, co-payment, or coinsurance for a health care service or dental service provided through telemedicine as long as it does not exceed the deductible, co-payment, or coinsurance applicable to an in-person consultation.

A health insurance plan may limit coverage to health care providers in the plan’s network. A health insurance plan shall not impose limitations on the number of telemedicine consultations a covered person may receive that exceed limitations otherwise placed on in-person covered services.

Nothing in this section shall be construed to prohibit a health insurance plan from providing coverage for only those services that are medically necessary and are clinically appropriate for delivery through telemedicine, subject to the terms and conditions of the covered person’s policy.

SOURCE: VT Statutes Annotated, Title 8 Sec. 4100k (Accessed Nov. 2024).

To be covered, services shall be:

Clinically appropriate for delivery through telemedicine, and
Be medically necessary.

SOURCE: VT Health Care Administrative Rules 13.174.003 (3.101.2), Telehealth, (Accessed Nov. 2024).

Health Care Administrative Rule 3.101 Telehealth can be found on the Agency of Human Services website at: https://humanservices.vermont.gov/rules-policies/health-care-rules. Providers use of telehealth practices are subject to the requirements of administrative rule. Information contained in rule will not be repeated in the provider manuals.

Billing Rules for Telemedicine:

All providers are required to follow correct coding rules, including application of modifiers, and only bill for services within their scope of practice that can be done via telemedicine.
All professional claims (CMS-1500 form) with services billed for telemedicine must have POS 02. Modifier GT should not be used on professional services.
All facility claims (UB-04 form) must include modifier GT on any telemedicine services delivered via interactive audio and/or video.
Originating facility site providers (patient site) may be reimbursed a facility fee (Q3014)
Facility fees will not be reimbursed if the provider is employed by the same entity as the originating site
GT modifier should not be used on Q301.
DVHA will not reimburse for teleophthalmology or teledermatology by store and forward means.

Dialysis – Revenue code 780, Telemedicine – is reimbursable when billed with the appropriate HCPCS code. Pricing is the current Level II price on for the HCPCS code billed on the claim.

Partial Hospitalization Programs (PHP) and Intensive Outpatient Programs (IOP) Billing Guidance: Providers billing for PHP/IOP services in an office-based setting may not separately bill for professional services. This applies to PHP/IOP services provided in-person or via telehealth.

SOURCE: VT Agency of Human Services. General Billing and Forms Manual. Sec. 5.3.53, 5.3.46, & 6.9.2 (Aug. 1, 2024). (Accessed Nov. 2024).

FAQ – Is telemedicine a covered service under Vermont Medicaid?

Yes – this type of service is reimbursable through Vermont Medicaid as long as it is clinically appropriate and within the provider’s licensed scope of practice. This includes the provision of mental health and substance use disorder treatment. Telehealth services should include the appropriate Place of Service codes: Place of Service Code 10 for Telehealth Provided in Patient’s Home or Place of Service Code 02 Telehealth Provided Other Than in Patient’s Home.

SOURCE: Department of Vermont Health Access. Agency of Human Services. Telehealth: Methods for healthcare service delivery using telecommunications technologies. (Accessed Nov. 2024).

Effective 1/1/24, Telehealth coding for place of service and modifier guidance given during the Public Health Emergency (PHE) period no longer applies. Vermont Medicaid updated the following changes to telehealth coding: Place of Service code 10 – Telehealth Provided in Patient’s Home and Place of Service code 02 – Telehealth Provided Other than in Patient’s Home. Current Procedural Terminology (CPT) Code Modifier 93 for Telemedicine services delivered via audio-only telecommunications should be billed for clinically appropriate services delivered via telephone. Modifier 93 replaces the use of modifier V3. A list of allowable audio-only service codes can be found on the DVHA website. VT Medicaid follows Medicare place of service guidelines, CPT, and Healthcare Common Procedure Coding System (HCPCS) modifiers as indicated in the VT Medicaid General Billing and Forms Manual.

SOURCE: Department of VT Health Access, Banner Notice, Feb. 9, 2024, Telehealth Guidance (Accessed Nov. 2024).

ELIGIBLE SERVICES/SPECIALTIES

Services delivered shall:

Include any service that a provider would typically provide to a beneficiary in a face-to-face setting, and
Adhere to the same program restrictions, limitations, and coverage that exist for the service when not provided through telemedicine.

Services provided through telehealth are subject to the same prior authorization requirements that exist for the service when not provided through telehealth.

Non-Covered Services

Services and procedures that are not covered in a face-to-face setting under Vermont Medicaid are not covered under telemedicine or audio-only.
Services delivered via facsimile, text communication, or electronic mail messages are not considered telehealth and are not covered.

SOURCE: VT Health Care Administrative Rules 13.174.003 (3.101.2), Telehealth, (Accessed Nov. 2023).

All providers are required to follow correct coding rules, including application of modifiers, and only bill for services within their scope of practice that can be done via telemedicine.

All professional claims (CMS-1500 form) with services billed for telemedicine must have POS 02. Modifier GT should not be used on professional services.

All facility claims (UB-04 form) must include modifier GT on any telemedicine services delivered via interactive audio and/or video.

SOURCE: VT Agency of Human Services. General Billing and Forms Manual. Sec. 5.3.53, p. 82, (Aug. 1, 2024). (Accessed Nov. 2024).

Substance Use Disorder

In order to facilitate the use of telemedicine in treating substance use disorder, when the originating site is a health care facility, health insurers and the Department of Vermont Health Access shall ensure that the health care provider at the distant site and the health care facility at the originating site are both reimbursed for the services rendered, unless the health care providers at both the distant and originating sites are employed by the same entity.

SOURCE: VT Statutes Annotated, Title 8 Sec. 4100k(h), (Accessed Nov. 2023).

Re/Habilitative Therapy

Telehealth services are a covered benefit. Best practice allows for the type of physical examination, tests, and measures which result in establishment of the diagnosis, management plan, and outcome measures. It includes a plan to allow for in-person visits if required, and the ability to monitor patient safety. There may be circumstances where an evaluation is done via telehealth when necessary to prevent delays in essential care. If the testing required to complete a thorough evaluation requires physical contact with the patient, telehealth-only service is not indicated. If the management plan requires the use of physical agents such as ultrasound, electrical stimulation, or light, or manual therapies such as joint mobilization, telehealth-only services are not indicated.

SOURCE: VT Agency of Human Services, PT/OT/SLP Supplement, Sec. 2, (Oct. 15, 2024), (Accessed Nov. 2024).

ELIGIBLE PROVIDERS

“Distant site” means the location of the health care provider delivering services through telemedicine at the time the services are provided.

SOURCE: VT Statutes Annotated, Title 8 Sec. 4100k.(Accessed Nov. 2024).

“Distant site” means the site where the provider is located, and the beneficiary is not located, when telemedicine, audio-only, or store and forward services are provided.

SOURCE: VT Health Care Administrative Rules 13.174.003 (3.101.1(f)), Telehealth, (Accessed Nov. 2024).

Telehealth services must be provided by a provider who is working within the scope of his or her practice and enrolled in Vermont Medicaid.

Qualified telemedicine and store and forward providers shall:

Meet or exceed applicable federal and state legal requirements of medical and health information privacy, including compliance with HIPAA.
Provide appropriate informed consent, in a language that the beneficiary understands, consistent with 18 VSA § 936l(c)(l) (see code for details)
Take appropriate steps to establish the provider-patient relationship and conduct all appropriate evaluations and history of the beneficiary consistent with traditional standards of care.
Maintain medical records for all beneficiaries receiving health care services through telemedicine that are consistent with established laws and regulations governing patient health care records.
Establish an emergency protocol when care indicates that acute or emergency treatment is necessary for the safety of the beneficiary.
Address needs for continuity of care for beneficiaries (e.g., informing beneficiary or designee how to contact provider or designee and/or providing beneficiary or identified providers timely access to medical records).
If prescriptions are contemplated, follow traditional standards of care to ensure beneficiary safety in the absence of a traditional physical examination.

SOURCE: VT Health Care Administrative Rules 13.174.003 (3.101.3), Telehealth, (Accessed Nov. 2024).

Dentists

Vermont Medicaid is encouraging Medicaid-participating providers, including dentists, to utilize telemedicine for delivery of medically necessary and clinically appropriate services to Medicaid members when possible. For more information, see the DVHA website at: https://dvha.vermont.gov/sites/dvha/files/documents/News/DVHA%20Telemedicine%20%26%20Emergency%20Telephonic%20Coverage_Dental%20Providers%2004.10.2020.pdf

SOURCE: Department of Vermont Health Access, Dental Supplement, pg. 13, (Aug. 11, 2024), (Accessed Nov. 2024).

Substance Use Disorder

SOURCE: VT Statutes Annotated, Title 8 Sec. 4100k(h), (Accessed Nov. 2024).

ELIGIBLE SITES

SOURCE: Department of VT Health Access, Banner Notice, Feb. 9, 2024, Telehealth Guidance (Accessed Nov. 2024).

Telehealth services are reimbursed at the same rate as in person visits. A system error was discovered for telehealth services billed with place of service 10. POS 10 is defined as – patient is located in their home (which is a location other than a hospital or other facility). The system has been corrected and claims will be adjusted and reprocessed by Gainwell, retroactive to 1/1/2023.

SOURCE: Department of VT Health Access, Banner Notice, Dec. 15, 2023, Place of Service 10 (Accessed Nov. 2024).

“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 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: VT Statutes Annotated, Title 8 Sec. 4100k (Accessed Nov. 2024).

“Originating site” means the site where the beneficiary is located, whether or not accompanied by a health care provider, when telemedicine, or audio-only services are provided. The originating site may include the beneficiary’s home or another nonmedical setting (e.g., school, workplace), a health care provider’s office, a facility, or a hospital.

SOURCE: VT Health Care Administrative Rules 13.174.003 (3.101.1), Telehealth, (Accessed Nov. 2024).

Substance Use Disorder

SOURCE: VT Statutes Annotated, Title 8 Sec. 4100k(h), (Accessed Nov. 2024).

GEOGRAPHIC LIMITS

No Reference Found

FACILITY/TRANSMISSION FEE

Originating facility site providers (patient site) may be reimbursed a facility fee (Q3014).

Facility fees will not be reimbursed if the provider is employed by the same entity as the originating site.

GT modifier should not be used on Q3014.

SOURCE: VT Agency of Human Services. General Billing and Forms Manual. Sec. 5.3.52, p. 88, (Jun 7, 2024). (Accessed Jul. 2024).

Substance Use Disorder

SOURCE: VT Statutes Annotated, Title 8 Sec. 4100k(h), (Accessed Jul. 2023).

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Virgin Islands

Last updated 09/10/2024

Policy

No reference found.

Eligible Services/Specialties

No reference found.

Eligible

…

Policy

No reference found.

Eligible Services/Specialties

No reference found.

Eligible Providers

No reference found.

Eligible Sites

No reference found.

Geographic Limits

No reference found.

Facility/Transmission Fee

No reference found.

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Virginia

Last updated 12/18/2024

POLICY

The Board, subject to the approval of the Governor, …

POLICY

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.

SOURCE: VA Code Annotated Sec. 32.1-325, (Accessed Dec. 2024).

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 Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes, as defined by the American Medical Association (AMA), unless otherwise noted in Table 1 – Table 8 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 Managed Care Organization (MCO)-enrolled members, Providers must follow their respective contract with the MCO.

SOURCE: VA Dept. of Medical Assistant Svcs., Medicaid Provider Manual Supplement-Telehealth Services, (5/13/2024) (Accessed Dec. 2024).

ELIGIBLE SERVICES/SPECIALTIES

Attachment A lists covered services that may be reimbursed when provided via telehealth. Specifically:

Table 1 – Table 3 list Telemedicine services
Table 4 list Radiology-Related Procedures for Physician Billing Included under
Telehealth Coverage (store and forward)
Table 5 lists Remote Patient Monitoring services
Table 6 lists Virtual Check-In services
Table 7 and Table 8 lists audio-only telehealth services

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 Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes, as defined by the American Medical Association (AMA), unless otherwise noted in Table 1 – Table 8 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 Managed Care Organization (MCO)-enrolled members, Providers must follow their respective contract with the MCO. Additional information about the Medicaid MCO programs can be found at https://www.dmas.virginia.gov/for-providers/managed-care/cardinal-caremanaged-care/

Telemedicine and Audio-Only Telehealth

Services delivered via telemedicine or audio-only telehealth must be provided with the same standard of care as services provided in person.
Telemedicine or audio-only telehealth must not be used when in-person services are medically and/or clinically necessary. The distant Provider is responsible for determining that the service meets all requirements and standards of care. 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 or audio-only telehealth visit, the telemedicine or audio-only telehealth 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 member. In this circumstance, the Provider shall be reimbursed only for services successfully delivered.

Unless otherwise noted in Attachment A, limitations for services delivered via telehealth are the same as for those delivered in-person.

All coverage requirements for a particular covered service described in the DMAS Provider Manuals apply regardless of whether the service is delivered via telehealth or in-person.

Clinicians shall use their clinical judgment to determine the appropriateness of service delivery via telehealth considering the needs and presentation of each individual. See Attachment A for code lists.

Virtual Check-In

A Virtual Check-In is a brief patient-initiated asynchronous or synchronous communication and technology-based service intended to be used to decide whether an office visit or other service is needed.

Services must be patient-initiated.
Patients must be established with the provider practice.
Must not be billed if services originated from a related service provided within the previous 7 days or lead to a service or procedure within the next 24 hours or at the soonest available appointment.

SOURCE: VA Dept. of Medical Assistant Svcs., Medicaid Provider Manual Supplement-Telehealth Services, (5/13/24) & Updates to Telehealth Services Supplement Memo, May 13, 2024, (Accessed Dec. 2024).

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 Dec. 2024).

School-Based Services

The following school-based services may be provided via telemedicine: PT, OT, speech and language, behavioral 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, if a paid staff person is present in a supervisory capacity at the time of the service, the LEA may submit 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, (Jan. 12, 2024). (Accessed Dec. 2024).

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.

Telehealth visits may be used for face-to-face nutritional assessments.

NOTE: Home health visits for the sole purpose of performing a nutritional assessment for individuals whose conditions are stable and chronic in nature will not be covered under the home health program. Telehealth visits should be considered for these cases and for those who are not able to travel due to complex health conditions.

SOURCE: VA Dept. of Medical Assistant Svcs. Medicaid Provider Manual, Durable Medical Equipment and Supplies Manual, Covered Svcs. and Limitations, (10/24/24), (Accessed Dec. 2024).

Home Health

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 encounters by telephone or email.

SOURCE: VA Dept. of Medical Assistant Svcs. Home Health, Covered Services and Limitations, 8/28/24, p. 4. (Accessed Dec. 2024).

Opioid Treatment Services

“Face-to-face” means encounters that occur in person or through telehealth.

The substance use case management ISP shall be developed with the member, in consultation with the member’s family, as appropriate as defined in 12VAC30-130-5020. The ISP shall be completed within 30 calendar days of initiation of this service with the member in a person-centered manner and shall document the need for active substance use case management before such case management services can be billed. The ISP shall require a minimum of two distinct substance use case management activities being performed each calendar month and a minimum of one face-to-face client contact, which is separate from the required monthly activities, at least every 90 calendar days. These required face-to-face contacts can be delivered via telehealth.

Substance use case management shall include an active ISP which requires:

A minimum of two substance use case management service activities each month, that consist of two separate and distinct case management activities occurring on different days with the member, and
At least one face-to-face contact, separate from the two distinct activities per month minimum, with the member at least every 90 calendar days. The face-to-face contacts may be met delivered via telehealth.

Outpatient services: Services can be provided face-to-face or by telehealth according to DMAS Telehealth Supplemental manual.

