Currentblue cross blue shield - michiganPolicy MAPPO

Online Visits (E-visits)

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Policy governing coverage, billing, and requirements for synchronous online visits (e-visits) for Medicare Plus Blue PPO members and most Medicare Plus Blue Group PPO members, including provider, security, and documentation expectations.

Policy Summary

Payerblue cross blue shield - michigan

PolicyOnline Visits (E-visits)

Policy CodePolicy MAPPO

Change TypeNo material change

Effective DateJan 1, 2019

Last ReviewAug 31, 2022

Next Review Date

Key ActionUse a secure, HIPAA-compliant real-time (synchronous) platform and document patient-initiated online visits with required CPT/diagnosis codes and patient identifiers.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

synchronous onlyModality required

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Currentblue cross blue shield - michiganPolicy MAPPO

Online Visits (E-visits)

Customize your policy alerts

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Get alerted when Policy MAPPO changes without checking for updates manually.

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Policy Summary

Payerblue cross blue shield - michigan

PolicyOnline Visits (E-visits)

Policy CodePolicy MAPPO

Change TypeNo material change

Effective DateJan 1, 2019

Last ReviewAug 31, 2022

Next Review Date

Key ActionUse a secure, HIPAA-compliant real-time (synchronous) platform and document patient-initiated online visits with required CPT/diagnosis codes and patient identifiers.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

synchronous onlyModality required

Originating-site restriction

patient-initiatedInitiation

HIPAA & PCI-DSSSecurity standards

99441,99442,90834Example codes

Coverage Criteria for Online Visits (E-visits)

General coverage criteria

Covered when ALL of the following are met

Synchronous patient initiation: The online visit must be initiated by the patient and be real-time (synchronous) between the patient and healthcare professional.

Appropriate complexity: The encounter is low complexity with straightforward decision-making for urgent (but not emergent) clinical conditions; the provider does not require face-to-face contact to make an optimal diagnosis or treatment decision.

Visit structure and content: The online visit should reflect an algorithmic question-and-answer approach and is not anticipated to require a follow-up encounter for the same condition.

Provider and platform security: Providers must use secure electronic transmission and handle electronic patient information in compliance with privacy requirements (e.g., encryption, authentication, appropriate recordkeeping); payment-card security (PCI-DSS) is required if collecting credit-card payments.

Member and provider applicability: Covered for Medicare Plus Blue PPO members and most Medicare Plus Blue Group PPO members unless the group has opted out; services are not restricted to specific originating sites and members may receive online primary care and behavioral health services anywhere in the U.S.

The following modalities and scenarios are explicitly excluded from coverage under this online visit policy: store-and-forward (collecting clinical information and sending it electronically for later evaluation), telemonitoring, email-only, telephone-only, text-only, facsimile transmission, requests for medication refills, reporting of normal test results, provision of educational materials, scheduling, registration, or billing updates, reminders, referrals to other providers, any online visit that results in an office/urgent care/emergency visit on the same day for the same condition, and ongoing treatment typically requiring more than 3–5 visits without expectation of a face-to-face visit with the same treating clinician or group.

Independent telephone, text, or email communications performed alone do not meet the criteria for an online visit and are not covered; while these channels may be used to enhance an otherwise compliant online visit, telephone-, text- or email-only interactions are excluded when delivered independently.

Representative Billable Codes and Modifiers

Billable CPT Codes (representative list)CPT

99441	Online medical visit, 5-10 minutes
99442	Online medical visit, 11-20 minutes
90834	Individual psychotherapy, 45 minutes
90792	Psychiatric diagnostic interview (for prescribers/medical services)
99213	Level 3 established office visit

ModifiersModifier

GT	Modifier for telehealth (as listed for psychotherapy and other services)
AJ	Modifier example listed (Masters Level)
AH	Modifier example listed (Doctorate Level)

Provider Requirements, Billing & Documentation

Billing Rule

Prior authorization and payment rules for non-contracted providers

No prior authorization is specified in this policy; payment for providers without a Medicare Advantage PPO contract will follow the Medicare Physician Fee Schedule and out-of-network providers are paid per the Medicare fee schedule. Submit claims to the local Blue Cross plan per billing instructions.

