CurrentHealth NetPolicy N/A

Telehealth services (Medi-Cal): coverage, billing, and provider requirements

Governs delivery, documentation, billing, and provider requirements for Medi-Cal covered benefits and services delivered via telehealth modalities in California; affects Medi-Cal enrolled providers and their patients.

Policy Summary

PayerHealth Net

PolicyTelehealth services (Medi-Cal): coverage, billing, and provider requirements

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionMaintain documentation equivalent to in-person services, obtain and record patient consent for telehealth (including audio-only), and be prepared to meet TAR requirements where applicable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3telehealth billing modifiers specified

Californialicensure requirement state

Audio-only allowedaudio-only allowed for new patients

Patient choice requiredpatient modality choice required

2e-consult CPT codes listed

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Q3014/T1014originating/transmission codes restricted

Coverage Criteria for Telehealth Services

Reimbursable Telehealth Services

Covered when ALL of the following are satisfied:

Telehealth Medical Appropriateness: The treating health care provider at the distant site believes the benefits/services are clinically appropriate to be delivered via telehealth based on evidence-based medicine and/or best practices.

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CPT/HCPCS Procedural Conformity: The benefits/services delivered via telehealth meet the procedural definition and components of the CPT or HCPCS code(s) associated with the Medi‑Cal covered service or benefit (as defined by the AMA and any extended guidelines in this section).

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Privacy and Confidentiality: The benefits/services provided via telehealth meet all laws regarding confidentiality of health care information and the patient's right to medical information.

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Reimbursable Telehealth Services

Covered when ALL of the following are met:

Telehealth coverage general criteria: Medi‑Cal covered benefits or services may be provided via telehealth only if the treating provider determines the service is clinically appropriate, the service meets the CPT/HCPCS procedural definition and components, and confidentiality and patient rights requirements are met.

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Establishing New Patients

Conditions permitting establishment of new patient via telehealth

New patient via video: Providers may establish a relationship with new patients via synchronous video telehealth visits.

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New patient via audio-only: Providers may establish a relationship with new patients via audio-only synchronous interaction only if one or more of the following apply: the visit is for a 'sensitive service' as defined in Civil Code section 56.05(s); the patient requests audio-only; or the patient attests they do not have access to video.

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Modality-specific Billing Criteria

Billing rules by telehealth modality:

Modifier assignment: Synchronous audio‑video services must be billed with modifier 95; asynchronous store‑and‑forward services must be billed with modifier GQ; synchronous audio‑only services must be billed with modifier 93. Only the portion(s) of the telehealth service rendered at the distant site are billed with the applicable modifier, and modifier use does not alter base code reimbursement.

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Audio-only standards: Audio‑only systems must permit real‑time interactive communication of sufficient quality to meet the procedural definition and components of the billed CPT/HCPCS code; providers must document patient written or verbal consent for audio‑only encounters. Audio‑only services are not eligible for originating site or transmission fees.

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E-Consult Coverage and Limits

E-consults covered when requirements below are met:

E-consult documentation and service components: Originating and distant site providers must document that the e‑consult relates to ongoing patient care. The distant‑site (consultant) provider must document review and analysis of transmitted information, record date and time spent, and produce a written report of findings and recommendations (99451 requires ≥5 minutes and a written report). The originating‑site (treating/referring) provider must document the request for e‑consult and preparation time (99452 requires ≥16 minutes preparation).

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E-consult reimbursement limits: CPT 99451 is not reimbursable more than once in a seven‑day period for the same patient and provider, is not reportable if the consultant saw the patient within the prior 14 days, and is not reportable if it results in a face‑to‑face visit within the next 14 days. CPT 99452 is not reimbursable more than once in a 14‑day period for the same patient and originating provider and requires at least 16 minutes preparation.

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Originating Site and Transmission Fee Criteria

Fees for originating site and transmission:

Originating site fee: HCPCS Q3014 (telehealth originating site facility fee) is reimbursable to the originating site and may be billed once per day for the same patient/same provider. When billing store‑and‑forward, originating site providers may bill Q3014 but may not bill the transmission fee.Once per day, same patient; same provider

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Transmission fee: HCPCS T1014 (telehealth transmission, per minute) is reimbursable for transmission costs with units in minutes; maximum of 90 minutes per day (1 unit = 1 minute) per same patient/same provider. Originating site and transmission fees are not available for audio‑only synchronous services.Maximum of 90 minutes per day (1 unit = minute)

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Patient-initiated asynchronous consultations (including those submitted via mobile applications) are not covered under this policy. As defined, asynchronous store-and-forward means transmission of a patient’s medical information from an originating site to a distant site, but consultations initiated directly by patients through electronic transmission are excluded from coverage. Additionally, services that inherently require the patient’s in-person presence (see examples below) are not appropriate for telehealth delivery.

Services that are performed in an operating room or while the patient is under anesthesia, that require direct visualization or instrumentation of bodily structures, that involve sampling of tissue, or that require insertion or removal of medical devices are not appropriate for telehealth. Any benefit or service that, by its nature, requires the in-person presence of the patient is excluded from telehealth reimbursement.