Outpatient services (ASAM Level 1) shall include the following service components as medically necessary and indicated in the member’s ISP: …

Individual psychotherapy between the member and a CATP. Services provided face-to-face or by telemedicine shall qualify as reimbursable.

Intensive outpatient service providers shall meet the ASAM Level 2.1 service components. The following service components shall be assessed and monitored weekly and shall be provided in accordance to the ASAM Criteria, as directed by the member’s ISP and based on the member’s treatment needs identified in the multidimensional assessment. The provider must demonstrate the following service components in the member’s ISP as medically necessary, through provision of services or through referral: …

Requests for a psychiatric or a medical consultation shall be available within 24 hours of the requested consult by telephone and preferably within 72 hours of the requested consult in person or via telemedicine. Referrals to external resources are allowed in this setting;

Partial hospitalization (ASAM Level 2.5) service components shall include the following provided at least once weekly or as directed by the ISP and based on the member’s treatment needs identified in the multidimensional assessment: …

Psychiatric and medical formal agreements to provide medical consult within 8 hours of the requested consult by telephone, or within 48 hours in person or via telemedicine. Referrals to external resources are allowed in this setting;

In addition to the above, Partial Hospitalization Services (ASAM Level 2.5) co-occurring enhanced programs shall offer the following: …

Psychiatric services as appropriate to meet the member’s mental health condition. Services may be available by telephone and on site, or closely coordinated off site, or via telemedicine.
Clinical leadership and oversight and, at a minimum, capacity to consult with an addiction psychiatrist via telephone, telemedicine, or in person.

In addition to the Level 3.1 service components listed in this section, Clinically Managed Low Intensity Residential:

Programs for members who have both unstable substance use and psychiatric disorders including appropriate psychiatric services, medication evaluation and laboratory services. Such services are provided either on-site, via telemedicine, or closely coordinated with an off-site provider, as appropriate to the severity and urgency of the member’s mental health condition

Clinically managed population-specific high intensity residential services (ASAM Level 3.3) as defined in 12VAC30-130-5120 and 12VAC35-105-1590 to 1620, must have all the following service components through service provision or through referral:

Access to consulting physician or physician extender and emergency services 24 hours a day and seven days a week via telephone and in person.

Clinically managed high-intensity residential services (adult) and clinically managed medium-intensity residential services (adolescent) (ASAM Level 3.5) as defined in 12VAC30-130-5130 and 12VAC35-105-1530 to 1570, are residential treatment services which shall include through service provision or through referral:

Telephone or in-person consultation with a physician or physician-extender who shall be available to perform required physician services. Emergency services shall be available 24 hours per day and seven days per week.

Clinically managed high-intensity residential services (adult) and clinically managed medium-intensity residential services (adolescent) (ASAM Level 3.5) co-occurring enhanced programs shall include the services listed in this section in addition to psychiatric services (psychiatric evaluation and/or therapy individual, group, family), medication evaluation, and laboratory services which shall be available by telephone within eight hours of requested service and on-site or via telemedicine, or closely coordinated with an off-site provider within 24 hours of requested service, as appropriate to the severity and urgency of the member’s mental and physical condition. Level 3.5 cooccurring enhanced programs offer planned clinical activities designed to stabilize the member’s mental health problems and psychiatric symptoms, and to maintain such stabilization. Planned clinical activities shall be required and shall be designed to stabilize and maintain the member’s mental health problems and psychiatric symptoms.

A psychiatric assessment of the member shall occur within four hours of admission by telephone and within 24 hours following admission in person or via telemedicine, or sooner, as appropriate to the member’s behavioral health condition, and thereafter as medically necessary. A behavioral health-focused assessment at the time of admission shall be performed by a registered nurse or licensed mental health clinician. A licensed registered nurse or licensed practical nurse supervised by a registered nurse shall be responsible for monitoring the member’s progress and administering or monitoring the member’s self-administration of medications.

SOURCE: VA Dept. of Medical Assistance Svcs. Medicaid Provider Manual, Addiction and Recovery Treatment Services, Opioid Treatment Services/Medication Assisted Treatment, (1/10/24), (Accessed Aug. 2024).

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.

DMAS recognizes that there may be situations that telemedicine is necessary to engage the member in treatment and recovery, especially if the member makes this request. 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.

The Board of Medicine requires the prescriber to see the member weekly during the induction phase for prescribing MOUD … These visits shall be in-person/onsite however may be delivered through telemedicine based on the individual needs of the member to ensure access during this critical phase. The member must have documented clinical stability before spacing out visits beyond weekly. This applies to all members regardless of SUD diagnosis.

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.

Preferred OBAT and OTPs must include the following activities, which must be documented in each member’s record:

These visits shall be in-person/onsite however may be delivered through telemedicine based on the individual needs of the member to ensure access during this critical phase. The member must have documented clinical stability as defined earlier in this Supplement before spacing out visits beyond weekly. This applies to all members regardless of SUD diagnosis. The IPOC must be updated to reflect these changes.

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, [Memos/bulletins prior to 2020 need to be requested by email] (Accessed Dec. 2024).

Residential Treatment Services

DMAS reimburses for telemedicine services under limited circumstances. Refer to the Telehealth Services Supplement for additional information.

SOURCE: VA Dept. of Medical Assistance Svcs. Medicaid Provider Manual, Residential Treatment Services, Covered Services and Limitations, 11/26/24 (Accessed Dec. 2024).

Department of Behavioral Health and Developmental Services

A licensed psychiatrist or nurse practitioner shall be available to the program, either in person or via telemedicine, 24 hours per day, seven days per week;
One PRS, and either one QMHP (QMHP-A or QMHP-C) or one CSAC or CSAC-supervisee. A licensed staff member shall be required to be available via telemedicine for the assessment;
One CSAC-A, and either one QMHP (QMHP-A or QMHP-C) or one CSAC or CSAC-supervisee. A licensed staff member shall be required to be available via telemedicine for the assessment;
Two QMHPs (QMHP-A, QMHP-C, or QMHP-T; however, the team shall not be two QMHP-Ts). A licensed staff member shall be required to be available via telemedicine for the assessment;
Two CSACs. A licensed staff member shall be required to be available via telemedicine for the assessment; or
One QMHP (QMHP-A or QMHP-C), and one CSAC or CSAC-supervisee. A licensed staff member shall be required to be available via telemedicine for the assessment.

Crisis stabilization units shall meet the following staffing requirements:

A licensed psychiatrist or psychiatric nurse practitioner shall be available 24 hours per day, seven days per week either in person or via telemedicine

SOURCE: VA Admin Code Title 12, 35-105-1830, (Accessed Sept. 2024).

Comprehensive Crisis Services

“Telemedicine assisted assessment” means the in-person service delivery encounter by a QMHPA, QMHP-C, CSAC with synchronous audio and visual support from a remote LMHP, LMHPR, 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.

Mobile Crisis Response – Covered service components of Mobile Crisis Response include:

Assessment, including telemedicine assisted assessment

Providers conducting an assessment through telemedicine or a telemedicine assisted assessment must follow the requirements for the provision of telemedicine described in the “Telehealth Services Supplement” including the use of the GT modifier for units billed for assessments completed through telemedicine or a telemedicine assisted assessment. Mobile Crisis Response services are not eligible for originating site fee reimbursement. MCO contracted providers should consult with the contracted MCOs for their specific policies and requirements for telehealth.

23-Hour Crisis Stabilization Billing Requirements – 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 Billing Requirements – Psychiatric evaluations and individual, group and family therapy 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. 12 Appendix G: Comprehensive Crisis Services, 11/15/24, (Accessed Dec. 2024).

Comprehensive Needs Assessment

For information on whether a service assessment is required in-person or is allowed through telemedicine, refer to the service specific sections located in Appendices to this manual. A provider cannot use a Comprehensive Needs Assessment conducted through telemedicine as a Comprehensive Needs Assessment for a service that requires an in-person assessment. If a provider has a valid Comprehensive Needs Assessment that was conducted through telemedicine and later wants to use the assessment as a Comprehensive Needs Assessment for another service that requires an in-person assessment, the assessment update completed to recommend the service must be conducted in-person.

SOURCE: VA Dept. of Medical Assistant Svcs., Medicaid Provider Manual Mental health Services, Ch. 4, (11/15/24) & Updates to the Mental Health Services Manual, Memo, May 15, 2024, (Accessed Dec. 2024).

Developmental Disabilities Waivers

For therapeutic consultation behavioral services, direct therapy consists of the behavioral consultant implementing strategies with the individual that can only be accomplished while being physically present in the same environment as the individual and cannot be accomplished via telehealth modalities.

Providers may refer to the Telehealth Services Supplement for information on what percentage of the DD Waiver services can be billed via telehealth.

While Group Day services may be provided through telemedicine, not all allowable activities easily translate to a telemedicine model. The allowable activities noted with an asterisk are ones that may be applicable and may be incorporated into the ISP and the PFS along with an accompanying schedule depending on the individual’s specific needs and desired outcomes. Examples of ways to translate these activities into a telemedicine modality of service delivery follow the applicable allowable activity. Providers will only be permitted to perform through telehealth and bill for the allowable activities that are included in the regulations, appropriate to the individual, and included in the individual’s ISP and PFS.

• Interviewing the individual, family members, caregivers, and relevant others to identify issues to be addressed and desired outcomes of consultation either in-person or via telehealth platforms;

Assessing the individual’s need for an assistive device for a modification or adjustment of an assistive device, or both, in the environment or service, including reviewing documentation and evaluating the efficacy of assistive devices and interventions identified in the therapeutic consultation plan or services which may include some assessment elements conducive to telehealth platforms;

Training family/caregivers and other relevant persons to assist the individual in using an assistive device; to implement specialized, therapeutic interventions; or to adjust currently utilized support techniques which may (if appropriate) include some training elements conducive to telehealth platforms;

The delivery of In-home Supports via telehealth in the home setting is permitted in order to support individuals in remaining independent and ensure continuity of care, as well as increasing monitoring of vulnerable individuals’ health and safety. The following allowable activities followed by an asterisk are ones that may be applicable and may be incorporated into the Individual Support Plan (ISP) and the Plan for Supports (PFS) along with accompanying schedule depending on the individual’s specific needs and desired outcomes. Providers will only be permitted to perform through telehealth and bill for the allowable activities that are included in the regulations, appropriate to the individual, and included in the individual’s ISP and PFS.

Skill-building and routine supports related to ADLs and IADLs*;. Telehealth examples may include but are not limited to:

Talking the individual through and/or monitoring the performance of ADLs such as toothbrushing, hands and face washing, dressing, or IADLs such as meal preparation, laundry completion, and other housekeeping tasks.

Supporting the individual in replacing challenging behaviors with positive, accepted behaviors for home and community environments *Telehealth examples may include but are not limited to:

Observing the individual’s demeanor, behavior, mental state for signs of distress or inappropriate reactions
Talking the individual through ways to demonstrate positive, accepted behaviors when displaying challenging behavior and implementing the behavior support plan, as possible.

Monitoring the individual’s health and physical condition and providing routine and safety supports with medication or other medical needs*;. Telemedicine examples may include but are not limited to:

Observing the individual’s physical appearance for signs of deterioration or illness
Talking the individual through or observing self-administration of medications.

Providing general supports as needed*. Telemedicine examples may include but are not limited to:

Observing/monitoring/checking in with the individual to ensure he is where he is supposed to be and safe.
Assisting the individual to resolve any general issues he states he is experiencing.

SOURCE: VA Dept. of Medical Assistant Svcs., Medicaid Provider Manual DD Waivers, (10/10/24) (Accessed Dec. 2024).

PAP Supplement

Telehealth services will not be eligible for payment at this time. Any change will be announced in future editions of this supplement.

SOURCE: VA Dept. of Medical Assistant Svcs., Medicaid Provider Manual PAP Supplement, (7/3/24) (Accessed Dec. 2024).

Teledentistry

Teledentistry codes for synchronous and asynchronous encounters are listed as covered.

SOURCE: VA Dept. of Medical Assistant Svcs., DentaQuest, (6/2/23) (Accessed Dec. 2024).

Intensive Clinic Based Support

In addition to the required activities for all mental health services providers located in Chapter IV, the following required activities apply to MH-PHP: …

Initial medication evaluation must be conducted by the Psychiatrist, Nurse Practitioner, or Physician Assistant with the individual via in-person or telemedicine evaluation within 48 hours of admission.

SOURCE: VA Dept. of Medical Assistant Svcs., Medicaid Provider Manual Mental Health Services, Intensive Clinic Based Support, (11/22/21) (Accessed Dec. 2024).

Telehealth for Various Services:

Coverage of services delivered by telehealth are described in the “Telehealth Services Supplement”.

MCO contracted providers should consult with the contracted MCOs for their specific policies and requirements for telehealth.

SOURCE: VA Dept of Medical Assistance, Psychiatric Services, Ch. 4, [language used in multiple manuals], (2/23/24), (Accessed Dec. 2024).

Peer Services

Face-to-face services may be provided through telemedicine. Coverage of services delivered by telemedicine are described in the “Telehealth Services Supplement”. MCO contracted providers should consult with the contracted MCOs for their specific policies and requirements for telehealth.

SOURCE: VA Dept. of Medical Assistance Svcs., Medicaid Provider Manual Mental Health, Peer Services Supplement, (12/29/23) (Accessed Dec. 2024).

Intensive Community Based Support – Youth

Billing requirements state that: Coverage of services delivered by telehealth are described in the “Telehealth Services Supplement”. MCO contracted providers should consult with the contracted MCOs for their specific policies and requirements for telehealth.

SOURCE: VA Dept. of Medical Assistance Svcs., Medicaid Provider Manual Mental Health Services, Appendix D: Intensive Community Based Support – Youth, (5/15/24) (Accessed Dec. 2024).

ELIGIBLE PROVIDERS

For purposes of this manual supplement, 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.

Distant site Providers must include:

the modifier GT on claims for services delivered via telemedicine
the modifier 93 on claims for services delivered via audio-only telehealth.

CPT codes for activities that are not considered to be essentially in-person services per the CPT Manual do not require telehealth modifiers. Examples include codes used exclusively for audio-only delivery of services (see Table 7 in this supplement below).

Refer to the CPT Manual for additional guidance.

All coverage requirements for a particular covered service described in the DMAS Provider Manuals apply regardless of whether the service is delivered via telehealth or in-person.

Providers must maintain a practice at a physical location in the Commonwealth or be able to make appropriate referral of patients to a Provider located in the Commonwealth in order to ensure an in-person examination of the patient when required by the standard of care.

Providers must meet state licensure, registration or certification requirements per their regulatory board with the Virginia Department of Health Professions to provide services to Virginia residents via telemedicine. Providers shall contact DMAS Provider Enrollment (888-829-5373) or the Medicaid MCOs for more information.

No billing modifier is required on claims for the covered Virtual Check-In codes listed, in Table 6 of Attachment A.

Virtual Check-In services do not require service authorization.

Only physicians and other qualified health care professionals – previously defined by the American Medical Association as being an individual who by education, training, licensure/regulation, and facility privileging (when applicable) performs a professional service within his/her scope of practice and independently reports a professional service – may furnish and bill for Virtual Check-In services.

SOURCE: VA Dept. of Medical Assistant Svcs., Medicaid Provider Manual Supplement-Telehealth Services, (5/13/24) & Updates to Telehealth Services Supplement Memo, May 13, 2024, (Accessed Dec. 2024).

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: VA Dept. of Medical Assistance Services. Medicaid Provider Manual, Mental Health Services, Ch. 12 Appendix G: Comprehensive Crisis Services, 11/15/24, (Accessed Dec. 2024).

