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    v1.0.28
    OpenPayerPolicy UpdatesTelehealth & Remote MonitoringBCBS Michigan telemonitoring Coverage Update | Ope…
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    Currentblue cross blue shield - michiganPolicy BCPFFS 1003

    Remote Patient Monitoring (telemonitoring)

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    Defines Blue Cross Medicare PFFS coverage, eligibility, and administrative payment/participant requirements for remote patient monitoring (telemonitoring) services provided through the Chronic Condition Management (CCM) program.

    Policy Summary
    Payerblue cross blue shield - michigan
    PolicyRemote Patient Monitoring (telemonitoring)
    Policy CodePolicy BCPFFS 1003
    Change TypeNo material change
    Effective DateJan 1, 2016
    Last ReviewAug 22, 2017
    Next Review Date
    Key ActionVerify member referral and enrollment in the Blue Cross Medicare PFFS CCM telemonitoring program before providing services.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    0Member cost share for contracted telemonitoring services
    3Target conditions

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    1Contracted vendor
    Not coveredOriginal Medicare stance

    Coverage Criteria for Telemonitoring

    Coverage criteria for telemonitoring under CCM

    Covered when ALL of the following are met

    Enrollment and referral: Member is referred to and enrolled in the Blue Cross Medicare PFFS Chronic Condition Management (CCM) telemonitoring program.

    Direct enrollment and referral by Blue Cross required; eligibility verified prior to referral.

    Service delivery: Telemonitoring services are delivered by the single-source vendor under contract with Blue Cross as part of the CCM program.

    Services administered under contract; vendor payments handled per contract terms and no member billing by the provider.

    Clinical target population: Member has a diagnosis of heart failure OR chronic obstructive pulmonary disease OR diabetes and is identified as high risk.

    Only members meeting program clinical criteria and without exclusionary conditions are eligible.

    Living situation and exclusions: Member is in an independent living situation and has no exclusionary conditions per program rules.

    Member must agree to participate in the CCM program; specific exclusionary conditions are referenced by the program.

    Coverage for remote patient monitoring (telemonitoring) under this policy is available only to members of the Blue Cross Medicare PFFS plan who are referred to and enrolled in the Chronic Condition Management (CCM) telemonitoring program. Original Medicare does not cover remote patient monitoring; therefore Blue Cross defines the scope of the benefit, reimbursement methodology, maximum allowed payment amounts, and member cost sharing for this enhanced PFFS benefit.

    Remote patient monitoring (telemonitoring) is not covered by Original Medicare. This policy’s coverage for telemonitoring applies only within the Blue Cross Medicare PFFS CCM program and does not extend to services billed under Original Medicare.

    Contract / Administrative Billing Codes

    Contract/administrative billingmixed
    No codes listed

    Provider Actions & Enrollment Requirements

    Prior Authorization

    Program enrollment required

    Coverage is available only for members who have been referred to and enrolled in the Blue Cross Medicare PFFS Chronic Condition Management (CCM) telemonitoring program; members must meet program criteria and agree to participate before receiving services.

    • Referral and enrollment by Blue Cross required prior to service delivery
    • Member must meet program criteria (e.g., independent living, no exclusionary conditions) and agree to participate
    Step Therapy

    Step therapy not specified

    The policy does not specify a step therapy requirement for telemonitoring under the Blue Cross Medicare PFFS CCM program.

    Background

    Remote patient monitoring, also called telemonitoring, is an ambulatory service in which a patient uses an internet-capable device or symptom-appropriate monitor placed in the home to send routine physiologic or symptom data in real time to a health care professional for analysis and follow-up. The Blue Cross CCM telemonitoring program targets high-risk members with chronic conditions such as heart failure, chronic obstructive pulmonary disease, or diabetes, providing timely, actionable data to the member and their regular health care provider so that interventions can be initiated when status changes are detected.

    Definitions

    Remote patient monitoring (telemonitoring) — definition
    TermRemote patient monitoring (telemonitoring)
    DefinitionAn ambulatory service in which a patient uses an internet-capable device to perform routine tests and transmit the test data in real-time to a health care professional for analysis and follow-up.
    SettingAmbulatory (patient in independent living situation) as part of chronic condition management programs.
    PurposeProvide timely physiologic or symptom data to clinicians to support monitoring and follow-up for chronic conditions (e.g., heart failure, COPD, diabetes).
    Alternate nameTelemonitoring
    Policy Summary
    Payerblue cross blue shield - michigan
    PolicyRemote Patient Monitoring (telemonitoring)
    Policy CodePolicy BCPFFS 1003
    Change TypeNo material change
    Effective DateJan 1, 2016
    Last ReviewAug 22, 2017
    Next Review Date
    Key ActionVerify member referral and enrollment in the Blue Cross Medicare PFFS CCM telemonitoring program before providing services.
    SourceLink
    On This Page
    Coverage Criteria for TelemonitoringContract / Administrative Billing CodesProvider Actions & Enrollment RequirementsBackgroundDefinitions
    Documentation Required

    Eligibility and enrollment documentation

    Blue Cross verifies member program eligibility prior to referral; providers should document the member's referral, agreement to participate, enrollment status, and that the member meets living-situation and exclusion criteria.

    • Verification of eligibility performed by Blue Cross before referral
    • Documentation should show referral to CCM, member agreement to participate, enrollment status, and that member is in an independent living situation with no exclusionary conditions
    Denial Risk

    Coverage limited to contracted CCM program

    Telemonitoring services are covered only when delivered under the Blue Cross CCM program by the single contracted vendor; services provided outside this contracted program may be denied or excluded.

    • All services must be administered by the single-source provider under contract with Blue Cross as part of the CCM program
    • Vendor payments and billing are handled per contract; providers should not bill members for these services