Emergency Measures to Address and Stop the Spread of COVID-19 — Telehealth Access, Prior Authorization and Reimbursement Guidance
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Directs Massachusetts commercial carriers and HMOs to expand telehealth access, waive prior authorization and cost-sharing for telehealth COVID-19 treatment, allow audio-only modalities, and require reimbursement parity and appropriate documentation during Governor Baker's Emergency Order.
Carriers must forego prior authorization requirements and cost-sharing for medically necessary Coronavirus treatment delivered via telehealth during the Emergency Order.
Carriers must permit all in-network providers to deliver clinically appropriate, medically necessary covered services via telehealth during the Emergency Order, including audio-only and live video.
Carriers must reimburse telehealth services at least at the same rate as comparable in-person services during the Emergency Order and should not include facility fees for distant/originating sites.
Telehealth Coverage During Emergency Order
Telehealth coverage during Emergency Order
Carriers must permit and cover telehealth-delivered medically necessary services as follows during the Emergency Order:
Carriers may set reasonable requirements but cannot impose technology-specific limitations (e.g., prohibit audio-only).
This modifies Bulletin 2020-02 for the duration of the Emergency Order.
Carriers may request telehealth place of service codes or modifiers for tracking but should not reduce reimbursement below contractually agreed rates; carriers may pend initial claims while systems are updated but must implement parity.
Providers prescribing via telehealth must comply with applicable statutes/regulations, maintain policies for timely and accurate prescription delivery (mail, phone, e-prescribing, fax), and document prescriptions and the substance of the encounter in the medical record consistent with in-person care.
This Bulletin clarifies that telehealth coverage during the Emergency Order is intended to mirror coverage for in‑person services: carriers must permit in‑network providers to deliver clinically appropriate, medically necessary services via telehealth for those services that the carrier already covers when provided in‑person. Carriers should make telehealth available across applicable service types (for example, medical, behavioral health, and non‑physician care) when in‑person treatment is not clinically required. However, this Bulletin does not obligate carriers to cover a service via telehealth if that service is not covered when delivered in‑person under the member’s plan.
What Providers and Billing Teams Must Do
Waive prior authorization for telehealth COVID‑19 treatment
During Governor Baker's Emergency Order, carriers must forego any prior authorization requirements for medically necessary Coronavirus treatment when that treatment is delivered via telehealth by in‑network providers; carriers also must not impose prior authorization barriers for telehealth services that would not apply in-person.
No new step therapy requirements
No additional step therapy directives are issued in this Bulletin beyond the waiver of prior authorization and cost‑sharing for medically necessary Coronavirus treatment delivered via telehealth during the Emergency Order.
Document encounters and prescriptions as you would in‑person
Providers must document the substance of the provider–patient encounter consistent with in‑person care—including patient history, chief complaint, relevant exams as applicable, assessment and plan—and must record prescriptions in the patient's medical record following applicable statutes and regulations.
- For new patients, review the patient's relevant medical history and records before initiating services.
- Follow consent, privacy, and location (distant/originating site) protocols and inform patients how to obtain in‑person care if needed.
Expect documentation review and possible claim pend
Carriers may review claims and supporting documentation to verify medical necessity and that the billed E/M level is supported by the encounter; as carriers update systems for telehealth reimbursement they may pend initial claims for review.
- Be prepared to supply documentation of patient history, chief complaint, exam findings, discussion time, and assessment to justify the E/M code billed.
- Claims may be pended while carrier systems are implemented, but carriers are expected to make reimbursements consistent with the Bulletin.
Key Definitions
Policy Background and Purpose
The Bulletin’s background intent is to reduce face‑to‑face encounters to limit transmission risk during Governor Baker’s Emergency Order and to ensure continued access to testing, diagnosis, counseling, and treatment. To achieve that objective, the Division expects carriers to expand telehealth access so clinicians can deliver needed care remotely when clinically appropriate.
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