Residential Treatment Services – IACCT Appendix

The LMHP, LMHP-R, LMHP-RP or LMHP-S will assess the youth (expedited, if possible) through either a face-to-face or telemedicine contact. For youth who are currently in an inpatient setting where telemedicine is not available and distance is a barrier for the IACCT LMHP, LMHP-R, LMHP-RP or LMHP-S, a telephonic interview with the youth may be conducted while the IACCT LMHP, LMHP-R, LMHP-RP or LMHP-S conducts a face to face with the legal guardian.

SOURCE: VA Dept. of Medical Assistance Services. Medicaid Provider Manual, Residential Treatment Services – IACCT, 11/26/24, (Accessed Dec. 2024).

ELIGIBLE SITES

“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 Dec. 2024).

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).

Providers must use the place of service code that reflects the originating site:

POS 02 – used for telehealth services when the originating site is other than the member’s home
POS 10 – used for telehealth services when the originating site is the member’s home

SOURCE: VA Dept. of Medical Assistant Svcs., Medicaid Provider Manual Supplement-Telehealth Services, (5/13/24) & Updates to Telehealth Services Supplement Memo, May 13, 2024, (Accessed Dec. 2024).

For the purposes of this subdivision, “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

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 pursuant to Title XIX of the United States Social Security Act and any amendments thereto. The Board shall include in such plan: …

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.
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.

SOURCE: VA Code Annotated Sec. 32.1-325, (Accessed Dec. 2024).

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-servicecodes/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,(12/29/23), (Accessed Dec. 2024).

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 can be received (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.

Originating site fee guidance specific to emergency ambulance transport providers is contained in the Transportation manual (Chapter 5).

Originating site Providers, such as hospitals and nursing homes, submitting UB04/CMS-1450 claim forms, must include the appropriate telemedicine revenue code of 0780 (“Telemedicine-General”) or 0789 (“Telemedicine-Other”).

SOURCE: VA Dept. of Medical Assistant Svcs., Medicaid Provider Manual Supplement-Telehealth Services, (5/13/24) (Accessed Dec. 2024).

Reference the “DMAS Telehealth Manual Supplement” for additional details on DMAS’s requirements for telemedicine.

SOURCE: VA Dept. of Medical Assistant Svcs. Medicaid Provider Manual, Local Education Agency Provider Manual, Covered Svcs. and Limitations, (1/12/24), (Accessed Dec. 2024).

The National Provider Identifier (NPI) of a DMAS-enrolled ordering, referring or prescribing (ORP) provider must be included on interim claims as a referring provider for school-based services, with the exemptions listed in the next bullet. This includes claims for the telehealth originating site facility fee (Q3014)*.

The modifier “GT” must be used for billing services delivered via telehealth.

The services of a school employee supervising the student during a telehealth session must be billed using procedure code, Q3014.

SOURCE: VA Local Education Manual, Billing Instructions, (9/17/24), (Accessed Dec. 2024).

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.

Medication Assisted Treatment (MAT) – Outpatient Settings – non OTP/OBAT Settings

The telehealth originating site facility fee is not authorized.

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.

SOURCE: VA Code Annotated Sec. 32.1-325, (Accessed Dec. 2024).

Emergency ambulance transportation providers 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.

SOURCE: Medicaid Memo: Reimbursement for a Telemedicine Originating Site Fee for Emergency Ambulance Transport Providers. Oct. 3, 2022. (Accessed Dec. 2024).

READ LESS

Washington

Last updated 06/19/2024

POLICY

Washington Health Care Authority (HCA) reimburses medically necessary covered …

POLICY

Washington Health Care Authority (HCA) reimburses medically necessary covered services through telemedicine when the service is provided by a Washington Apple Health provider and is within their scope of practice. The payment amount for the professional service provided through telemedicine by the provider at the distant site is equal to the current fee schedule amount for the service provided.

SOURCE: WA State Health Care Authority. Medicaid Telemedicine Policy and Billing Guide, p. 18-19 (Jun. 2024). (Accessed Jun. 2024).

The medicaid agency determines the health care services that may be paid for when provided through telemedicine or store and forward technology as authorized by state law, including RCW 71.24.335, 74.09.325, and 74.09.327.

The agency’s designee, including an agency-contracted managed care entity (managed care organization (MCO) or behavioral health administrative services organization (BH-ASO)), pays providers for health care services delivered through telemedicine or store and forward technology in the same amount as when the health care services are provided in person, except as provided in these rules, RCW 71.24.335, and 74.09.325.

SOURCE: WAC 182-501-0300(3)(a) & 5(a). (Accessed Jun. 2024).

Managed Care

All managed care organizations contracted with the authority for the medicaid program shall reimburse a provider for a health care service provided to a covered person through telemedicine or store and forward technology if:

The managed care organization in which the covered person is enrolled provides coverage of the health care service when provided in person by the provider;
The health care service is medically necessary;
The health care service is a service recognized as an essential health benefit under section 1302(b) of the federal patient protection and affordable care act in effect on January 1, 2015;
The health care service is determined to be safely and effectively provided through telemedicine or store and forward technology according to generally accepted health care practices and standards, and the technology used to provide the health care service meets the standards required by state and federal laws governing the privacy and security of protected health information; and
Beginning January 1, 2023, for audio-only telemedicine, the covered person has an established relationship with the provider.

A managed health care system shall reimburse a provider for a health care service provided to a covered person through telemedicine the same amount of compensation the managed health care system would pay the provider if the health care service was provided in person by the provider.

Hospitals, hospital systems, telemedicine companies, and provider groups consisting of eleven or more providers may elect to negotiate an amount of compensation for telemedicine services that differs from the amount of compensation for in-person services.

A managed health care system may subject coverage of a telemedicine or store and forward technology health service under subsection (1) of this section to all terms and conditions of the plan in which the covered person is enrolled including, but not limited to, utilization review, prior authorization, deductible, copayment, or coinsurance requirements that are applicable to coverage of a comparable health care service provided in person.

SOURCE: RCW 74.09.325 . (Accessed Jun. 2024).

Behavioral Health Services

Upon initiation or renewal of a contract with the authority, behavioral health administrative services organizations and managed care organizations shall reimburse a provider for a behavioral health service provided to a covered person through telemedicine or store and forward technology if:

The behavioral health administrative services organization or managed care organization in which the covered person is enrolled provides coverage of the behavioral health service when provided in person by the provider;
The behavioral health service is medically necessary; and
Beginning January 1, 2023, for audio-only telemedicine, the covered person has an established relationship with the provider.

SOURCE: RCW 71.24.335 (Accessed Jun. 2024).

If the service is provided through store and forward technology there must be an associated visit between the covered person and the referring provider. Nothing in this section prohibits the use of telemedicine for the associated office visit.

SOURCE: RCW 71.24.335. (Accessed Jun. 2024).

ELIGIBLE SERVICES/SPECIALTIES

The agency reimburses medically necessary covered services through telemedicine when the service is provided by a Washington Apple Health (Medicaid) provider and is within their scope of practice.

Submit claims for telemedicine services using the appropriate CPT® or HCPCS code for the professional service. Use place of service (POS) 02 or 10 to indicate that a billed service was furnished as a telemedicine service from a distant site.

When billing with POS 02 or 10:

Add modifier 95 if the distant site is designated as a nonfacility.

Nonfacility providers must add modifier 95 to the claim to distinguish them from facility providers and ensure that they receive the nonfacility rate.

For licensed behavioral health agencies (BHA)—Using modifier 95 and distinguishing between facility/nonfacility are not applicable for behavioral health providers who use the following guides: Service encounter reporting instructions (SERI) guide; Mental health billing guide (Part 2); Substance use disorder (SUD) billing guide

For health homes—Modifier 95 is not applicable to health home providers.

HCA discontinued the use of modifier GT for claims submitted for professional services (services billed on a CMS-1500 claim form, when submitting paper claims). Distant site practitioners billing for telemedicine services under the Critical Access Hospital (CAH) optional payment method must use modifier GT.

SOURCE: WA State Health Care Authority. Medicaid Telemedicine Policy and Billing Guide, p. 18-20 (Jun. 2024). (Accessed Jun. 2024).

Health care services that are authorized to be provided through telemedicine or store and forward technology are identified in the agency’s provider guides and fee schedules. The agency determines the health care services that may be provided through telemedicine or store and forward technology based on whether the health care service is:

A covered service when provided in person by the provider;
Medically necessary;
Determined to be safely and effectively provided through telemedicine or store and forward technology based on generally accepted health care practices and standards; and
Provided through a technology that meets the standards required by state and federal laws governing the privacy and security of protected health information.

SOURCE: WAC 182-501-0300(3)(d). (Accessed Jun. 2024).

School Based Services

HCA covers telemedicine when it is used to substitute for an in-person, face-to-face, hands-on encounter for only those services specifically listed in this billing guide. For a school district to receive reimbursement for telemedicine, the provider furnishing services must be enrolled as a servicing provider under the school district’s ProviderOne account. Services provided by nonlicensed school staff must be billed under the supervising provider’s NPI in ProviderOne. School districts are reimbursed for services provided through telemedicine at the same rate as if the service was provided in person.

To indicate that the service was provided through HIPAA-compliant audio/visual telemedicine, school districts must submit claims for telemedicine services using either place of service (POS) 02 or POS 10 and enter modifier 95 on any claims for services provided through audio/visual telemedicine. When billing for telemedicine through the SBHS program, the school district always submits a claim on behalf of both the originating and distant site.

Telemedicine claims must include one of the following modifiers based on the platform used to deliver the service: 93 or 95.

SOURCE: WA State Health Care Authority, Medicaid Provider Guide, School-Based Health Services, p. 35-38 (Oct. 2023). (Accessed Jun. 2024).

Applied Behavior Analysis (ABA)

Applied Behavior Analysis (ABA) services delivered using telemedicine may be reimbursed by HCA when billed in accordance with the rules regarding telemedicine and store-and-forward technology as outlined in WAC 182-501-0300 and HCA’s published billing instructions for ABA and telemedicine services.

The LBA may use telemedicine to supervise the CBT’s delivery of ABA services to the client, the family, or both. LBAs who use telemedicine are responsible for determining if telemedicine can be performed without compromising the quality of the caregiver training, or the outcome of the ABA therapy treatment plan.

See manual for eligible service codes.

SOURCE: WA State Health Care Authority, Medicaid Provider Guide, Applied Behavior Analysis, p. 36 (Jul. 2024). (Accessed Jun. 2024).

Applied behavior analysis (ABA) services delivered using telemedicine may be reimbursed by the agency when billed in accordance with the rules regarding telemedicine and store-and-forward technology in WAC 182-501-0300 and the agency’s published billing instructions.

SOURCE: WAC 182-531A-1200. (Accessed Jun. 2024).

Effective for dates of service on and after October 1, 2023, some services provided as part of an early childhood intensive behavioral intervention day treatment program (CPT® code H2020) may occur via synchronous, audio-visual telemedicine. Speech and language pathology services must occur face-to-face, either in-person or via audio-visual telemedicine.

Additionally, a minimum of 2 caregiver training sessions must occur in-person and additional sessions may occur either in-person or via audio-visual telemedicine. Supervision of Certified Behavior Technicians (CBTs) may occur via audio-visual telemedicine; however, a Lead Behavior Analysis Therapist (LBAT) is required to be on-site for all hours the day treatment program is in session.

SOURCE: WA State Health Care Authority Provider Bulletin (Sept. 2023). (Accessed Jun. 2024).

Teledentistry

Teledentistry can be delivered through a synchronous or asynchronous method. The agency covers teledentistry as a substitute for an in-person, face-to-face, hands-on encounter when medically necessary, within the scope of practice of the performing agency-contracted providers, and Department of Health teledentistry guidelines.

A dentist or authorized dental provider may delegate allowable tasks to Washington State Registered Dental Hygienists and Expanded Function Dental Assistants through teledentistry. Delegation of tasks must be under general supervision. Teledentistry does not meet the definition of close supervision.

See manual for acceptable CPT codes.

SOURCE: WA State Health Care Authority, Medicaid Provider. Dental-Related Services, p. 74-75. (Apr. 2024). (Accessed Jun. 2024).

Behavioral Health Services

To bill for outpatient behavioral health services via telemedicine, see the appropriate billing guidance to report the service modality/procedure code (CPT® or HCPC code) consistent with the instructions on the telemedicine page in the Service Encounter Reporting Instructions (SERI), or Part I or Part II of HCA’s Mental Health Services Billing Guide.

SOURCE: WA State Health Care Authority, Medicaid Behavioral Health Policy and Billing FAQ, p. 2. (Oct. 2023). (Accessed Jun. 2024).

Drug monitoring must be provided during an in-person visit with the client, unless it is part of a qualified telemedicine visit.

SOURCE: WA State Health Care Authority, Medicaid Provider. Mental Health Services, p. 47. (Apr. 2024). (Accessed Jun. 2024).

Home Health Services

The face-to-face encounter requirements of this section may be met using telemedicine services.

SOURCE: WA Admin Code 182-551-2040. (Accessed Jun. 2024).

Home Health and Hospice

Certain supervisory visits may be conducted on-site, via telemedicine, or via audio-only telemedicine and must be conducted by a licensed nurse or licensed therapist in accordance with the appropriate practice acts. A supervisory visit conducted via audio-only telemedicine is only permitted for patients that have an established relationship with the provider consistent with WAC 246-335-510(8). A supervisory visit conducted via telemedicine or via audio-only telemedicine may not be used to fulfill the annual performance evaluations and on-site observation of care and skills requirements in WAC 246-335-525(16).

SOURCE: WAC 246-335-545 & WAC 246-335-645. (Accessed Jun. 2024).

Comprehensive assessment and care planning for persons living with cognitive impairment

Face-to-face visits via an in-person or audio-visual encounter are allowed, but HCA does not allow telephonic and email encounters.

SOURCE: WA State Health Care Authority, Medicaid Provider Guide, Physician-Related Svcs./Health Care Professional Svcs., p. 80 (Apr. 2024). (Accessed Jun. 2024).

Abortion

Medical abortion services provided via telemedicine to a client who does not receive ultrasound(s) and laboratory studies from the medical abortion provider are not eligible for the HCPCS S0199 bundled payment.

SOURCE: WA State Health Care Authority, Medicaid Provider Guide, Physician-Related Svcs./Health Care Professional Svcs., p. 240 (Apr. 2024). (Accessed Jun. 2024).

Prenatal Genetic Counseling

Medicaid covers prenatal genetic counseling via in-person or audio-visual telemedicine encounters.

SOURCE: WA State Health Care Authority, Medicaid Provider Guide, Physician-Related Svcs./Health Care Professional Svcs., p. 208 (Apr. 2024). (Accessed Jun. 2024).

Obstetrical Services

HCA allows obstetrical services to be provided via telemedicine. When billing for audio-visual telemedicine, use the place of service (POS) relevant to the service provided on the date of service or the last date of service for a global or bundled code. For example:

If the service was provided in-person in an office setting, use POS 11 (office).
If the service was provided via audio-visual telemedicine, use either POS 02 (telehealth) or 10 (telehealth provided in patient home), whichever is appropriate
If the service was provided via audio-only telemedicine, refer to HCA’s Telemedicine policy and billing document

SOURCE: WA State Health Care Authority, Medicaid Provider Guide, Physician-Related Svcs./Health Care Professional Svcs., p. 236 (Apr. 2024). (Accessed Jun. 2024).

Maternal Support Services (MSS)

MSS clients may be eligible for telemedicine. Infant case management (ICM) clients and their parents may be eligible for telemedicine. Refer to HCA’s Provider billing guides and fee schedules webpage, under Telehealth, for more information.

SOURCE: WA State Health Care Authority, Maternity Support Services and Infant Case Management Billing Guide, p. 9-10 (Oct. 2023). (Accessed Jun. 2024).

