CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Payment Policy Telemedicine/ Telephone Services for Commercial Products and Medicare Advantage Plans

BCBSRI reimbursement policy governing when and how telemedicine (real-time audiovisual) and telephone (audio-only) services are covered and reimbursed for Commercial products and Medicare Advantage plans.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyTelemedicine/ Telephone Services Payment Policy for Commercial Products and Medicare Advantage Plans

Policy CodePolicy N/A

Change TypeNo material change

Effective Date01/01/2024

Next Review DateN/A

Key ActionOnly the provider rendering the services may submit for reimbursement.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

100%reimbursement of telemedicine/telephone services relative to in-office allowable

01/01/2024effective date listed

01/01/2025policy last reviewed

Not applicablemedical criteria required

Not applicableprior authorization

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Coverage Criteria

Telemedicine/telephone services are covered when the following criteria are met for Commercial Products and Medicare Advantage Plans:

ALL of the following

Patient is present at time of service.
Services must be equivalent or similar to in-person services with a patient.
Services must be medically necessary and otherwise covered under the member's benefit booklet or subscriber agreement.
The extent of any evaluation and management (E&M) services provided via telemedicine or telephone technology is an appropriate substitute for a face-to-face encounter for the service being rendered.
Services must be within the provider's scope of license.
A permanent record of telemedicine or telephone communications relevant to the ongoing medical care and follow-up of the patient must be maintained as part of the patient's medical record, following all medical record documentation and requirements; when E&M is coded by time, the time must be documented.
For telemedicine (real-time, two-way electronic audiovisual communications) services only: services must comply with non-public electronic communication requirements defined by CMS and/or as otherwise designated by the State of Rhode Island (audio and video components required).

Exclusions

Excluded provider types and service exclusions:

Excluded provider types

Ambulance service
Acupuncture
Ambulatory surgical facility
Audiologist
Certified registered nurse first assist
Durable medical equipment supplier

Coding and Claims

Covered telehealth and telephone codes (see attached grid)mixedCovered

No codes listed

Place of Service and ModifiersCPTCovered

POS=02	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	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) when receiving health services or health related services through telecommunication technology
Modifier 95	Synchronous Telemedicine Service Rendered Via Real-Time Interactive Audio and Video Telecommunications System
Modifier GT	Synchronous Telemedicine Service Rendered Via Real-Time Interactive Audio and Video Telecommunications System is used for institutional billing for Distant site practitioners billing telehealth under the CAH Optional Payment Method II
Modifier FQ	Synchronous Telemedicine Service Rendered Via Real-Time Interactive Audio Telecommunications System (Providers may bill with Modifier FQ, but SO is not mandatory)

Claims filing validation

Validation ruleClaims filed with a CPT code NOT listed in the attached covered codes grid when submitted with Place of Service (POS) 02 or 10 and Modifier 95 or Modifier FQ may be denied as an invalid place of service (provider liability).

Required POS codesPOS=02 (patient not located in home) or POS=10 (patient located in home).

Required modifiersModifier 95 for synchronous audio/video; Modifier FQ optional for synchronous audio-only telephone services.

ScopeApplies to claims for telemedicine (audiovisual) and telephone (audio-only) services as described in the attached coding grid.

ConsequenceClaims may be denied for incorrect POS/modifier combination when CPT code is not in the covered grid.

Provider Actions and Billing Rules

Prior Authorization

Prior Authorization Not Required

Not applicable.

Documentation Required

Recordkeeping & Audit Risk — Maintain Detailed Encounter Documentation

BCBSRI may audit medical and administrative records to verify the nature of services provided, medical necessity, appropriateness of telemedicine/telephone modality, and the appropriateness of the level of E&M coding; documentation must contain details of the provider–patient encounter and, for time‑based E&M, clearly document time to substantiate the code billed.

BCBSRI reserves the right to audit medical and administrative records to verify services, medical necessity, appropriateness of telemedicine/telephone modality, and level of E&M coding.
Documentation must contain details of the provider–patient encounter; time must be clearly documented for time‑based E&M codes.

Definitions

Telemedicine (real‑time audiovisual) — definition

DefinitionTelemedicine services: healthcare services delivered by means of real two-way electronic audiovisual communications that facilitate assessment, diagnosis, treatment, and care management at a distant site, consistent with applicable state and federal laws and regulations.

Modality requirementRequires real-time, interactive audio and video (audiovisual) communication between provider and patient.

Documentation requirementPermanent record of the telemedicine encounter must be maintained in the patient’s medical record with sufficient documentation; time-based E&M must be documented by time when billed accordingly.

Coverage contextTelemedicine services covered when criteria in policy (medical necessity, patient present, within provider scope of license, equivalent to in-person service, etc.) are met.

Telephone services (audio‑only) — definition

Service exclusions

Public-facing video applications (e.g., Facebook Live, Twitch, TikTok) are excluded.
The technical and overhead component of the facility fee associated with telemedicine/telephone services is included in the professional maximum allowable and is not separately billed or reimbursed.
Services rendered over the telephone (audio-only) that are not specifically allowed under this policy are excluded.
Telemedicine/telephone services that occur on the same day as a face-to-face visit when performed by the same provider for the same condition are excluded.
Services rendered by email, fax, or other non-designated means are excluded.
Services that consist solely of triage when a separately identifiable E&M service does not occur are excluded.
Patient communications incidental to E&M (e.g., test result reporting, educational materials, check-ins where no separately identifiable E&M occurs, portal messages) are excluded.
Administrative matters (scheduling, registration, billing updates, reminders, med refill requests, referrals, ordering diagnostic studies, medical history intake completed by the patient) are excluded.
Proactive outreach to members not in active care by the provider for conditions requiring intervention is excluded.
Telemedicine or telephonic encounters conducted by office staff or RNs when a higher-level E&M is not warranted are excluded; for E&M services coded by time, the time spent must be clearly documented to substantiate the code billed.