The brief virtual communication and e-consult provisions in this policy do not apply to Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs), or clinics operating under the Indian Health Service Memorandum of Agreement (IHS‑MOA). Those clinic types must follow the billing and policy guidance specific to their respective manuals (RHCs, FQHCs, and IHS/MOA clinics).

Benefits or services that inherently require the in-person presence of the patient — for example, operative procedures, services under anesthesia, direct visualization or instrumentation, tissue sampling, or device insertion/removal — are not appropriate for telehealth and therefore are not reimbursable when delivered via telehealth modalities.

Coding, Modifiers, and Fee Codes

Telehealth ModifiersModifierCovered

95	Modifier for synchronous interactive audio and visual telecommunications systems
GQ	Modifier for asynchronous store and forward telecommunications systems
93	Modifier for synchronous telephone or other real-time interactive audio-only telecommunications systems

Telehealth ModifiersModifier

95	Modifier for synchronous interactive audio-video telehealth
GQ	Modifier for asynchronous store-and-forward telehealth
93	Modifier for synchronous audio-only telehealth

E-Consult CPT CodesCPTCovered

99451	Interprofessional telephonelInternetlelectronic health record assessment and management service provided by a consultative physician or other qualified health care professional, including a written report to the patient's treating/requesting physician, 5 minutes or more of medical consultative time
99452	Interprofessional telephonelInternetlelectronic health record referral service(s) provided by a treating/requesting physician or other qualified health care professional, 30 minutes

Brief Virtual CommunicationsHCPCS | CPTCovered

G2010	Remote evaluation of recorded video and/or images submitted by an established patient, including interpretation with follow-up within 24 hours (not originating from a related E/M service within previous 7 days nor leading to an E/M within next 24 hours)
98016	Brief communication technology-based service (virtual check-in) by a physician or other qualified health care professional for an established patient; 5-10 minutes of medical discussion (not originating from a related E/M within previous 7 days nor leading to an E/M within next 24 hours)

Originating Site and Transmission FeesHCPCS

Q3014	Telehealth originating site facility fee (originating site reimbursed; frequency limit: once per day, same patient; same provider)
T1014	Telehealth transmission, per minute (transmission fee); professional services billed separately; frequency limit: maximum of 90 minutes per day (1 unit = 1 minute), same patient; same provider

E-consult time and frequency limits

99451 (distant-site consultant)Requires at least 5 minutes of consultative time and a written report; not reimbursable more than once in a 7‑day period for the same patient and provider; not reportable if consultant saw patient within prior 14 days or leads to face‑to‑face within next 14 days.

99452 (originating/treating provider)Requires at least 16 minutes of preparation/communication by the originating/treating provider; not reimbursable more than once in a 14‑day period for the same patient and provider.

Documentation requirementsOriginating site must record that the e‑consult relates to ongoing patient management and the request for the e‑consult; distant site must document review, date/time spent, and a written report conveyed to the originating site.

T1014 frequency limit

Provider Actions, Documentation, and Authorization

Prior Authorization

TAR and Existing Medi‑Cal Requirements

Services provided via telehealth remain subject to all existing Medi‑Cal coverage and reimbursement policies, including any Treatment Authorization Request (TAR) requirements. Providers must ensure any service billed via telehealth meets TAR rules where applicable and follow existing Medi‑Cal operational requirements for authorization prior to delivery or billing when those requirements apply.

Telehealth services are subject to any applicable TAR requirements
Ensure prior authorization is obtained per existing Medi‑Cal rules before delivering/billing services that require TAR

Documentation Required

Audio‑Only Documentation and Consent

For synchronous audio‑only telehealth (modifier 93), providers must document that the patient gave written or verbal consent for the audio‑only encounter. The audio system used must allow real‑time communication and be of sufficient quality/resolution to support the procedural components of the billed CPT/HCPCS code. If documentation of consent or sufficient audio quality/documentation is absent such that the encounter does not meet the procedural definition of the billed code, the claim is at risk for denial.

Definitions

Telehealth definition

DefinitionTelehealth means delivering health care services via information and communication technologies to facilitate diagnosis, consultation, treatment, education, care management and self‑management.

Modalities includedIncludes both synchronous interactions (real‑time) and asynchronous store‑and‑forward transfers.

ScopeFacilitates patient self‑management and caregiver support and applies to covered benefits/services identified by CPT/HCPCS codes when procedural components are met.

Asynchronous (store-and-forward) definition

DefinitionAsynchronous store and forward means transmission of a patient's medical information from an originating site to a health care provider at a distant site.

Patient‑initiated transmissions

Background

Telehealth encompasses both synchronous (real‑time) interactions and asynchronous (store-and-forward) transmission of patient data to support diagnosis, consultation, treatment, education, and care management. E‑consults are asynchronous provider-to-provider consultations where the consulting clinician reviews the patient record and documents time spent and written recommendations. Brief virtual communications (e.g., HCPCS G2010, CPT 98016) are short remote evaluations or virtual check-ins for established patients and have specific billing conditions and timing restrictions.