Physical Therapy, Occupational Therapy, and Speech Therapy Services

HCA pays for evaluation, re-evaluation, and treatment of some physical therapy (PT), occupational therapy (OT), and speech therapy (ST) services when provided via audio-visual telemedicine. HCA pays for telehealth services for PT, OT, or ST when provided via audio-visual telemedicine and billed with specific procedure codes if clinically appropriate as determined by the practitioner, per standard of care. Services delivered by synchronous audio-visual technology may require participation of a caregiver to assist with the treatment. Providers are responsible for making this determination and ensuring there is appropriate assistance or supervision, or both.

SOURCE: WA State Health Care Authority, Neurodevelopmental Centers Billing Guide, p. 13 (Oct. 2023). (Accessed Jun. 2024).

Federally Qualified Health Center (FQHC)

A face-to-face or telemedicine (including audio-only telemedicine) visit between an encounter eligible client and an FQHC provider who exercises independent judgment when providing services that qualify for encounter rate reimbursement.

SOURCE: WA State Health Care Authority, Medicaid Provider Guide, Federally Qualified Health Centers, p. 9 (Apr. 2024). (Accessed Jun. 2024).

Rural Health Clinic (RHC)

A face-to-face or telemedicine (including audio-only telemedicine) visit between an encounter-eligible client and an RHC provider who exercises independent judgment when providing services that qualify for encounter rate reimbursement.

SOURCE: WA State Health Care Authority, Medicaid Provider Guide, Rural Health Clinics, p. 8. (Apr. 2024). (Accessed Jun. 2024).

ELIGIBLE PROVIDERS

RHCs & FQHCs

RHCs & FQHCs are authorized to serve as an originating site for telemedicine services. RHCs and FQHCs may receive the encounter rate when billing as a distant site provider if the service being billed is encounter eligible. Clients enrolled in an agency-contracted MCO must contact the MCO regarding whether or not the plan will authorize telemedicine coverage.

SOURCE: WA State Health Care Authority, Medicaid Provider Guide, Rural Health Clinics, p. 48, (Apr. 2024); Federally Qualified Health Centers, p. 64-65. (Apr. 2024). (Accessed Jun. 2024).

School Based Health Care Services

Under the SBHS program, HCA pays for services provided through telemedicine as outlined in this billing guide. Licensed providers, licensed assistants, compact license holders, interim permit holders, and nonlicensed school staff practicing under the supervision of a licensed provider may provide SBHS through telemedicine.

In order for a school district to receive reimbursement for telemedicine, the provider furnishing services must be enrolled as a servicing provider under the school district’s ProviderOne account. Services provided by nonlicensed school staff must be billed under the supervising provider’s NPI in ProviderOne.

SOURCE: WA State Health Care Authority, Medicaid Provider Guide, School-Based Health Services, p. 35 (Oct. 2023). (Accessed Jun. 2024).

Tribal Health Program

An encounter can be conducted face-to-face or via real-time telemedicine.

SOURCE: WA State Health Care Authority, Tribal Health Billing Guide, p. 20 (Jun. 2024). (Accessed Jun. 2024).

Kidney Centers and Ambulatory Surgery Centers

For kidney centers or ambulatory surgery centers to bill for telemedicine services, either the client or the provider must be physically present at the facility at the time the service was rendered.

SOURCE: WA State Health Care Authority. Medicaid Telemedicine Policy and Billing Guide, p. 18 (Jun. 2024). (Accessed Jun. 2024).

ELIGIBLE SITES

An originating site and a distant site must be located within the continental United States, Hawaii, District of Columbia, or any United States territory (e.g., Puerto Rico). Specific documentation requirements apply to both originating and distant sites. See the Telemedicine Policy and Billing Guide for more information.

SOURCE: WA State Health Care Authority. Medicaid Telemedicine Policy and Billing Guide, p. 16-18 (Jun. 2024). (Accessed Jun. 2024).

Managed Care

The following are eligible originating sites.

Hospital;
Rural health clinic;
Federally qualified health center;
Physician’s or other health care provider’s office;
Licensed or certified behavioral health agency;
Skilled nursing facility;
Home or any location determined by the individual receiving the service; or
Renal dialysis center, except an independent renal dialysis center.

SOURCE: RCW 74.09.325. (Accessed Jun. 2024).

School-Based Health Care Services (SBHS)

The school district must submit a claim on behalf of both the originating and distant site. The location of the student and provider must be documented. The SBHS program allows the following approved originating sites:

The school
The home, daycare, or any location determined appropriate by the students or parents

See manual for specific scenarios and appropriate modifiers.

SOURCE: WA State Health Care Authority, Medicaid Provider Guide, School Based Health Care Services, p. 36-37 (Oct. 2023). (Accessed Jun. 2024).

Applied Behavior Analysis (ABA) Services

For the purposes of ABA services, an originating site is:

For therapy, where the client is located.
For caregiver training, where the caregiver is located.

The distant site is the physical location where the lead behavior analysis therapist (LBAT) is located during the telemedicine session. If a separately identifiable service for the client is performed on the same day as the telemedicine service, documentation for both services must be clearly and separately identified in the client’s medical record.

SOURCE: WA State Health Care Authority, Medicaid Provider Guide, Applied Behavior Analysis, p. 36 (Jul. 2024). (Accessed Jun. 2024).

GEOGRAPHIC LIMITS

A managed health care system may not distinguish between originating sites that are rural and urban in providing the coverage required in subsection (1) of this section.

SOURCE: RCW 74.09.325 (Accessed Jun. 2024).

An originating site and a distant site must be located within the continental United States, Hawaii, District of Columbia, or any United States territory (e.g., Puerto Rico).

SOURCE: WA State Health Care Authority. Medicaid Telemedicine Policy and Billing Guide, p. 17-18 (Jun. 2024), WAC 182-501-0300(7)(a). (Accessed Jun. 2024).

FACILITY/TRANSMISSION FEE

Originating sites that are enrolled with HCA to provide services to HCA clients and bill HCA may be paid a facility fee for infrastructure and client preparation. Originating site facility fees are not paid for audio-only or store-and-forward telemedicine services.

Facility fees are available for originating sites, except hospitals (inpatient services), skilled nursing facilities, homes or other locations receiving payment for the client’s room and board. HCA does not pay an originating site facility fee if the site is part of the same entity as the distant site or if the provider is employed by the same entity as the distant site, nor does HCA pay an originating site facility fee to the client in any setting.

Eligible originating sites explicitly listed for the facility fee include:

Hospital outpatient
Critical access hospitals
FQHCs and RHCs
Physicians or other health professional office
Other setting

See manual for specific billing instructions for each.

SOURCE: WA State Health Care Authority. Medicaid Telemedicine Policy and Billing Guide, p. 17-18 (Jun. 2024) & WAC 182-501-0300(7). (Accessed Jun. 2024).

A hospital that is an originating site or distant site for audio-only telemedicine may not charge a facility fee.

SOURCE: RCW 70.41.530. (Accessed Jun. 2024).

Managed Care

The following eligible originating sites (besides #7) can charge a facility fee for infrastructure and preparation of the patient.

Hospital;
Rural health clinic;
Federally qualified health center;
Physician’s or other health care provider’s office;
Licensed or certified behavioral health agency;
Skilled nursing facility;
Home or any location determined by the individual receiving the service; or
Renal dialysis center, except an independent renal dialysis center.

Reimbursement for a facility fee must be subject to a negotiated agreement between the originating site and the managed care organization. A distant site, a hospital that is an originating site for audio-only telemedicine, or any other site not identified in subsection (3) of this section may not charge a facility fee.

SOURCE: RCW 74.09.325. (Accessed Jun. 2024).

FQHCs/RHCs

FQHCs and Rural Health Clinics that serve as an originating site for telemedicine services are paid an originating site facility fee. Charges for the originating site facility fee may be included on a claim, but the originating site facility fee may not be included on the cost report.

SOURCE: WA State Health Care Authority, Medicaid Provider Guide Rural Health Clinics, p. 48 (Apr. 2024) & Federally Qualified Health Centers, p. 64-65 (Apr. 2024). (Accessed Jun. 2024).

School-Based Health Care Services (SBHS)

To receive payment for the telemedicine fee (HCPCS code Q3014), the student must be located at the school and a corresponding procedure code must be billed for the same date of service. Treatment notes must clearly reflect when services were provided through telemedicine. HCA does not reimburse for the telemedicine facility fee for audio-only services.

SOURCE: WA State Health Care Authority, Medicaid Provider Guide, School Based Health Care Services, p. 39 (Oct. 2023). (Accessed Jun. 2024).

Abortion

When telemedicine is used to provide HCPCS S0199 bundled services, HCA does not pay any additional originating facility fees.

SOURCE: WA State Health Care Authority, Medicaid Provider Guide, Physician-Related Svcs./Health Care Professional Svcs., p. 240 (Apr. 2024). (Accessed Jun. 2024).

Tribal Health

The telemedicine facility fee (HCPCS code Q3014) is not included in the encounter rate, but it is payable separately from the encounter rate at the applicable rate in the fee schedule. The telemedicine facility fee must be billed on a separate claim from the encounter claim to avoid including the item in the encounter payment.

SOURCE: WA State Health Care Authority, Tribal Health Billing Guide, p. 21-22 (Jun. 2024). (Accessed Jun. 2024).

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West Virginia

Last updated 11/07/2024

TEMPORARY POLICY

Ongoing Telehealth Medicaid Flexibilities until December 31, 2024:…

TEMPORARY POLICY

Ongoing Telehealth Medicaid Flexibilities until December 31, 2024:

As noted in a 2023 WV Medicaid Provider Newsletter, with the end of the federal Public Health Emergency (PHE), the Centers for Medicare and Medicaid Services (CMS) have extended telehealth flexibilities until December 31, 2024. West Virginia Medicaid and the WVCHIP will also continue to follow CMS in allowing Telehealth flexibilities until this date.

For more information on WV Medicaid COVID Telehealth Policies, see the Medicaid memos located on the WV Medicaid COVID-19 Telehealth Website. In addition, in August 2023 WV Medicaid added an appendix to its Practitioners Services Medicaid Policy Manual Telehealth Section with available codes specific to the PHE Medicaid Telehealth Services Flexibilities – see Policy 519.17 Appendix B.

PERMANENT POLICY

The Medicaid plan, which issues, renews, amends, or adjusts a plan, policy, contract, or agreement on or after July 1, 2021, shall provide reimbursement for a telehealth service at a rate negotiated between the provider and the insurance company for virtual telehealth encounters. The Medicaid plan, which issues, renews, amends, or adjusts a plan, policy, contract, or agreement on or after July 1, 2021, shall provide reimbursement for a telehealth service for an established patient, or care rendered on a consulting basis to a patient located in an acute care facility whether inpatient or outpatient on the same basis and at the same rate under a contract, plan, agreement, or policy as if the service is provided through an in-person encounter rather than provided via telehealth.

SOURCE: WV Statute Sec. 9-5-28. (Accessed Nov. 2024).

To utilize Telehealth, providers must document that the service was rendered under that modality. When filing a claim, the provider must bill the service code with Place of Service code 02 or 10. West Virginia Medicaid covers and reimburses Telehealth services that are identified in designated policies as appropriate to be rendered through this modality.

West Virginia Medicaid does not limit Telehealth services to members in non-metropolitan statistical professional shortage areas as defined by the Centers for Medicare and Medicaid Services (CMS) Telehealth guidance.

SOURCE: WV Dept. of Health and Human Svcs. Medicaid Provider Manual, Chapter–519.17 Practitioner Services: Telehealth Services, p. 2 (Effective Jan. 1, 2022). (Accessed Nov. 2024).

Effective January 1, 2022, the CMS added place of service 10 – telehealth provided in a patient’s home. This is a location other than a hospital or other facility where the patient receives care in a private residence. The patient is in their home when receiving health services or health related services through telecommunication technology. Place of service 02 will still be utilized for telehealth provided other than in the patient’s home.

SOURCE: WV Dept. of Health and Human Svcs. Medicaid Provider Newsletter, Qtr. 1 2022, p. 6. (Accessed Nov. 2024).

Federally Qualified Health Center and Rural Health Clinic Services:

The member must be able to see and interact with the off-site provider at the time services (“real-time not delayed”) are provided via telehealth. Services provided via videophone or webcam are not covered.

SOURCE: WV Dept. of Health and Human Svcs. Medicaid Provider Manual, Chapter 522.8 Federally Qualified Health Center and Rural Health Clinic Svcs. P. 9. (July 1, 2019). (Accessed Nov. 2024).

ELIGIBLE SERVICES/SPECIALTIES

See the applicable chapters of the WV BMS Policy Manual for more detail on specific services, including whether telehealth is an accepted modality to render the service. If not indicated as available, telehealth should be considered a non-covered modality to render the service.

See Chapter 519 Practitioners Services Policy 519.17 Appendix A for Medicaid Telehealth Standard Codes.

SOURCE: WV Dept. of Health and Human Svcs. Medicaid Provider Manual, Chapter–519.17 Practitioner Services: Telehealth Services., p. 3 (Effective Jan. 1, 2022). (Accessed Nov. 2024).

School-based health services manual refers to the Telehealth Chapter (519.17) of the practitioner manual, and lists under each code in the manual whether or not it is eligible for telehealth.

SOURCE: WV Dept. of Health and Human Svcs. Medicaid Provider Manual, Chapter–538 School-Based Health Services. Revised Aug. 1, 2019, (Accessed Nov. 2024).

The West Virginia Bureau for Medical Services encourages providers that have the capability to render services via Telehealth to allow easier access to services for WV Medicaid Members. To utilize Telehealth providers will need to document that the service was rendered under that modality. When filing a claim the Provider will bill the service code with a GT Modifier. Each service in this manual is identified as “Available” or “Not Available” for Telehealth. Some services codes give additional instruction and/or restriction for Telehealth as appropriate. See manuals for additional details.

SOURCE: WV Dept. of Health and Human Svcs., Medicaid Provider Manual, Chapter 523: Targeted Case Management, p. 6. (Jul. 1, 2016), WV Dept. of Health and Human Service Medicaid Provider Manual, Chapter—503.12 Licensed Behavioral Health Center Services (Jul. 15, 2018); 504.10 Substance Use Disorder Services (Jan. 1, 2023); 521.9 Behavioral Health Outpatient Services (Jan. 15, 2018); Children with Serious Emotional Disorder Waiver (July 1, 2021). (Accessed Nov. 2024).

Manual on Children with Serious Emotional Disorder Waiver refers to the Telehealth Chapter (519.17) of the practitioner manual, and lists under each code in the manual whether or not it is eligible for telehealth.

Many services, including Child and Family Team (CFT) meetings, can be provided via telehealth (i.e., video conferencing). This delivery method is reimbursable, for the wraparound facilitator, as it is considered a face-to-face meeting. In extenuating circumstances, plan of care (POC) members may participate by teleconferencing (i.e., telephone). Team members may not bill for the time spent in the POC, and the wraparound facilitator must note on the signature sheet that they attended by phone. The wraparound facilitator must obtain signatures within 10 days for any POC member who attended the meeting via telehealth or teleconference and must forward copies of the POC to all participating CFT members and the managed care organization (MCO) Care Manager within 14 days of the meeting. If the clinical record does not include a valid signature page with required signatures, in ink or in an electronic documentation system, the service plan will be invalid, and subsequently, no services provided under its auspices will be billable. Please see Chapter 519.17, Telehealth Services for more information on telehealth requirements.

SOURCE: WV Dept. of Health and Human Svcs. Medicaid Provider Manual, Ch. 502 Children with Serious Emotional Disorder Waiver, 7/1/21, Pg. 33. (Accessed Nov. 2024).

