Telemedicine Services
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Administrative policy governing coverage, reimbursement, and conditions for telemedicine (including store-and-forward and remote monitoring) for CareSource Arkansas PASSE members and enrolled Arkansas Medicaid providers.
No material clinical or coverage changes in this revision.
Coverage and Clinical Criteria
General coverage criteria
Covered when ALL of the following are met:
ALL of the following
- The telemedicine service is provided by a licensed or certified healthcare professional or entity authorized to bill Arkansas Medicaid directly.
- The service provided through telemedicine is comparable to the same service provided in person.
- Medically necessary telehealth services follow the same clinical and utilization review criteria, plan requirements, limitations, and cost sharing as when delivered in person.
- The modality of telemedicine/telehealth services is documented in the applicable medical record.
- The distant-site professional or entity is an enrolled Arkansas Medicaid Provider (distant-site enrollment requirement).
- When applicable, reimbursement is submitted using approved HCPCS and CPT codes with appropriate modifiers per the fee schedule.
- Remote patient monitoring and store-and-forward technologies are included as telemedicine modalities and are reimbursed on the same basis as in-person services when the above requirements are met.
Exclusions and documentation
The following modalities are not covered via telemedicine, and documentation expectations for non-covered audio-only contacts are specified:
ANY of the following
- Audio-only communication is not covered unless it is real-time, interactive, and substantially meets the requirements for a health care service that would otherwise be covered by the health benefit plan.
- Internet questionnaires are not covered as telemedicine services.
- Email messages are not covered as telemedicine services.
- Client-generated medical histories are not covered as telemedicine services.
- Text messaging is not covered as telemedicine services.
- Facsimile (fax) and E-fax are not covered as telemedicine services.
- Any combination of the above and any future technology that does not meet the criteria outlined in this section are not covered.
- For audio-only engagements that do meet the allowable exception, documentation of the engagement must be maintained in the medical record addressing the problem, content of the conversation, medical decision-making, and plan of care after the contact; medical documentation is subject to the same audit and review processes as in-person visits.
Coding, POS & Documentation Requirements
| POS 02 | Telehealth services provided other than in member home |
| POS 10 | Telehealth services provided in member home |
Billing, Enrollment, and Facility Rules
Submit approved HCPCS/CPT codes and document telemedicine modality
Reimbursement is contingent on submitting approved Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) codes with appropriate modifiers, and the telemedicine modality must be documented in the member's medical record to be reimbursed. Providers must follow applicable state and federal requirements for informed consent, privacy, medical record keeping, and fraud/waste/abuse as part of documentation standards.
- Submit approved HCPCS and CPT codes with appropriate modifiers per the applicable fee schedule.
- Document the telemedicine modality and encounter in the medical record; documentation is required for reimbursement and is subject to audit.
- Follow state and federal laws for informed consent, privacy, medical record keeping, and fraud/waste/abuse.
Facility fee rules for originating and distant sites
Payment includes a reasonable facility fee to the originating site when that site is operated by a licensed or certified professional or entity that is authorized to bill Arkansas Medicaid directly; there is no facility fee payable to the distant site and originating sites that are not authorized to bill Arkansas Medicaid are not eligible to bill a facility fee.
- Facility fee payable to originating site only if the originating professional/entity is authorized to bill Arkansas Medicaid directly.
- No facility fee for the distant site.
- Any originating sites not authorized to bill Arkansas Medicaid cannot bill a facility fee.
Enroll distant-site providers and document professional relationship
The distant-site professional or entity must be an enrolled Arkansas Medicaid provider and may only use telemedicine with a member when a documented professional relationship exists (exceptions described in allowed relationship criteria).
- Distant site provider must be an enrolled Arkansas Medicaid Provider.
- A professional relationship exists when the provider has previously conducted an in-person exam, personally knows the member through an ongoing relationship, is consulting upon referral with a provider who has an ongoing relationship and agreed to supervise, or has an on-call/cross-coverage arrangement with the member's regular treating provider.
- Telemedicine must not be used absent a documented professional relationship, except as allowed by the policy's relationship criteria.
Key Definitions
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