Providers without an MA PPO contract: paid in accordance with the Medicare Physician Fee Schedule.
Out-of-network providers: paid in accordance with the Medicare fee schedule.
Submit claims to your local Blue Cross plan using Medicare Advantage PPO billing requirements.

Step Therapy

Limit on ongoing treatment ( >3–5 visits )

Ongoing treatment that typically requires more than 3–5 visits without expectation of a face-to-face visit with the same treating clinician or provider group is excluded from coverage.

Background and Scope

Online visits (e-visits) are synchronous, patient-initiated virtual encounters used to evaluate and manage low-complexity, non-emergent conditions when face-to-face contact is not required. These real-time interactions are intended for brief problem-focused or straightforward decision-making and are not intended to replace ongoing longitudinal care; they must be initiated by the patient and occur via a secure, real-time electronic channel.

Key Definitions

inv-12: Online visit (E-visit) — definition

TermOnline visit (E-visit)

DefinitionA structured, real-time (synchronous) health encounter using secure online communication technology where the patient initiates the visit and medical information is exchanged via secured servers.

Key characteristicsPatient-initiated; real-time (synchronous) video; algorithmic Q&A approach for low-complexity, non-emergent conditions.

Intended useDiagnose illness and provide medical or other health treatment when face-to-face contact is not required (e.g., primary provider unavailable, patient unable to leave home).

inv-13: Original Medicare telehealth vs MA Advantage

Original Medicare requirementOriginal Medicare telehealth generally requires the patient to be at a qualifying 'originating site' (one of eight specified facility types) and the modality to be real-time interactive video.

Policy Summary

Payerblue cross blue shield - michigan

PolicyOnline Visits (E-visits)

Policy CodePolicy MAPPO

Change TypeNo material change

Effective DateJan 1, 2019

Last ReviewAug 31, 2022

Next Review Date

Key ActionUse a secure, HIPAA-compliant real-time (synchronous) platform and document patient-initiated online visits with required CPT/diagnosis codes and patient identifiers.

SourceLink

On This Page

Frequency limitations: see exclusions — ongoing treatment (typically >3–5 visits) without expectation of an in‑person visit is not covered.

Documentation Required

Documentation and claim data requirements

Maintain a record of online communications and include patient name/ID in the message when applicable; report CPT/HCPCS and diagnosis codes to the highest level of specificity and include your NPI on all claims. Bill on the CMS 1500 form and submit claims to the local Blue Cross plan following Medicare Advantage PPO billing requirements.

Keep descriptive records of the e-visit and make them available to the patient if requested.
Include patient name and identification number in the body of messages when applicable.
Report CPT/HCPCS and diagnosis codes to highest specificity and report your NPI on all claims.
Use CMS 1500 (02/12) and electronic billing per local Blue Cross instructions.

Prior Authorization

Obtain and document patient informed consent prior to the visit

Obtain and document the patient’s informed consent before the consultation, including expectations, disclaimers, service terms, any fees, and privacy considerations as part of the consent process.

Discuss appropriate expectations, disclaimers, service terms, and any fees prior to the online visit.
Include privacy considerations and guidance on avoiding emergency use and handling highly sensitive topics in the consent.

Denial Risk

Same‑day in‑person follow‑up excludes the online visit

Online visit encounters that result in an office, urgent care, or emergency department visit on the same day for the same condition are excluded and may be denied.

If the patient has an in-person visit (office/urgent/ED) the same day for the same condition, the online visit is excluded from coverage and may be denied.

Originating site examplesDoctor's office, hospital, critical access hospital, rural health clinic, federally qualified health center, dialysis facility, skilled nursing facility, community mental health center.

Medicare Advantage (Medicare Plus Blue) distinctionMedicare Advantage (Medicare Plus Blue) offers broader originating-site flexibility — MA members may receive services from any U.S. location without the Original Medicare originating-site restriction.

Modality alignmentBoth Original Medicare and this MA policy require real-time (synchronous) interactive video for covered telehealth/online visits.