Diabetes self-management programs may offer telehealth education when resources are limited, and may otherwise communicate by telephone when patients lack access to broadband internet.

SOURCE: WV Rule Sec. 64-115-3, (Accessed Nov. 2024).

For therapeutic leave/pass, the psychiatric residential treatment facilities must make therapy services available for the member (individual or family sessions) either in-person or via telehealth.

SOURCE: WV BMS Provider Manual, Chapter 531 Psychiatric Residential Treatment Facility Services (Jan. 1, 2023), p. 34. (Accessed Nov. 2024).

Office-Based Medication Assisted Treatment Programs

Counseling sessions may be conducted via telehealth. Counseling sessions are defined as a face-to-face interaction, which may include telehealth, in a private location between a patient(s) and a primary counselor for a period of no less than 30 continuous minutes designated to address patient substance use disorder issues or coping strategies and individualized treatment plan of care.

SOURCE: WV Rule Sec. 69-12-2 & 23. (Accessed Nov. 2024).

Partial Hospitalization

Telehealth services delivered in the Partial Hospitalization Programs must align with the Telehealth policy in Chapter 503, Licensed Behavioral Health Center (LBHC) Services unless otherwise described. Medicaid will reimburse according to the fee schedule for services provided.

SOURCE: WV Dept. of Health and Human Svcs, Partial Hospitalization Program, Chapter 510, p. 6 (Jan. 1, 2024). (Accessed Nov. 2024).

ELIGIBLE PROVIDERS

Authorized distant site providers include:

Physicians;
Podiatrists;
Physician Assistants (PA);
Advanced Practice Registered Nurses (APRN)/Nurse Practitioners (NP)
Certified Nurse Midwife (CNM);
Clinical Nurse Specialists (CNS);
Community Mental Health Center (CMHC);
Licensed Behavioral Health Center (LBHC);
Licensed Psychologists (LP) and Supervised Psychologist (SP);
Licensed Independent Clinical Social Worker (LICSW); and
Licensed Professional Counselor (LPC)

SOURCE: WV Dept. of Health and Human Svcs. Medicaid Provider Manual, Chapter–519.17.1 Practitioner Services: Telehealth Services. (Effective Jan. 1, 2022) p. 2-3. (Accessed Nov. 2024).

FQHC and RHC may only serve as a distant site for Telehealth services provided by a psychiatrist or psychologist and are reimbursed at the encounter rate.

The distant-site practitioner must bill the appropriate Current Procedural Technology/Healthcare Common Procedure Coding System (CPT/HCPCS) code with the appropriate Place of Service (02). The GT modifier is no longer required to be billed with the service code. Effective January 1, 2022, Telehealth provided in a patient’s home will require the appropriate Place of Service code 10.

SOURCE: WV Dept. of Health and Human Svcs. Medicaid Provider Manual, Chapter–519.17 Practitioner Services: Telehealth Services., p. 3 (Effective Jan. 1, 2022); WV Dept. of Health and Human Svcs. Medicaid Provider Manual, Chapter 522 Federally Qualified Health Center and Rural Health Clinic Svcs. P. 9. (Jul. 1, 2019). (Accessed Nov. 2024).

Medication-Assisted Treatment Program Licensing Act

A practitioner providing medication-assisted treatment may perform certain aspects of telehealth if permitted under his or her scope of practice.

SOURCE: WV Code Section 16-5Y-5 and SB 300 (2024 Session). (Accessed Nov. 2024).

ELIGIBLE SITES

Authorized originating sites:

Offices of physicians or practitioners;
Hospitals;
Critical Access Hospitals (CAH);
Rural Health Clinics (RHCs);
Federally Qualified Health Centers (FQHCs);
Renal Dialysis Facilities including Hospital-Based or CAH-Based Renal Dialysis Centers and satellites;
Skilled Nursing Facilities (SNF);
Licensed behavioral health centers;
Community Mental Health Centers (CMHC);
School-Based Health Centers;
University-Based Health Centers;
A patient’s home; and
Work location of a patient

SOURCE: WV Dept. of Health and Human Svcs. Medicaid Provider Manual, Chapter–519.17 Practitioner Services: Telehealth Services., p. 2 (Effective Jan. 1, 2022). (Accessed Nov. 2024).

The originating site may bill for an office, outpatient, or inpatient evaluation and management (E&M) service in addition to the Telehealth service and for other Medicaid-covered services the distant site orders, or for services unrelated to the medical problem for which the Telehealth service was requested.

SOURCE: WV Dept. of Health and Human Svcs. Medicaid Provider Manual, Chapter–519.17 Practitioner Services: Telehealth Services., p. 3 (Effective Jan. 1, 2022). (Accessed Nov. 2024).

SOURCE: WV Dept. of Health and Human Svcs. Medicaid Provider Newsletter. Qtr. 1 2022. (Accessed Nov. 2024).

GEOGRAPHIC LIMITS

WV Medicaid does not limit telehealth services to members in non-metropolitan statistical professional shortage areas as defined by CMS telehealth guidance.

SOURCE: WV Dept. of Health and Human Svcs. Medicaid Provider Manual, Chapter–519.17 Practitioner Services: Telehealth Services., p. 2 (Effective Jan. 1, 2022). (Accessed Nov. 2024).

FACILITY/TRANSMISSION FEE

An originating site must bill the appropriate telehealth originating site code (Q3014) unless the originating site is the home of the member.

Separate payment for review and interpretation of medical records, telephone line charges, or facility fees are not covered. The billing of the originating site code when the originating site is the home of the member is not covered.

SOURCE: WV Dept. of Health and Human Svcs. Medicaid Provider Manual, Chapter–519.17 Practitioner Services: Telehealth Services., p. 3-4 (Effective Jan. 1, 2022). (Accessed Nov. 2024).

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Wisconsin

Last updated 12/19/2024

POLICY

The department shall provide reimbursement under the Medical Assistance …

POLICY

The department shall provide reimbursement under the Medical Assistance program for any benefit that is a covered benefit under s. 49.46 (2) and that is delivered by a certified provider for Medical Assistance through interactive telehealth.

SOURCE: WI Statute 49.45(61), (Accessed Dec. 2024).

Both synchronous (two-way, real-time, interactive communications) and asynchronous (information stored and forwarded to a provider for later review) services identified under permanent policy may be reimbursed when provided via telehealth (also known as “telemedicine”). ForwardHealth will require providers to follow permanent billing guidelines for both synchronous and asynchronous telehealth services.

The following requirements apply to the use of telehealth:

Both the member and the provider of the health care service must agree to the service being performed via telehealth. If either the member or provider decline the use of telehealth for any reason, the service should be performed in-person.
The member retains the option to refuse the delivery of health care services via telehealth at any time without affecting their right to future care or treatment and without risking the loss or withdrawal of any program benefits to which they would otherwise be entitled.
Medicaid-enrolled providers must be able and willing to refer members to another provider if necessary, such as when telehealth services are not appropriate or cannot be functionally equivalent, or the member declines a telehealth visit.
Title VI of the Civil Rights Act of 1964 requires recipients of federal financial assistance to take reasonable steps to make their programs, services, and activities accessible by eligible persons with limited English proficiency.
The Americans with Disabilities Act requires that health care entities provide full and equal access for people with disabilities.

Services provided via telehealth must be of sufficient audio and visual fidelity and clarity as to be functionally equivalent to a face-to-face visit where both the rendering provider and member are in the same physical location. Both the distant and originating sites must have the requisite equipment and staffing necessary to provide the telehealth service.

Coverage of a service provided via telehealth is subject to the same restrictions as when the service is provided face to face (for example, allowable providers, multiple service limitations, PA).

Providers are reminded that HIPAA confidentiality requirements apply to telehealth services. When a covered entity or provider utilizes a telehealth service that involves PHI, the entity or provider will need to conduct an accurate and thorough assessment of the potential risks and vulnerabilities to PHI confidentiality, integrity, and availability. Each entity or provider must assess what are reasonable and appropriate security measures for their situation.

Note: Providers may not require the use of telehealth as a condition of treating a member. Providers must develop and implement their own methods of informed consent to verify that a member agrees to receive services via telehealth. These methods must comply with all federal and state regulations and guidelines.

SOURCE: WI ForwardHealth Online Handbook. Topic #510 Telehealth (Accessed Dec. 2024).

ForwardHealth includes virtual check-in and e-visit options for members to connect with their providers remotely.

A virtual check-in is a brief patient-initiated asynchronous or synchronous communication and technology-based service intended to be used to decide whether an office visit or other service is needed. The encounter may involve synchronous discussion over a phone or exchange of information through video or image. A provider may respond to the member’s concern by phone, audio-visual communications, or a secure patient portal. Covered services include both the remote evaluation of a recorded video or image submitted by a member and the interpretation and follow-up by the provider.

An e-visit is a communication between a member and their provider through an online HIPAA-compliant patient portal. These patient-initiated asynchronous services involve a member having non-face-to-face communications cumulatively over a span of seven days with a provider with whom they have an established relationship. Providers who can bill E&M services may utilize online digital E&M codes while other providers may be eligible to bill online assessment and management codes.

SOURCE: WI ForwardHealth Online Handbook, Virtual Check-In, E-Visit and Telephone Evaluation and Management Services, Topic #22742. (Accessed Dec. 2024).

Behavioral Health Services

Behavioral health services should be indicated by the following modifiers.

FQ*: A telehealth service was furnished using audio-only communication technology
FR*: A supervising practitioner was present through a real-time two-way, audio/video communication technology
GQ: Via asynchronous telecommunications system
GT: Via interactive audio and video telecommunication systems

*Use for behavioral health services only.

SOURCE: WI ForwardHealth Online Handbook. Topic #22737 Behavioral Health Telehealth Services, (Accessed Dec. 2024).

ELIGIBLE SERVICES/SPECIALTIES

The department shall reimburse providers for medically necessary and appropriate health care services listed in this chapter and ss. 49.46 (2) and 49.47 (6) (a), Stats., when provided to currently eligible MA recipients via telehealth. Services provided via telehealth are subject to the same restrictions as services provided in an in-person setting unless otherwise specified in chs. DHS 101 to 109. Providers shall ensure that the locations from which they provide services via telehealth ensure privacy and confidentiality of recipient information and communications in a functionally equivalent manner to services provided in person. Benefits or services that may not be delivered via telehealth include any of the following:

Services that are not covered when provided in person.
Services that do not meet applicable laws, regulations, licensure requirements, or procedure code definitions if delivered via telehealth.
Services when a provider is required to physically touch or examine the recipient and delegation is not appropriate.
Services the provider declines to deliver via telehealth.
Services the recipient declines to receive via telehealth.
Services provided by personal care workers, home health aides, private duty nurses, or school based service care attendants.
Transportation.

SOURCE: Department of Health Services Administrative Rules Sec. 107.02(5), (Accessed Dec. 2024).

How does telehealth work?

Normally, you need to meet with your doctor or other health care provider in person for many health care services. Now you can get many services through telehealth if it can be securely delivered through your smartphone, computer, or tablet with the same quality and effectiveness.

Your doctor or health care provider, using guidance from the Wisconsin Department of Health Services, will decide if you can receive a service through telehealth. If you do not want to receive a service through telehealth or do not have the right technology—such as a phone, computer, or tablet—for it to be effective, you can still see your doctor in-person.

What types of services are allowed through telehealth when using Wisconsin Medicaid?

Services allowed through telehealth include:

General health services, like seeing your provider or getting prescriptions for supplies or equipment
Behavioral health services, like mental health screenings or treatment
Dental consultations, like diagnosing an infected tooth and prescribing antibiotics until you can be seen in person
Case management services
Therapy services, like physical therapy, speech and language therapy, and occupational therapy

Are in-person services that are not covered allowed through telehealth?

No. Services that are not currently covered will not be paid when supplied through telehealth.

Families should review the HealthCheck “Other Services” benefit for services available for children under the age of 21.

See FAQ for questions related to specify covered services.

SOURCE: Wisconsin Department of Health Services, Medicaid Telehealth Expansion: Frequently Asked Questions, May 11, 2023, (Accessed Dec. 2024).

Providers should refer to the Max Fee Schedules page for a complete list of services allowed under permanent telehealth policy. Effective for dates of service on and after April 1, 2022, procedure codes for services allowed under permanent telehealth policy have POS codes 02 and 10 listed as an allowable POS in the fee schedule. Complete descriptions of these POS codes are as follows:

POS code 02: Telehealth Provided Other Than in 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 code 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.

Claims for services delivered via telehealth must include all modifiers required by the existing benefit coverage policy in order to reimburse the claim correctly. Telehealth delivery of the service is shown on the claim by indicating POS code 02 or 10 and including either the GQ, GT, FQ, or 93 modifier in addition to any other required benefit-specific modifiers.

County-administered programs, school-based services, and any other programs that utilize cost reporting must include required modifiers, such as renderer credentials and group versus individual services, as well as correct details for cost reporting to ensure correct reimbursement.

Note: The GT, FQ or 93 modifiers may not be listed on the fee schedule, but it is still required on all claim submissions that use POS code 02 or 10 to indicate the telehealth service was performed synchronously. The GQ modifier is required to indicate the telehealth service was performed asynchronously.

Certain types of benefits or services that are not appropriately delivered via telehealth include:

Services that are not covered when provided in-person.
Services that do not meet applicable laws, regulations, licensure requirements, or procedure code definitions if delivered via telehealth.
Services where a provider is required to physically touch or examine the recipient and delegation is not appropriate.
Services the provider declines to deliver via telehealth.
Services the recipient declines to receive via telehealth.
Transportation services.
Services provided by personal care workers, home health aides, private duty nurses, or school-based service care attendants.

The health care provider at the distant site must determine the following:

The service delivered via telehealth meets the procedural definition and components of the CPT or HCPCS procedure code, as defined by the American Medical Association, or the CDT procedure code, as defined by the American Dental Association.
The service is functionally equivalent to an in-person service for the individual member and circumstances.

Reimbursement is not available for services that cannot be provided via telehealth due to technical or equipment limitations.

The following cannot be billed to the member:

Telehealth equipment like tablets or smart devices
Charges for mailing or delivery of telehealth equipment
Charges for shipping and handling of:
- Diagnostic tools
- Equipment to allow the provider to assess, diagnose, repair, or set up medical supplies online such as hearing aids, cochlear implants, power wheelchairs, or other equipment

Services that are not covered when delivered in person are not covered as telehealth services. In addition, services that are not functionally equivalent to the in-person service when provided via telehealth are not covered.

Group Treatment

Additional privacy considerations apply to members participating in group treatment via telehealth. Group leaders should provide members with information on the risks, benefits, and limits to confidentiality related to group telehealth and document the member’s consent prior to the first session. Group leaders should adhere to and uphold the highest privacy standards possible for the group.

Group members should be instructed to respect the privacy of others by not disclosing group members’ images, names, screenshots, identifying details, or circumstances. Group members should also be reminded to prevent non-group members from seeing or overhearing telehealth sessions.

Providers may not compel members to participate in telehealth-based group treatment and should make alternative services available for members who elect not to participate in telehealth-based group treatment.

SOURCE: WI ForwardHealth Online Handbook. Topic #510 Telehealth (Accessed Dec. 2024).

Subject to par. (e), the department shall provide reimbursement under the Medical Assistance program for any benefit that is a covered benefit under s. 49.46 (2) and that is delivered by a certified provider for Medical Assistance through interactive telehealth.

