Virtual Care (Telehealth & Telemedicine)
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Defines Blue Cross Blue Shield of South Carolina coverage, provider eligibility, and program enrollment for telehealth and telemedicine services across applicable commercial lines of business.
No material clinical or coverage changes in this revision.
Coverage Criteria for Telehealth & Telemedicine
Covered when ALL criteria are met
Telehealth/telemedicine services are covered when ALL of the following are met:
The following lines of business are excluded from this virtual care program: Medicare Advantage and Healthy Blue℠ (BlueChoice Medicaid).
Services that do not meet the policy guidelines are not covered. Examples include encounters where the patient is not present at the time of service, services that are not medically appropriate and necessary, encounters that fail to satisfy the elements of the patient‑provider relationship as determined by the applicable state regulatory board, or services not delivered via an interactive audio and video telecommunications system. For telemedicine involving referring/consultant sites, claims may also be denied when the member has reasonable access to appropriate specialty care (i.e., access is not difficult, inaccessible, or unavailable) or the situation is not urgent such that immediate access is required without travel.
Coding and Modality Requirements
| No explicit CPT/HCPCS/ICD-10 codes listed in this document. |
Provider Credentialing, Documentation, and Billing Actions
Credentialing & telehealth onboarding required to bill
Providers must be credentialed, be network providers that meet the outlined requirements, and complete the telehealth onboarding process to be eligible to bill BlueCross BlueShield of South Carolina for telehealth services.
Confirm network eligibility and retain onboarding proof
Ensure provider meets all network and program requirements and retains documentation of eligibility and onboarding completion before submitting telehealth claims.
- Be a credentialed, network provider meeting outlined requirements.
- Complete the telehealth onboarding process prior to billing.
- Retain records proving onboarding and credentialing status.
Document patient presence, medical appropriateness, relationship elements, and modality
Documentation must demonstrate the patient was physically present at the time of service, the service was medically appropriate and necessary, elements of the patient–provider relationship were satisfied per the state regulatory board, and the service was delivered via an interactive audio and video telecommunications system; consultant sites must document appropriate licensure.
- Record that the patient was present at time of service.
- Document medical necessity and appropriateness for each service.
- Document how patient–provider relationship elements were met per the patient's state board.
- Document use of an interactive audio and video telecommunications system.
- Consulting physicians must document current and appropriate state licensure.
Risk of denial if documentation or medical appropriateness is lacking
Services that do not meet CAM 176 guidelines — for example, if the patient was not present, the service was not medically appropriate, or the encounter did not satisfy required patient–provider relationship elements — risk denial.
- Verify patient presence at time of service.
- Ensure and document medical necessity.
- Ensure encounter meets patient–provider relationship standards per state board.
Claims may be denied if specialty access/urgency criteria are not met
Telemedicine claims may be denied if the member’s access to appropriate specialty care is not difficult, inaccessible or unavailable, or if the situation is not urgent such that immediate access is needed without travel; confirm and document access/urgency criteria when billing referring-site telemedicine services.
- Document that access to appropriate specialty care is difficult, inaccessible, or unavailable for the member, or that the situation was urgent requiring immediate care without travel.
- For referring-site services, retain evidence supporting the access or urgency determination per CAM 032.
Background
Virtual care encompasses services delivered via telehealth and telemedicine that enable remote clinical interactions using electronic communications. Telehealth refers to the interaction of a patient and clinician via electronic communications to improve a patient’s clinical health status, while telemedicine specifically describes the use of medical information exchanged between eligible referring and consulting provider sites via two‑way, real‑time, interactive, secured and HIPAA‑compliant audio and video telecommunications systems. Telemedicine as used here is intended to provide an alternative delivery method for covered services when the referring‑site conditions in CAM 032 are met.
Definitions
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