Virtual Care (Telehealth/Telemedicine) coverage
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This policy governs coverage and reimbursement for telehealth and telemedicine services delivered to Blue Cross Blue Shield of South Carolina members (except specified excluded lines of business) and defines provider eligibility and program enrollment requirements.
No material clinical or coverage changes in this revision.
Telehealth Coverage Criteria
General Telehealth Coverage Criteria
Telehealth/telemedicine services are covered when ALL of the following are met
Providers must complete the Virtual Care Services application in the My Provider Enrollment Portal to be considered for services
See Referring Site eligibility conditions
This policy does not apply to all lines of business. Lines excluded from this policy: Healthy Blue and Medicare Advantage. Members covered under these lines must follow their specific product terms and any separate telehealth guidance.
Telemedicine is a method of delivering care, not a change to what services are covered. Services that are not covered under the member’s benefit remain not covered when delivered via telemedicine; only services that meet the medical necessity and encounter requirements in this policy are eligible for reimbursement when provided through telehealth or telemedicine.
Coding and Modality
| No codes listed |
Provider Enrollment, Documentation, and Eligibility
Prior Authorization / Enrollment
Prior Authorization / Enrollment — Credentialed, network providers that meet BlueCross contracting requirements and complete the Virtual Care (telehealth) onboarding process are eligible to bill BlueCross for telehealth/telemedicine services. Ensure providers are credentialed with BlueCross and approved through Virtual Care before submitting claims.
- Complete BlueCross Virtual Care/telehealth onboarding and contracting prior to billing.
- Only credentialed network providers approved through Virtual Care may submit claims for telemedicine and telepsychiatry.
- Lines of business included: BlueCross BlueShield of South Carolina, BlueChoice HealthPlan, Blue Essentials and Blue Option, State Health Plan. Excluded: Healthy Blue, Medicare Advantage.
Required Encounter Elements and Provider Enrollment
Required encounter elements and provider enrollment — Telehealth services must satisfy the medical policy CAM 176 (and where noted CAM 032) requirements. The patient must be physically present at the time of service, the service must be medically appropriate and necessary, the encounter must satisfy the elements of the patient-provider relationship as determined by the regulatory board where the patient is located, and services must be delivered via an interactive audio and video telecommunications system.
- The patient must be present and located within a state where the provider is authorized to practice.
- Document the patient-provider relationship elements per applicable state regulatory requirements.
- Use secure, HIPAA-compliant, real-time interactive audio-video systems for telemedicine.
- Retain documentation to demonstrate medical necessity and that encounter elements were met.
Eligibility Based on Access to Specialty Care
Eligibility based on access to specialty care — Plan members are eligible for telemedicine services when access to appropriate specialty care is difficult, inaccessible, or unavailable to the member, or in urgent situations where immediate access is required without travel. Telemedicine may increase access to specialists and continuity of care; confirm eligibility when submitting claims.
- Telemedicine is appropriate when member cannot reasonably access specialty care due to distance, availability, or urgent need.
- Referring site: member must be personally presented by the referring physician to the consulting physician at the time service is furnished when applicable.
- Services must remain within the provider's scope of practice.
PROVIDER ACTIONS
Provider Actions — Summary of actionable items: complete BlueCross Virtual Care onboarding and contracting, confirm credentialing and scope of practice, ensure technology meets interactive audio-video requirements, verify member eligibility (including line of business), document patient presence and elements of the patient-provider relationship, and retain documentation to support medical necessity.
- Verify the member's line of business to confirm telehealth coverage applicability.
- Confirm provider credentialing and Virtual Care approval prior to billing.
- Document encounter elements, medical necessity, and technology used in the medical record.
- Ensure services billed are within the provider's licensed scope of practice.
Key Definitions
Background and Rationale
Telemedicine and telehealth are intended to improve access to care by enabling real‑time, interactive audio‑video exchange between a patient and an eligible clinician. The modality can increase access to specialists, support continuity of care, and reduce travel burden. Use of telemedicine does not alter clinical appropriateness requirements: services must be medically necessary, the patient must be physically present at the time of service, the encounter must satisfy the elements of the patient‑provider relationship as determined by the state where the patient is located, and the service must be delivered via an interactive audio and video telecommunications system.
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