Subject to par. (e), the department shall provide reimbursement under the Medical Assistance program for all of the following:

Except as provided by the department by rule, a consultation pertaining to a Medical Assistance recipient conducted through interactive telehealth between a certified provider of Medical Assistance and the Medical Assistance recipient’s treating provider that is certified under Medical Assistance.
Except as provided by the department by rule, remote patient monitoring of a Medical Assistance recipient and asynchronous telehealth service in which the medical data pertains to a Medical Assistance recipient.
Except as provided by the department by rule and subject to par. (e) 4., services that are covered under the Medicare program under 42 USC 1395 et seq. for which the federal department of health and human services provides Medical Assistance federal financial participation and that are any of the following:
- Telehealth services, as defined under 42 USC 1395m (m) (4) (F),
- Remote physiologic monitoring,
- Remote evaluation of prerecorded patient information,
- Brief communication technology-based services,
- Care management services delivered through telehealth;
- Any other telehealth or communication technology-based services.

Any service that is not specified in subds. 1. to 3. or par. (b) that is provided through telehealth and that the department specifies by rule under par. (d) is a covered and reimbursable service under the Medical Assistance program.

The department shall promulgate rules specifying any services under par. (c) 4. that are reimbursable under Medical Assistance. The department may promulgate rules excluding services under par. (c) 1. to 3. from reimbursement under Medical Assistance. The department may promulgate rules specifying any telehealth service under par. (b) or (c) 1. or 2. that is provided solely by audio-only telephone, facsimile machine, or electronic mail as reimbursable under Medical Assistance.

The department may not require a certified provider of Medical Assistance that provides a reimbursable service under par. (b) or (c) to obtain an additional certification or meet additional requirements solely because the service was delivered through telehealth, except that the department may require, by rule, that the transmission of information through telehealth be of sufficient quality to be functionally equivalent to face-to-face contact. The department may apply any requirement that is applicable to a covered service that is not provided through telehealth to any service provided under par. (b) or (c).

The department may not cover or provide reimbursement under Medical Assistance for a service described under par. (c) 3. that is first covered under the Medicare program under 42 USC 1395 et seq. after July 1, 2019, until the date that is one year after the date the service is covered under the Medicare program or the date the secretary explicitly approves the service as a Medical Assistance covered service, whichever is earlier.

SOURCE: WI Statute Sec. 49.45 (61). (Accessed Dec. 2024).

Telestroke Services

Telestroke, also known as stroke telemedicine, is a delivery mechanism of telehealth services that aims to improve access to recommended stroke treatment.

ForwardHealth allows providers to be reimbursed for telestroke services. Telestroke services typically consist of the member and emergency providers at an originating site consulting with a specialist located at a distant site.

Providers are required to use CPT consultation and E&M procedure codes when billing telestroke services. Telestroke services are subject to the same enrollment policy, coverage policy, and billing policy as telehealth services. All other services rendered by the provider at the originating site, and by any providers to which the member is transferred, should be billed in the same manner as visits or admissions that do not involve telehealth services.

Originating sites that have established contractual relationships for telestroke services may bill as they would for any other contracted professional services for both the professional service claim on behalf of the distant site provider and the originating site fee.

SOURCE: WI ForwardHealth Online Handbook. Topic #22741 Telestroke (Accessed Dec. 2024).

School-Based Services

ForwardHealth reimburses assessments, individual services, and group services delivered by telehealth when the service is documented in the child’s IEP as an identified service and the mode of delivery is clearly described in documentation as telehealth (using the IEP team’s chosen term for telehealth delivery) and all other coverage requirements are met for the following services:

Audiology
Counseling service
Nursing
Occupational therapy
Physical therapy
Psychological service
Social work service
Speech and language therapy

The following services do not meet the definition of functionally equivalent and are not covered as a telehealth service:

Attendant care
Transportation

Note: School documentation may use a different term to represent telehealth such as, but not limited to, teleservice, virtual learning platform, or virtual services. ForwardHealth will accept the IEP team’s chosen term for telehealth used in documentation.

As part of the IEP team meeting, the IEP team should determine if the service delivered by telehealth meets the ForwardHealth definition of functionally equivalent to be reimbursed. The decision to utilize telehealth as a delivery mode must be documented in the IEP in the section the IEP team determines appropriate.

SOURCE: ForwardHealth School-Based Services: Covered and Noncovered Services, Allowable Services via Telehealth. #22638 (Accessed Dec. 2024).

Teledentistry

ForwardHealth covers synchronous (two-way, real-time, interactive communications) and asynchronous (information stored and forwarded to a provider for subsequent review) teledentistry services.

The use of teledentistry services should be evaluated on an individual basis based on the member’s individual situation and will not be required by ForwardHealth.

Providers should report code D9995 or D9996 along with the applicable allowable oral evaluation procedure codes to indicate the service was delivered via synchronous or asynchronous teledentistry.

Note: D9995 and D9996 are informational only and are not separately reimbursable.

The applicable teledentistry code is reported on a separate service line of a claim submission that also reports all the other procedures delivered during a virtual evaluation.

When providing diagnostic imaging services via teledentistry, providers should submit claims for either the interpretation or image capture of the radiograph.

All telehealth services must follow the guidelines for functional equivalency.

To maintain functional equivalency, a facilitator may be needed to assist with the teledentistry visit.

Facilitators may include dental hygienists and other appropriately trained medical or dental professionals within their scope of practice. Facilitators are allowed for teledentistry when appropriate but are not separately reimbursed.

Dental hygienists can perform and bill for an assessment (D0191) of a member via teledentistry if the service is delivered with functional equivalency and the dental hygienist is individually enrolled in Wisconsin Medicaid.

SOURCE: ForwardHealth Teledentistry Policy, Topic #22637, (Accessed Dec. 2024).

Virtual Check-In and E-Visit

Allowable procedure codes for virtual check-in and e-visit services are listed in handbook.

These services do not require prior authorization and are patient-initiated by established patients of the provider’s practice.

Virtual check-in and e-visit telehealth services are not covered or billable if they:

Take place during an in-person visit.
Take place within seven days after an in-person visit furnished by the same provider.
Trigger an in-person visit within 24 hours or the soonest available appointment.
Do not have sufficient information from the remote evaluation of an image or video (store and forward) for the provider to complete the service.

Only the relevant in-person procedure code that was rendered would be reimbursed if any of the above conditions apply.

See handbook for list e-visit and virtual check-in codes.

SOURCE: Virtual Check-In, E-Visit and Telephone Evaluation and Management Services, Topic #22742. (Accessed Dec. 2024).

Birth to 3 Telehealth Services

ForwardHealth reimburses therapy providers supplying services as part of the Birth to 3 Program at an enhanced rate when occupational therapy, physical therapy, and/or speech therapy is performed using telehealth and the member is located in their natural environment as defined in both 34 C.F.R. Part 303 and Wis. Admin. Code § DHS 90.03(25).

To receive this reimbursement, therapy providers must meet all other requirements and indicate the following modifier types when submitting a claim:

Therapy type modifier: GN (Services delivered under an outpatient speech language pathology plan of care), GO (Services delivered under an outpatient occupational therapy plan of care), or GP (Services delivered under an outpatient physical therapy plan of care)
Birth to 3 enhanced rate modifier: TL (Early IFSP)
Telehealth modifier: GQ, GT, FQ, or 93

SOURCE: ForwardHealth: Therapies, Physical, Occupational and Speech Language, Birth to 3 Telehealth Services, Topic #22617, (Accessed Dec. 2024).

Psychotherapy

Except as provided in par. (b), outpatient psychotherapy services shall be covered services when provided by a provider certified under s. DHS 105.22, and when the following conditions are met: … Psychotherapy is performed only in any of the following: …

Via telehealth when the provider is in a location that ensures privacy and confidentiality of recipient information and communications.

The provider who performs psychotherapy shall engage in contact with the recipient in person, via real-time interactive audio-visual telehealth, or real-time interactive audio-only telehealth for at least 5/6 of the time for which reimbursement is claimed under MA.

AODA treatment services are performed only in the office of the provider, a hospital or hospital outpatient clinic, an outpatient facility, a nursing home or a school or by telehealth when functionally equivalent to services provided in person.

The provider who performs AODA treatment services shall engage in contact with the recipient in person, via real-time interactive audio-visual telehealth, or real-time interactive audio-only telehealth for at least 5/6 of the time for which reimbursement is claimed.

SOURCE: Department of Health Services Administrative Rules Sec. 107.13(2)((a)4)(h), (5), (3)(a)(5) & (6), (Accessed Dec. 2024).

Interpretive Services

Interpreters may provide services either in-person or via telehealth. Services provided via telehealth must be functionally equivalent to an in-person visit, meaning that the transmission of information must be of sufficient quality as to be the same level of service as an in-person visit. Transmission of voices, images, data, or video must be clear and understandable. Both the distant and originating sites must have the requisite equipment and staffing necessary to provide the telehealth service.

SOURCE: WI ForwardHealth Online Handbook. Topic #22917 Telehealth (Accessed Dec. 2024).

Mobile Crisis Teams

Wisconsin Medicaid reimburses Medicaid-enrolled crisis programs for up to three providers on a mobile crisis team who render services as part of a mobile crisis team response per DOS.

To receive reimbursement, the mobile crisis team must meet the following requirements:

All team members must be trained and rostered with the county crisis intervention program, per Wis. Admin. Code ch. DHS 34.
Each team includes at least one behavioral health professional who is qualified to do assessments in accordance with Wis. Admin. Code § DHS 34.22(3)(b) and at least one additional Wisconsin Medicaid provider.
At least one team member must provide services in person. Additional team members may provide services in person or through telehealth.

SOURCE: WI ForwardHealth Online Handbook. Topic #22777 Telehealth (Accessed Dec. 2024).

Crisis Response—H2011 (Crisis intervention service, per 15 minutes)—This service provides a rapid response to a member experiencing a behavioral health crisis, regardless of the member’s location. The service is typically provided in person by going to the member in crisis (that is, mobile crisis) but may also be provided on a walk-in basis or via telehealth according to telehealth guidelines. Crisis response includes individual assessment and crisis resolution services rendered by a practitioner or team of practitioners rendering services simultaneously for a member in crisis. Team responses of two practitioners are encouraged whenever possible. Up to three simultaneous practitioners are eligible for reimbursement on a single DOS when medically necessary. One practitioner must be in person when providing a team response. Additional practitioners may participate in-person or via telehealth.

SOURCE: WI ForwardHealth Online Handbook. Topic #6763 Covered Services (Accessed Dec. 2024).

Medication Therapy Management Services

MTM services must be provided face-to-face with the member. Providers should attempt to provide MTM services in person whenever possible, but audio-visual telehealth delivery is allowable in cases that better fit the circumstances of the member. If the member is a child or has physical or cognitive impairments that preclude the member from managing their own medications, MTM services may be provided face-to-face to a caregiver (for example, caretaker relative, legal guardian, power of attorney, licensed health professional) on the member’s behalf.

SOURCE: WI ForwardHealth Online Handbook. Topic #15199 Telehealth (Accessed Dec. 2024).

Postpartum Services

PNCC services are covered for a period after the pregnancy ends per Wis. Admin. Code § DHS 107.34(1)(a)2 if the Medicaid member was already receiving PNCC services on the last day of their pregnancy.

During the postpartum period, providers are required to:

Make at least one face-to-face or telehealth visit with the member.
Encourage and help the member to choose a primary health care provider for the baby.
Discuss with the member the importance of immunizations and regular HealthCheck well-child exams for the baby. Encourage the member to have further conversations with their and/or their child’s primary health care provider.
Help the member schedule necessary postpartum appointments and adhere to their appointment schedule.
Refer the member to additional community resources and services based on the parent and baby’s individual strengths and needs.
Follow up with the member and any providers or supportive persons as necessary to ensure that the member received all needed services and has obtained information to address any remaining needs or questions prior to the end of the PNCC benefit period.

SOURCE: WI ForwardHealth Online Handbook. Topic #944 Postpartum Services, (Accessed Dec. 2024).

Crisis Intervention

Providers may provide crisis intervention services by the following means:

Over the telephone
In person at any location where a member is experiencing a crisis or receiving services to respond to a crisis (including, but not limited to, mobile crisis services, and walk-in services), but does not include jail, secure detention, or services provided to IMD members between ages 21 and 64
Via telehealth

Providers are required to document the means and POS in the member’s record.

SOURCE: WI ForwardHealth Online Handbook. Topic #6806 Crisis Services Provided in Various Ways (Accessed Dec. 2024).

Speech and Language Pathology, Audiology, and Hearing Services

Reimbursement of SLP Evaluations – Consistent with Wis. Admin. Code §§ DHS 107.36(b),(c), and (d), an evaluation or testing to assess the child’s need for a therapy service performed in person or via audio-visual telehealth may be reimbursed when the evaluation or testing results are considered during the development or revision of an IEP. The student must qualify under IDEA in some disability category. The evaluation or testing does not need to result in that specific therapy service being added to the IEP.

Reimbursement of SLP Treatment – ForwardHealth will reimburse for coaching services when the therapist uses clinical judgment to assess student performance and the caretaker response to coaching results in direct service to the student during the therapy session. ForwardHealth confirms that speech and language therapy services rendered through telehealth may be reimbursed when a parent or caregiver is needed to assist the child during the therapy session. ForwardHealth only reimburses for services when the child is present.

SOURCE: WI ForwardHealth Online Handbook. Topic #1470 Covered Speech and Language Pathology, Audiology, and Hearing Services, (Accessed Dec. 2024).

School-Based Services – Testing and Assessment Procedures

Note: Consistent with Wis. Admin. Code §§ DHS 107.36(b),(c), and (d), an evaluation or testing to assess the child’s need for a therapy service performed in person or via audio-visual telehealth may be reimbursed when the evaluation or testing results are considered during the development or revision of an IEP. The student must qualify under IDEA in some disability category. The evaluation or testing does not need to result in that specific therapy service being added to the IEP.

SOURCE: WI ForwardHealth Online Handbook. Topic #249 Testing and Assessment Procedures, (Accessed Dec. 2024).

Health Education and Nutrition Counseling

ForwardHealth covers health education and/or nutrition counseling under the PNCC benefit when: …

Services are provided face-to-face. Information on allowable telehealth services is available.

SOURCE: WI ForwardHealth Online Handbook. Topic #942 Health Education and Nutrition Counseling, (Accessed Dec. 2024).

Home Health

Face to Face Visit Requirement: Note: For an initial prescription, a physician or qualified healthcare professional can meet the face-to-face requirement by providing functionally equivalent synchronous audio-visual telehealth.

SOURCE: WI ForwardHealth Online Handbook. Topic #20977 Home Health, Face to Face Visit Requirement (Accessed Dec. 2024).

Qualified Treatment Trainees (QTTs)

QTT services rendered via telehealth may be reimbursed when allowed by the coverage policy of the service provided and consistent with telehealth policy described in Telehealth Policy topic #510. Providers may refer to Supervision topic #22757 for guidance and supervision of behavioral health services via telehealth.

SOURCE: ForwardHealth Update, July 2024, No. 2024-22, (Accessed Dec. 2024).

QTT services rendered via telehealth may be reimbursed when allowed by the coverage policy of the service provided and consistent with telehealth policy.

SOURCE: WI ForwardHealth Online Handbook, Topic 23397, (Accessed Dec. 2024).

Community Health Centers

Physician-administered drugs, telehealth distant site services, and certain retail pharmacy services are considered “carved out” of the PPS rate and are reimbursed separately.

The following apply to telehealth services:

Telehealth services include “originating site” services and/or “distant site” services
Telehealth services are counted as encounters and require following PPS methodology guidelines

CHC costs associated with telehealth services may be reported for change in scope adjustment consideration; therefore, telehealth service costs may be used for future rate setting purposes.

SOURCE: WI ForwardHealth Online Handbook, Topic 22058, (Accessed Dec. 2024).

Prenatal Care Coordination

Certain modifiers are required when providing services via telehealth.

SOURCE: WI ForwardHealth Online Handbook, Topic 940, (Accessed Dec. 2024).

