Managed Care Practices and Continued Access to Telehealth Services
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This Bulletin directs Massachusetts-regulated commercial carriers on implementation expectations for telehealth coverage, reimbursement parity, utilization review, and provider requirements under Chapter 260 and supplements Bulletin 2020-04; it applies to commercial health insurers, Blue Cross and Blue Shield of Massachusetts, Inc., and HMOs operating in Massachusetts.
No material clinical or coverage changes in this revision.
Telehealth Coverage and Operational Criteria
Telehealth coverage and operational criteria
Covered when ALL of the following conditions are met:
ALL of the following
- Primary care and chronic care services delivered via telehealth must be reimbursed at the same level as in-person services for two years following passage of Chapter 260.
- Behavioral health services delivered via telehealth must be reimbursed at the same level as in-person services in perpetuity.
ALL of the following
- Carriers must reimburse providers for telehealth services at least at the rate defined in Chapter 260.
- Where carrier-provider agreements are inconsistent with Chapter 260 reimbursement requirements, carriers must take steps to align contractual arrangements to ensure reimbursement is no less than required by Chapter 260.
ALL of the following
- Carriers may perform utilization review or require preauthorization to determine the appropriateness of telehealth as the means of delivering a health care service.
- Such determinations must be made in the same manner as if the service were delivered in person.
- Carriers should not implement changes to utilization review or prior authorization processes for telehealth prior to submitting required implementation plans to the Division.
ALL of the following
- Providers delivering telehealth must comply with applicable state and federal statutes and regulations governing medication management and prescribing; they must maintain policies to provide timely and accurate prescriptions (mail, phone, e-prescribing, and/or fax) and document prescriptions in the patient medical record consistent with in-person care.
- For initial appointments with a new patient, the provider must review the patient's relevant medical history and any relevant medical records with the patient before initiating any service; for existing patients, the provider must review medical history and available records during the service.
- If a provider cannot meet the appropriate standard of care via telehealth, the provider must determine this prior to treatment, notify the patient, and advise the patient to seek in-person care.
- Providers must, to the extent feasible, ensure patient confidentiality and security equivalent to face-to-face services and inform patients of relevant privacy considerations prior to providing telehealth services.
ALL of the following
- Carriers may require the same claim submission documentation and supporting medical record information for telehealth encounters as for in-person visits, including documentation that the reason for the visit medically supports the level of service billed.
- Carriers may evaluate E/M coding and require documentation to support the complexity/time of the visit, and may require providers to present claim documentation for reimbursement qualification.
- Carriers may request use of a telehealth-specific place of service code or telehealth modifier when providers submit claims to record services provided via telehealth for tracking purposes.
ALL of the following
- Carriers may establish reasonable requirements for telehealth but may not impose technology-specific limitations (including limitations on audio-only or live video) absent Division guidance; carriers are expected to continue to provide access in a comparable manner until the Division issues further standards.
ALL of the following
- Telehealth reimbursement parity provided under Chapter 260 continues until at least 90 days after termination of the declared state of emergency; carriers must remain in compliance with this Bulletin while the Division issues further guidance and implementation plans must be submitted to the Division prior to making changes to utilization review or other processes.
Carriers are expected to communicate clearly with in-network providers about how to submit telehealth claims and any documentation requirements; carriers may continue to evaluate CPT/E/M documentation and require supporting records for claims review.
Telehealth Claim Coding
| place of service code or telehealth modifier | Carriers may request use of a telehealth-specific place of service code or modifier when submitting claims to record services provided via telehealth. |
Utilization Review, Preauthorization, and Provider Responsibilities
Utilization review and preauthorization for telehealth — submit implementation plan before changes
Carriers may perform utilization review, including preauthorization, to determine whether telehealth is an appropriate means of delivering a health care service, but any such determination must be made in the same manner as if the service were delivered in person. Carriers must not implement changes to telehealth utilization-review or preauthorization practices before submitting an implementation plan to the Division for review. The Division requests carriers submit by May 17, 2021: (1) proposed plans to inform members about accessing telehealth through in‑network providers (primary care, specialty care, behavioral health, and chronic‑condition providers); and (2) proposed plans to develop telehealth utilization‑review guidelines, define coding for reimbursement, and hold informational meetings for contracting providers about telehealth implementation and any related utilization‑review procedures.
- Determinations about appropriateness of telehealth must be made the same way as for in‑person services.
- Carriers must provide the Division an implementation plan before making changes to telehealth utilization‑review or preauthorization practices.
- Implementation plans should include: member communication plans for accessing in‑network telehealth; telehealth utilization‑review guideline development; defined coding for reimbursement; and plans to educate contracting providers on telehealth implementation and utilization‑review procedures.
Statutory References and Modality Definitions
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