Policy Summary

PayerHealth Net

PolicyTelehealth services (Medi-Cal): coverage, billing, and provider requirements

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionMaintain documentation equivalent to in-person services, obtain and record patient consent for telehealth (including audio-only), and be prepared to meet TAR requirements where applicable.

SourceLink

On This Page

T1014 (transmission fee)

Billed per minute (1 unit = 1 minute); maximum of 90 minutes per day for the same patient and same provider.

Site assignmentT1014 may be billed to originating and distant sites as specified in the policy; transmission fees are not available for audio‑only services.

FQHC/RHC/IHS exceptionOriginating site and transmission fee restrictions do not apply to FQHCs, RHCs, or IHS‑MOA clinics (see manual sections referenced).

Q3014 frequency limit

Q3014 (originating site facility fee)Reimbursable once per day for the same patient and same provider when billed by the originating site.

Store-and-forward ruleWhen billing for store‑and‑forward services (including e‑consults), the originating site may bill Q3014 but may not bill the transmission fee (T1014) for the same service.

FQHC/RHC/IHS exceptionOriginating site and transmission fee rules are not applicable to FQHCs, RHCs, or IHS‑MOA clinics; those clinics follow separate manuals.

Document written or verbal patient consent for audio‑only encounters in the medical record
Use audio equipment capable of meeting procedural code requirements and document sufficient exchange to meet code components
Insufficient consent or documentation for audio‑only encounters may lead to claim denial

Documentation Required

Consent and E‑Consult Recordkeeping

When billing for e‑consults, both originating and distant site providers must clearly document and retain in the patient's medical record the required items related to the consult. Origination site records must show the e‑consult request, that the e‑consult relates to patient care/ongoing management, and pertinent prior care information. Distant site providers must document review/analysis (including date/time and time spent) and provide a written report of findings and recommendations conveyed to the originating site. All documentation must be available to DHCS upon request.

Originating site: record of e‑consult request, relation to patient care/ongoing management, and pertinent prior care
Distant site: record of review/analysis with date/time and time spent; written report of findings and recommendations conveyed to originating site
Maintain all e‑consult documentation in the patient's medical record and make available to DHCS upon request

Note

Linkage to In‑Person Care

Providers offering telehealth must either offer in‑person services themselves or maintain a documented process to link Medi‑Cal recipients to in‑person care within a reasonable time when in‑person services are unavailable. If linking to another provider, the referring provider must facilitate referral and ensure the referred provider at least attempts to contact the recipient to schedule an in‑person appointment. The linkage process must minimize burden on the recipient and be documented and available to DHCS upon request.

Offer in‑person services or have a documented linkage process to in‑person care
If referring, provide referral and facilitation that does not require the recipient to independently find another Medi‑Cal provider
Maintain documentation that the referred provider attempted to contact the recipient; documentation of the linkage process must be available to DHCS

Billing Rule

Clinical Appropriateness, Code Conformity, and General Documentation

Telehealth services must meet the procedural definitions and components of the billed CPT/HCPCS codes and be clinically appropriate. Maintain documentation in the patient's medical record equivalent to what would be required for a comparable in‑person service, including evidence supporting clinical appropriateness and any required consents. Providers are not required to document barriers to in‑person visits or cost‑effectiveness of telehealth for Medi‑Cal coverage, but must retain all records that substantiate the technical and professional components of billed services.

Document clinical appropriateness and that the telehealth encounter meets procedural code components
Maintain the same level and type of documentation as for comparable in‑person services in the medical record
No requirement to document barriers to in‑person visits or cost‑effectiveness for Medi‑Cal telehealth coverage

Consultations initiated directly by patients (including via mobile apps) are not covered under this policy.

Use casesUsed for e‑consults and other non‑real‑time clinical communications between sites/providers.

E-consults definition

DefinitionE‑consults are asynchronous provider‑to‑provider consultation services where a treating provider requests the opinion or treatment advice of a consultant without patient face‑to‑face contact.

Permissible partiesE‑consults are permissible only between health care providers (originating/treating and distant/consultant providers).

Documentation and billingOriginating site must document the e‑consult request and relation to ongoing care; distant site must document review, time spent and provide a written report to the originating site (these requirements support billing CPT codes such as 99451/99452).

Synchronous interaction definition

DefinitionSynchronous interaction means a real‑time interaction between a patient and a health care provider located at a distant site.

ExamplesIncludes video visits and audio‑only telephone encounters when conducted in real time.

Documentation expectationProviders must document patient consent for audio‑only encounters and ensure audio/video quality sufficient to meet procedural code components.

E‑consult and brief virtual communication

E‑consult / brief virtual communication distinctionE‑consults are interprofessional store‑and‑forward or electronic communications where providers document review, time spent and written recommendations; brief virtual communications (G2010, 98016) are short remote evaluations or virtual check‑ins for established patients that do not lead to immediate E/M services.

Codes referencedBrief virtual communications: HCPCS G2010 and CPT 98016; E‑consults commonly billed with CPT 99451 (distant) and 99452 (originating) with modifier GQ where applicable.

DocumentationBoth types require documentation in the patient's medical record demonstrating relation to care and timing relative to other E/M services per policy rules.