Durable Medical Equipment & Comprehensive Medication Review and Assessment

Certain face-to-face requirements apply for an initial prescription. See Topic #1766, Topic #21037and Topic #14677.

Intensive Outpatient Program (IOP)

Providers may offer IOP services via telehealth. Providers should refer to the Max Fee Schedule page for complete list of services allowed under telehealth policy and the ForwardHealth Online Handbook Telehealth Policy #510 for information about when to use telehealth, allowable services, reimbursement documentation requirements, allowable providers and other requirements and restrictions.

SOURCE: WI ForwardHealth Update: New Intensive Outpatient Program Benefit, No. 2024-38, Oct. 2024, (Accessed Dec. 2024).

ELIGIBLE PROVIDERS

There is no restriction on the location of a distant site provider. In addition, there are no limitations on what provider types may be reimbursed for telehealth services.

SOURCE: WI ForwardHealth Online Handbook. Topic #510 Telehealth (Accessed Dec. 2024).

Supervision

Paraprofessional providers are subject to supervision requirements. Paraprofessional providers are providers who do not hold a license to practice independently but are providing services under the direction of a licensed provider. Providers who supervise paraprofessionals are responsible for confirming if the required components of supervision can be met through telehealth delivery.

Supervision of PCWs and home health aides must be performed on site and in person by the RN. State rules and regulations necessitate supervising providers to physically visit a member’s home and directly observe the paraprofessional providing services.

Ancillary providers have specific requirements when providing care via telehealth. These providers are health care professionals that are not enrolled in Wisconsin Medicaid, such as staff nurses, dietician counselors, nutritionists, health educators, genetic counselors, and some nurse practitioners who practice under the direct supervision of a physician and bill under the supervising physician’s NPI. (Nurse practitioners, nurse midwives, and anesthetists who are Medicaid-enrolled should refer to their service-specific area of the Online Handbook for billing information).

For telehealth services, the supervising physician is not required to be onsite, but they must be able to interact with the member using real-time audio or audiovisual communication, if needed. For supervision of ancillary providers, remote supervision is allowed in circumstances where the physician feels the member is not at risk of an adverse event that would require hands-on intervention from the physician.

The FR modifier should be used for behavioral health services where the supervising provider is present through audio-visual means and the patient and supervised provider are in-person.

Providers should include how the service and the required supervision occurred in the member record and, if applicable, indicate the appropriate modifier on the claim form. For example, for a behavioral health service where the supervising provider is present through audio-visual means and the patient and supervised provider are in-person, modifier FR should be indicated on the claim.

SOURCE: ForwardHealth Update, No. 2023-02, Feb. 2023, (Accessed Aug. 2023), and ForwardHealth Online Handbook, Topic #22757, (Accessed Dec. 2024).

The distant site is where the provider is located during the telehealth visit. The provider who is providing health care services to the member via telehealth cannot bill the originating site fee because they are not hosting the member.

Ancillary Providers

Claims for services provided via telehealth by distant site ancillary providers should continue to be submitted under the supervising physician’s NPI using the lowest appropriate level office or outpatient visit procedure code or other appropriate CPT code for the service performed. These services must be provided under the direct on-site supervision of a physician who is located at the same physical site as the ancillary provider and must be documented in the same manner as services that are provided face to face.

Pediatric and Health Professional Shortage Area-Eligible Services

Claims for services provided via telehealth by distant site providers may additionally qualify for pediatric (services for members 18 years of age and under) or HPSA-enhanced reimbursement. Pediatric and HPSA-eligible providers are required to indicate POS code 02 or 10, along with modifier GQ, GT, FQ, or 93 and the applicable pediatric or HPSA modifier, when submitting claims that qualify for enhanced reimbursement.

FQHCs and RHCs

For the purpose of this Online Handbook topic, FQHC refers to Tribal and Out-of-State FQHCs. This topic does not apply to Community Health Centers subject to PPS reimbursement.

FQHCs and RHCs may serve as originating site and distant site providers for telehealth services.

FQHCs and RHCs may report services provided via telehealth on the cost settlement report when the FQHC or RHC served as the distant site and the member is an established patient of the FQHC or RHC at the time of the telehealth service. For currently covered services, services that are considered direct when provided in-person will be considered direct when provided via telehealth for FQHCs.

Services billed with modifier GQ, GT, FQ, or 93 will be considered under the PPS reimbursement method for non-tribal FQHCs. Billing HCPCS procedure code T1015 (Clinic visit/encounter, all-inclusive) with a telehealth procedure code will result in a PPS rate for fee-for-service encounters. Fee-for-service claims must include HCPCS procedure code T1015 when services are provided via telehealth in order for proper reimbursement.

SOURCE: WI ForwardHealth Online Handbook. Topic #22739 Originating and Distant Sites (Accessed Dec. 2024).

Community Health Centers

Services billed with modifier GQ, GT, FQ, FR, or 93 will be considered under the PPS reimbursement. Billing HCPCS procedure codes T1015 (Clinic visit/encounter, all-inclusive) with a telehealth procedure code will result in a PPS for an allowable encounter.

SOURCE: Telehealth for Community Health Centers, Topic #21997 (Accessed Dec. 2024).

CHCs may serve as originating site and distant site providers for telehealth services. CHC claims for services provided via telehealth must qualify as telehealth.

Services billed with modifier GT, FQ, or 93 will be considered under the PPS reimbursement. Billing HCPCS procedure codes T1015 (Clinic visit/encounter, all-inclusive) with a telehealth procedure code will result in a PPS rate for an allowable encounter.

Carved out services (physician-administered drugs and telehealth distant site services) may be submitted on the same claim as the encounter. Carved-out services will be reimbursed separately from the PPS rate at the same reimbursement rate as non-CHC providers.

SOURCE: WI ForwardHealth Online Handbook, Topic 21959, (Accessed Dec. 2024).

School-Based Services

Supervision of Certified Occupational Therapy and Physical Therapy Assistants

ForwardHealth accepts supervision of certified occupational therapy assistants and physical therapist assistants in schools conducted via audio-visual telehealth.

Refer to the Delegation of Physical Therapy Services topic (#1463) and the Delegation of Occupational Therapy Services topic (#1464) of the ForwardHealth Online Handbook for additional information.

SOURCE: WI ForwardHealth Online Handbook. Topic #1463 and #1464. (Accessed Dec. 2024).

Claims for telehealth services must include all modifiers required by coverage policy, in addition to POS code 02 (Telehealth Provided Other Than in Patient’s Home) or 10 (Telehealth Provided in Patient’s Home) and the GT, FQ, or 93 modifiers, in order to reimburse the claim correctly. The FQ or 93 modifiers should be used for any service performed via audio-only telehealth.

SOURCE: WI ForwardHealth Online Handbook. School-Based Services, School-Based Services Rate Changes and Fee Schedule, 1450. (Accessed Aug. 2024).

Teledentistry

To maintain functional equivalency, a facilitator may be needed to assist with the teledentistry visit.

SOURCE: ForwardHealth Teledentistry Policy, Topic #22637, (Accessed Dec. 2024).

Modifiers

Providers should include all applicable modifiers to identify the delivery method for telehealth services. Claims for synchronous telehealth services should be indicated by one or more of the following applicable modifiers:

GT (Via interactive audio and video telecommunication systems)
93 (Synchronous telemedicine service rendered via telephone or other real-time interactive audio-only telecommunications system)
FQ (A telehealth service was furnished using audio-only communication technology) Use this modifier when the patient is unable to use audio and video communications. (This modifier is for behavioral health services only.)
FR (A supervising practitioner was present through a real-time two-way, audio/video communication technology) (This modifier is for behavioral health services only.)

Note: The FQ and FR modifiers are for behavioral health services only.

For services that include both asynchronous and synchronous components, claims should indicate that the cumulative services were rendered through both real-time interactions and store-and-forward delivery. For example, in a virtual check-in, if a provider reviews an image submitted by an established patient sent through a secure provider portal and calls the member on the phone to discuss treatment and next steps, the claim should indicate both the 93 and GQ modifiers.

Providers are required to include any additional provider, benefit, or service specific modifiers that may apply to a service code when delivered through telehealth. For example, when a service is provided by a physical therapist (PT), the codes would need to include the corresponding therapy modifier GP (Services delivered under an outpatient physical therapy plan of care) to signify the telehealth service is furnished as therapy services furnished under a PT plan of care.

SOURCE: WI ForwardHealth Update: Expanded Coverage for Permanent Telehealth Policy, No. 2023-01, Jan. 2023, (Accessed Dec. 2024).

SOURCE: WI ForwardHealth Online Handbook. Topic #510 Telehealth, (Accessed Dec. 2024).

Physicians – Consultations

An E&M consultation requires face-to-face contact between the consultant and the member, either in person or via telehealth, where appropriate. A consultation must always result in a written report that becomes a part of the member’s permanent medical record.

SOURCE: ForwardHealth Physicians, Consultations, Topic #483, (Accessed Dec. 2024).

Intensive Outpatient Program (IOP) – Behavioral Health

Providers should use informational behavioral health modifiers when they render telehealth services:

FQ: A telehealth service was furnished using audio-only communication technology
FR: A supervising practitioner was present through a real time two way audio/video communication technology
GQ: Via asynchronous telecommunications system
GT: Via interactive audio and video telecommunication system

SOURCE: WI ForwardHealth Update: New Intensive Outpatient Program Benefit, No. 2024-38, Oct. 2024, (Accessed Dec. 2024).

ELIGIBLE SITES

The originating site is where the member is located during a telehealth visit. Only the provider at the originating site can bill for an originating site fee for hosting the member. The originating site should not use telehealth modifiers on the claims since all services are provided in-person.

See facility fee section for sites eligible for originating site fee.

Claims for services provided via telehealth by distant site providers must be billed with the same procedure code as would be used for a face-to-face encounter along with modifiers GQ, GT, FQ, or 93.

Note: Only the service rendered from the distant site must be billed with modifier GQ. The originating site for asynchronous services is not eligible to receive an originating site fee.

Claims must also include either POS code 02 or 10. ForwardHealth reimburses the service rendered by distant site providers at the same rate as when the service is provided face-to-face.

FQHCs and RHCs

For the purpose of this Online Handbook topic, FQHC refers to Tribal and Out-of-State FQHCs. This topic does not apply to Community Health Centers subject to PPS reimbursement.

FQHCs and RHCs may serve as originating site and distant site providers for telehealth services.

The originating site fee is not a FQHC or RHC reportable encounter on the cost report. Any reimbursement for the originating site fee must be reported as a deductive value on the cost report.

Although FQHCs are not directly reimbursed an originating site fee, HCPCS procedure code Q3014 should be billed for tracking purposes and for consideration in any potential future changes in scope.

SOURCE: WI ForwardHealth Online Handbook. Topic #22739 Originating and Distant Sites (Accessed Dec. 2024).

Community Health Centers

ForwardHealth will not separately reimburse the CHC for originating site services because all costs for providing originating site services have already been incorporated into the PPS rates for CHCs. However, claims billed by CHCs for originating site services may be used for future rate setting purposes, and CHC costs associated with telehealth services may be reported for change in scope adjustment consideration.

SOURCE: Telehealth for Community Health Centers, 21997 (Accessed Dec. 2024).

CHCs may serve as originating site and distant site providers for telehealth services. CHC claims for services provided via telehealth must qualify as telehealth.

CHCs should submit claims for originating site services on a professional claim form with HCPCS procedure code Q3014 (Telehealth originating site facility fee) and a POS code that represents where the member is located during the service. Modifier GT should not be included with procedure code Q3014 for originating site services to be considered under the PPS reimbursement method. ForwardHealth will not separately reimburse the CHC for originating site services because all costs for providing originating site services have already been incorporated into the PPS rates for CHCs. However, claims billed by CHCs for originating site services may be used for future rate setting purposes, and CHC costs associated with telehealth services may be reported for change in scope adjustment consideration.

SOURCE: WI ForwardHealth Online Handbook, Topic 21959, (Accessed Dec. 2024).

The department may not limit coverage or reimbursement of a service provided under par. (b) or (c) based on the location of the Medical Assistance recipient when the service is provided.

SOURCE: WI Statute Sec. 49.45 (61). (Accessed Dec. 2024).

Do I need to be in a private location to have a telehealth visit?

Providers need to follow federal laws to ensure your privacy and security. This might include making sure you have a private space for your visit. This will help keep your health information confidential.

SOURCE: Wisconsin Department of Health Services, Medicaid Telehealth Expansion: Frequently Asked Questions, May 11, 2023, (Accessed Dec. 2024).

Telestroke Services

SOURCE: WI ForwardHealth Online Handbook. Topic #22741 Telestroke (Accessed Dec. 2024).

POS code 02: Telehealth Provided Other Than in 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 code 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.

SOURCE: WI ForwardHealth Online Handbook. Topic #510 Telehealth, (Accessed Dec. 2024).

Birth to 3 Telehealth Services

Therapy providers must also indicate the POS where the therapy is performed. Allowable POS codes are as follows:

02 (Telehealth Provided Other than in Patient’s Home)
04 (Homeless Shelter)
10 (Telehealth Provided in Patient’s Home)
12 (Home)
99 (Other Place of Service)

SOURCE: ForwardHealth: Therapies, Physical, Occupational and Speech Language, Birth to 3 Telehealth Services, Topic #22617, (Accessed Dec. 2024).

POS codes 02 and 10 appear in a multitude of chapters in the Wisconsin Medicaid handbook. To see if they appear for you, go to the Online Wisconsin Medicaid Handbook, select your particular area and check Place of Services Codes under the “Code” chapter to see if they appear.

Intensive Outpatient Program (IOP)

POS codes:

02: Telehealth provided other than in patient’s home
10: Telehealth provided in patient’s home

SOURCE: WI ForwardHealth Update: New Intensive Outpatient Program Benefit, No. 2024-38, Oct. 2024, (Accessed Dec. 2024).

GEOGRAPHIC LIMITS

SOURCE: WI ForwardHealth Online Handbook. Topic #22739: Originating and Distant Sites, (Accessed Dec. 2024).

The department may not require a health care provider that is licensed, certified, registered, or otherwise authorized to provide health care services in this state and that exclusively offers health care services in this state through telehealth to maintain a physical address or site in this state to be eligible for enrollment as a certified provider under the Medical Assistance program.

The department may not require a provider group with health care providers that are licensed, certified, registered, or otherwise authorized to provide health care services in this state and that exclusively offer health care services in this state through telehealth to maintain a physical address or site in this state to be eligible for enrollment as a provider group under the Medical Assistance program.

SOURCE: WS Statute 49.45(61m)(b) & (c). (Accessed Dec. 2024).

FACILITY/TRANSMISSION FEE

The following locations are eligible for the originating site fee under permanent telehealth policy:

Office or clinic:
- Medical
- Dental
- Therapies (physical therapy, occupational therapy, speech and language pathology)
- Behavioral and mental health agencies
Hospital
Skilled nursing facility
Community mental health center
Intermediate care facility for individuals with intellectual disabilities
Pharmacy
Day treatment facility
Residential substance use disorder treatment facility

In addition to reimbursement to the distant site provider, ForwardHealth reimburses an originating site fee for the staff and equipment at the originating site requisite to provide a service via telehealth. Eligible providers who serve as the originating site should bill the fee with HCPCS procedure code Q3014 (Telehealth originating site fee). Modifier GQ, GT, FQ, or 93 should not be included with procedure code Q3014.

Outpatient hospitals, including emergency departments, must bill HCPCS procedure code Q3014 on an institutional claim form as a separate line item with revenue code 0780. ForwardHealth will reimburse hospitals for the fee based on the standard hospital reimbursement methodology. ForwardHealth will reimburse these providers for the fee based on the provider’s standard reimbursement methodology.

All other providers should bill HCPCS procedure code Q3014 with a POS code that represents where the member is located during the service. The POS must be a ForwardHealth-allowable originating site for HCPCS procedure code Q3014 in order to be reimbursed for the originating site fee. Billing-only provider types must include an allowable rendering provider on the claim form. The originating site fee is reimbursed based on a maximum allowable fee.

Although FQHCs are not directly reimbursed an originating site fee, HCPCS procedure code Q3014 should be billed for tracking purposes and for consideration in any potential future changes in scope.

To receive reimbursement, the originating site must:

Utilize an interactive audiovisual telecommunications system that permits real-time communication between the provider at the distant site and the member at the originating site.
Be in a physical location that ensures privacy.
Provide access to broadband internet with sufficient bandwidth to transmit audio and video data.
Provide access to support staff to assist with technical components of the telehealth visit.
Be compliant with Health Insurance Portability and Accountability Act of 1996 standards.

For the purpose of this Online Handbook topic, FQHC refers to Tribal and Out-of-State FQHCs. This topic does not apply to Community Health Centers subject to PPS reimbursement.

FQHCs and RHCs may serve as originating site and distant site providers for telehealth services.

The originating site fee is not a FQHC or RHC reportable encounter on the cost report. Any reimbursement for the originating site fee must be reported as a deductive value on the cost report.

SOURCE: WI ForwardHealth Online Handbook. Topic #22739: Originating and Distant Sites, (Accessed Dec. 2024).

SOURCE: WI ForwardHealth Online Handbook, Telehealth for Community Health Centers. (Accessed Dec. 2024).

Dental providers should bill Q3014 (Telehealth originating site facility) with a POS code that represents where the member is located during the service on a professional claim form. The POS must be a ForwardHealth-allowable originating site for procedure code Q3014 in order to be reimbursed for the originating site fee. Billing-only provider types must include an allowable rendering provider on the claim form.

SOURCE: WI ForwardHealth Online Handbook. Topic #22637: Teledentistry Policy, (Accessed Dec. 2024).

Nursing Homes, Family Planning Only Services, and Outpatient Hospital Services may bill Q3014.

SOURCE: WI ForwardHealth Online Handbook. Topic #3219: Topic #2624; and Topic #1364. (Accessed Aug. 2024).

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Wyoming

Last updated 10/14/2024

POLICY

For Medicaid payment to occur, interactive audio and video …

POLICY

For Medicaid payment to occur, interactive audio and video telecommunications must be permitting real-time communication between the distant site physician or practitioner and the patient with sufficient quality to assure the accuracy of the assessment, diagnosis, and visible evaluation of symptoms and potential medication side effects. All interactive video telecommunication must comply with HIPAA patient privacy regulations at the site where the patient is located, the site where the consultant is located, and in the transmission process. If distortions in the transmission make adequate diagnosis and assessment improbable and a presenter at the site where the patient is located is unavailable to assist, the visit must be halted and rescheduled. It is not appropriate to bill for portions of the evaluation unless the exam was actually performed by the billing Provider. The billing Provider must comply with all licensing and regulatory laws applicable to the Providers’ practice or business in Wyoming and must not currently be excluded from participating in Medicaid by state or federal sanctions.

SOURCE: WY Dept. of Public Health Insurance, Medicaid, CMS 1500 Provider Manual, pgs. 136-137 (Oct. 1, 2024), School Based Services Manual, pg. 16 (Oct. 1, 2024); & Institutional Provider Manual pg. 136. (Oct. 1, 2024). (Accessed Oct. 2024).

ELIGIBLE SERVICES/SPECIALTIES

Telehealth services must be properly documented when offered at the discretion of the provider as deemed medically necessary.

Each site will be able to bill for their own services as long as they are an enrolled Medicaid provider (this includes out-of-state Medicaid providers). Providers shall not bill for both the spoke and hub site; unless, the provider is at one location and the member is at a different location even though the pay to provider is the same. Examples include Community Mental Health Centers and Substance Abuse Treatment Centers. A single pay to provider can bill both the originating site (spoke site) and the distant site provider (hub site) when applicable.

Documentation Requirements

Quality assurance/improvement activities relative to telehealth delivered services need to be identified, documented and monitored.
Providers need to develop and document evaluation processes and patient outcomes related to the telehealth program, visits, Provider access, and patient satisfaction.
All service providers are required to develop and maintain written documentation in the form of progress notes the same as if they originated during an in-person visit or consultation with the exception that the mode of communication (such as, teleconference) should be noted
Documentation must be maintained at the hub and spoke locations to substantiate the services provided. Documentation must indicate that the services were rendered via telehealth and must clearly identify the location of the hub and spoke sites.

Billing Requirements

Telehealth consent must be obtained if the originating site is the Member’s home

The services must be medically necessary and follow generally accepted standards of care

The service must be a service covered by Medicaid

Claims must be made according to Medicaid billing instructions

The same procedure codes and rates apply for telehealth as in person.

The modifiers to indicate a telehealth service is “GT” or “95”, which must be used in conjunction with the appropriate procedure code to identify the professional telehealth services provided by the Distant Site Provider (for example, procedure code 90832 billed with modifier GT). The GT or 95 modifier must be billed by the Distant Site. Using the GT or 95 modifier does not change the reimbursement fee.

For ESRD-related services, at least one face-to-face “hands on” visit (not telehealth) must be furnished each month to examine the vascular access site by a qualified provider.

Care Management Entity service providers (CME Providers) are to use Place of Service code 02 Telehealth per their Provider agreement with Magellan Healthcare. CME Providers are NOT to use the “GT” or “95” modifier or “Q3014-Telehealth Originating Site Facility Fee” codes for virtual services.

If the patient or legal guardian indicate at any point that they want to stop using the technology, the service should cease immediately, and an alternative appointment set up.

See manual for billing examples.

SOURCE: WY Dept. of Public Health Insurance, Medicaid, CMS 1500 Provider Manual, p. 135-138 (Oct. 1, 2024), & Institutional Provider Manual pg. 135-138. (Oct. 1, 2024). (Accessed Oct. 2024).

Diabetes Prevention Program (DPP)

The first session of a DPP program cannot be performed via telehealth, but sessions 2-16 can be. The GT modifier should be used.

SOURCE: WY Dept. of Public Health Insurance, Medicaid, CMS 1500 Provider Manual p. 271 (Oct. 1, 2024), (Accessed Oct. 2024).

Mental Health Services

The following services are excluded:

Clinical services which are not provided in person or via a telehealth modality, other than collateral contacts necessary to develop or implement a treatment plan.

SOURCE: WY Admin Rules and Regulations, Agency 048, Department of Health-Medicaid, Behavioral Health Services, 37, Ch. 13, (Accessed Oct. 2024).

School Based Services (SBS)

All individual services covered under the SBS Program may be billed by participating LEAs when performed via telehealth, except for services that preclude a telehealth modality. Group services are only reimbursable if delivered face-to-face. Telehealth is not an approved modality for group services. For Medicaid payment to occur, interactive audio and video telecommunications must be permitting real-time communication between the distant site physician or practitioner and the student with sufficient quality to assure the accuracy of the assessment, diagnosis, and visible evaluation of symptoms and potential medication side effects.

Non-Covered Services

Telehealth does not include a telephone conversation, electronic mail message (email), or facsimile transmission (fax) between a healthcare practitioner and a student, or a consultation between two health care practitioners asynchronous “store and forward” technology. Group services delivered using telehealth are not a covered service for Medicaid reimbursement. In addition, Medicaid will not reimburse for the use or upgrade of technology, for transmission charges, for charges of an attendant who instructs a patient on the use of the equipment or supervises/monitors a patient during the telehealth encounter, or for consultations between professionals.

Services are reimbursable when performed according to telehealth guidelines and billed with the appropriate CPT code. Ancillary costs, such as equipment, technical support, facility fee, and transmission charges incurred while providing telehealth services via audio/video communication are not reimbursable.

SOURCE: WY Division of Health Insurance, School Based Services Manual, pg. 16-17, (Oct. 2024). (Accessed Oct. 2024).

Adverse Childhood Experiences

Providers may screen a patient for ACEs or Pediatric Traumatic Stress Screening Tool via telehealth if the provider believes that the screening can be administered in a clinically appropriate manner. Providers must continue to comply with all other billing procedures, Wyoming Medicaid guidelines, and confidentiality laws

SOURCE: WY Dept. of Public Health Insurance, Medicaid, CMS 1500 Provider Manual p. 211 & 322 (Oct. 1, 2024), (Accessed Oct. 2024).

Impaired Driving Education Service Standards.

A provider of impaired driving education services shall:

Provide a minimum of eight (8) hours of services, which may be delivered through telehealth, utilizing an evidence-based curricula that is appropriate to age and developmental levels

SOURCE: WY Regulations, Department of Health, Mental Health and Substance Use Disorder, Ch. 2, Sec. 14, (Accessed Oct. 2024).

“Engagement services” means face-to-face staff contact, which may include delivery through telehealth, with an individual who is waiting to be admitted into treatment for the purpose of maintaining the individual’s motivation and to help prepare them for treatment.

SOURCE: WY Regulations, Department of Health, Mental Health and Substance Use Disorder, Ch. 1, Sec. 3, (Accessed Oct. 2024).

ELIGIBLE PROVIDERS

The location of the physician or practitioner providing the professional services via a telecommunications system is called the Distant Site or Hub Site. A medical professional is not required to be present with the Member at the originating site unless medically indicated. However, to be reimbursed, services provided must be appropriate and medically necessary.

Examples of physicians/practitioners eligible to bill for professional services are:

Physicians;
Advanced practice nurses with a specialty of psychiatry/mental health;
Physician’s assistant;
Psychologists and neuropsychologists;
Licensed Mental health professionals (LCSW, LPC, LMFT, LAT);
Board Certified Behavioral Analysts;
Speech therapist.

Provisionally licensed mental health professionals cannot bill Medicaid directly, but must provide services through a supervising provider. Services provided by non-physician practitioners must be within their scope(s) of practice and according to Medicaid policy.

The modifiers to indicate a telehealth service is “GT” or “95”, which must be used in conjunction with the appropriate procedure code to identify the professional telehealth services provided by the Distant Site Provider (for example, procedure code 90832 billed with modifier GT). The GT or 95 modifier MUST be billed by the Distant Site. Using the GT or 95 modifier does not change the reimbursement fee.

SOURCE: WY Dept. of Public Health Insurance, Medicaid, CMS 1500 Provider Manual, p. 136-137 (Oct. 2024) & Institutional Provider Manual pgs. 136-137. (Oct. 2024). (Accessed Oct. 2024).

Providers shall not bill for both the spoke and hub site; unless the Provider is at one location and the Member is at a different location even though the pay to Provider is the same. Examples include Community Mental Health Centers and Substance Abuse Treatment Centers. A single pay to Provider can bill both the originating site (spoke site) and the distant site Provider (hub site) when applicable. See below for billing and documentation requirements.

SOURCE: WY Dept. of Public Health Insurance, Medicaid, CMS 1500 Provider Manual, p. 135 (Oct. 2024) & Institutional Provider Manual pg. 135. (Oct. 1, 2024). (Accessed Oct. 2024).

ELIGIBLE SITES

Each site will be able to bill for their own services as long as they are an enrolled Medicaid provider (this includes out-of-state Medicaid providers). Providers shall not bill for both the spoke and hub site; unless, the provider is at one location and the client is at a different location even though the pay to provider is the same. Examples include Community Mental Health Centers and Substance Abuse Treatment Centers. A single pay to Provider can bill both the originating site (spoke site) and the distant site Provider (hub site) when applicable.

The Originating Site or Spoke site is the location of an eligible Medicaid client at the time the service is being furnished via telecommunications system occurs.

Authorized originating sites:

Hospitals;
Office of a physician or other practitioner (this includes medical clinics)
Office of a psychologist or neuropsychologist
Community mental health or substance abuse treatment centers (CMHC/SATC);
Office of an advanced practice nurse (APN) with specialty of psych/mental health
Office of a Licensed Mental Health Professional (LCSW, LPC, LMFT, LAT);
Federally Qualified Health Centers;
Rural Health Clinics;
Skilled nursing facilities;
Indian Health Services Clinics;
Hospital-based or Critical Access Hospital-based renal dialysis centers (including satellites). Independent renal dialysis facilities are not eligible originating sites;
Development Center;
Family Planning Clinics;
Public Health Offices

SOURCE: WY Dept. of Public Health Insurance, Medicaid, CMS 1500 Provider Manual, p. 134-135 (Oct. 1, 2024), & Institutional Provider Manual pg. 134-135. (Oct. 1, 2024). (Accessed Oct. 2024).

School Based Services (SBS)

Telehealth claims must indicate that the place of service is “Telehealth” by selecting code “02”. Refer to the “1.2 Location of Services ” for more information. 03 indicates a school.

SOURCE: WY Division of Health Insurance, School Based Services Manual, (Oct. 1, 2024), pg. 17. (Accessed Oct. 2024).

GEOGRAPHIC LIMITS

No Reference Found

FACILITY/TRANSMISSION FEE

Medicaid will not reimburse for the use or upgrade of technology, for transmission charges, for charges of an attendant who instructs a patient on the use of the equipment or supervises/monitors a patient during the telehealth encounter, or for consultations between professionals.

The originating site fee is not billable if the client uses their own equipment, such as a personal phone, tablet, or computer. [not in school-based manual].

SOURCE: WY Dept. of Public Health Insurance, Medicaid, CMS 1500 Provider Manual, p. 137 (Oct. 1, 2024), School Based Services Manual, pg. 16 (Oct. 1, 2024); & Institutional Provider Manual pg. 136. (Oct. 1, 2024). (Accessed Oct. 2024).

When billing for the originating site facility fee, use procedure code Q3014. A separate or distinct progress note is not required to bill Q3014. Validation of service delivery would be confirmed by the accompanying practitioner’s claim with the GT or 95 modifier indicating the practitioner’s service was delivered via telehealth. Medicaid will reimburse the originating site provider the lesser of charge or the current Medicaid fee.

Providers cannot bill for Q3014 if clients used their own equipment, such as personal phones or computers.

Additional services provided at the originating site on the same date as the telehealth service may be billed and reimbursed separately according to published policies and the National Correct Coding Initiative (NCCI) guidelines.

Eligible sites include:

Hospitals
Office of a physician or other practitioner (this includes medical clinics)
Office of a psychologist or neuropsychologist
Community mental health or substance abuse treatment center (CMHC/SATC)
Office of an advanced practice nurse (APN) with specialty of psych/mental health
Office of a Licensed Mental Health Professional (LCSW, LPC, LMFT, LAT)
Federally Qualified Health Center (FQHC)
Rural Health Clinic (RHC)
Skilled nursing facility (SNF)
Indian Health Services Clinic (IHS)
Hospital-based or Critical Access Hospital-based renal dialysis centers (including satellites).
Independent Renal Dialysis Facilities are not eligible originating sites
Developmental Center
Family Planning Clinics
Public Health Offices

SOURCE: WY Dept. of Public Health Insurance, Medicaid, CMS 1500 Provider Manual, pgs. 135-138 (Oct. 1, 2024), & Institutional Provider Manual pg. 135-138, (Oct. 1, 2024). (Accessed Oct. 2024).

Care Management Entity service providers (CME Providers) are to use Place of Service code 02-Telehealth per their Provider agreement with Magellan Healthcare. CME Providers are NOT to use the “GT” modifier or “Q3014-Telehealth Originating Site Facility Fee” codes for virtual services.

SOURCE: WY Dept. of Public Health Insurance, Medicaid, CMS 1500 Provider Manual, p. 138 (Oct. 1, 2024), & Institutional Provider Manual pg. 138. (Oct. 1, 2024). (Accessed Oct. 2024).

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