ModifiedMass General Brigham Health PlanPolicy N/A

Telemedicine/Telehealth reimbursement

Defines Mass General Brigham Health Plan's reimbursement and billing requirements for telemedicine/telehealth services delivered by contracted providers, including modality definitions, provider requirements, and eligible procedure codes. Applies to contracted providers serving the plan's members.

Policy Summary

PayerMass General Brigham Health Plan

PolicyTelemedicine/Telehealth reimbursement

Policy CodePolicy N/A

Change TypeReimbursement rate revision + POS updates

Effective Date1/1/2024

Next Review DateN/A

Key ActionProviders must meet state licensure requirements and file claims with appropriate modifiers and place of service codes.

SourceLink

POLICY UPDATE CHANGES

Beginning January 1, 2024, specialty services delivered via telehealth will be reimbursed at 85% of in-person rates, with exceptions for primary care and behavioral health.

Commercial and Medicare Advantage telemedicine place of service code updates effective 1/1/2022 and MassHealth/ACO effective 10/01/2023 were documented.

MassHealth effective date for Telemedicine place of service codes was added October 1, 2023.

85%Specialty telehealth reimbursement vs in-person

100%Primary care & behavioral health telehealth reimbursement

1/1/2022Commercial POS update effective

10/01/2023

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

MassHealth POS update effective

93,95,FR,FQ,GO,GQ,GTTelemedicine modifiers listed

Coverage and Payment Criteria

Telemedicine coverage criteria

Covered when ALL of the following are met:

ALL of the following

Clinically appropriate, medically necessary covered services consistent with applicable state mandates and the member's benefit plan.
Evaluation and management components provided via telemedicine include at least a problem-focused history and straightforward medical decision making as defined by CPT.
Providers are eligible to independently perform and bill the equivalent face-to-face service and document a permanent record of online communications in the patient's medical record when applicable.
Services are filed with the appropriate telemedicine modifiers and place of service codes as required by the plan.

ALL of the following

Billing and payment rules: Telephonic and digital E&M codes should not be appended with telemedicine modifiers; routine or incidental communications (eg, test results, scheduling, administrative matters) are not separately compensated.
Telemedicine/telehealth services performed the same day as a face-to-face visit for the same condition by the same provider are not separately payable.
Telemedicine E&M services performed on the same day as a surgical procedure are not reimbursed unless the service is significant, separately identifiable, and above and beyond usual pre/postoperative care.

Telehealth payment criteria

Reimbursement rules for telehealth-delivered services effective January 1, 2024:

Most specialty services delivered via telehealth will be reimbursed at 85% of the in-person rate.

Exceptions: Primary care and behavioral health services (unless otherwise specified in a provider contract or applicable state regulation) will continue to be reimbursed at 100% of the in-person rate.

All telehealth claims are subject to audit and medical record requests.

In the event of a conflict between this payment guideline and a provider's contract, the provider contract prevails.

For telehealth visits, the Health Care Professional must obtain patient consent that the encounter will constitute a Visit and may be subject to health benefit plan cost-sharing if reimbursement is sought.

Procedure Codes, Modifiers, and Coding Rules

Telemedicine and digital E&M code listmixed

98000-98016	Proprietary telephonic & digital E&M codes (new and established patient time- and decision-making–based descriptions).
98966-98968, 98970-98972	Telephone assessment and non-physician online digital E&M codes with time ranges.
99421-99423, 99446-99449	Online digital E&M and interprofessional consult codes with time-based descriptions.

ModifiersModifier

93	Synchronous telemedicine service rendered via telephone or other real-time interactive audio-only telecommunications system (Effective January 1, 2022).
95	Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunication system.
FR	The supervising practitioner was present through two-way, audio/video communication technology (Effective January 1, 2022).
FQ	Service furnished using audio-only communication technology.
GO	Telehealth services for diagnosis, evaluation, or treatment, of symptoms of an acute stroke.
GQ	Via asynchronous telecommunications system.
GT	Via interactive audio and video telecommunications system.

Historical CPT and modifier updatesmixed

No codes listed

Time thresholds for code selection

Time-based selection summaryEach telephonic and digital E&M code is selected using total time on the date of the encounter (or cumulative time as specified) with minimum thresholds that vary by code (examples in policy: 10, 15, 20, 30, 40, 45, 60 minutes).

Examples — new patient synchronous audio-videoCodes 98000–98003 require minimum total times on the date of encounter of 15, 30, 45, and 60 minutes respectively for different levels of decision making.

Examples — established patient synchronous audio-videoCodes 98004–98007 require minimum total times on the date of encounter of 10, 20, 30, and 40 minutes respectively for different levels of decision making.

Examples — synchronous audio-only visitsCodes 98008–98011 (new patient) and 98012–98014 (established) specify minimum total times such as 15, 30, 45, 60 minutes for selection depending on level and discussion time.

LOB applicability

Provider Billing, Consent, and Claims Requirements

Documentation Required

Consent and Administrative Requirements for Telehealth

Providers must obtain patient consent for telehealth encounters consistent with Massachusetts requirements and the member's benefit plan. Consent should inform the patient that the encounter will constitute a visit, may be subject to cost-sharing, and that the provider may seek reimbursement from the patient or the patient’s carrier. Consent may be documented in the medical record and should be obtained prior to the telehealth encounter when feasible. Telehealth services must be delivered via a secure, private data connection and comply with HIPAA and state privacy regulations.

Obtain and document patient consent that the encounter is a visit and may be subject to cost‑sharing.
Ensure consent aligns with the state where the member is physically located at time of service.
Use secure, private connections and maintain documentation in the permanent medical record.

Definitions and Place of Service Codes

Telemedicine

DefinitionTelemedicine is the use of synchronous or asynchronous audio, video, electronic media, or other telecommunications technology (including interactive audio-video technology, remote patient monitoring devices, audio-only telephone, and online adaptive interviews) to evaluate, diagnose, consult, prescribe, treat, manage, or monitor a patient's health condition.

Provider obligationsProviders must deliver telemedicine via a secure and private data connection and comply with HIPAA; licensure and regulatory requirements of the state where the member is physically located at the time of service apply.

ScopeApplies to evaluation, diagnosis, consultation, prescribing, treatment, management, and monitoring across physical, oral, mental health, and substance use disorder conditions.

Asynchronous telecommunication (store-and-forward)

DefinitionAsynchronous telecommunication (store-and-forward) is the process where medical information is stored and forwarded to be reviewed at a later time by a physician or health care practitioner at a distant site; the review occurs without the patient present.

Policy Summary

PayerMass General Brigham Health Plan

PolicyTelemedicine/Telehealth reimbursement

Policy CodePolicy N/A

Change TypeReimbursement rate revision + POS updates

Effective Date1/1/2024

Next Review DateN/A

Key ActionProviders must meet state licensure requirements and file claims with appropriate modifiers and place of service codes.

SourceLink

On This Page

Policy notes many of these telephonic & digital E&M codes are reimbursable for Commercial lines of business; see code comments for specific reimbursement applicability.

Telehealth parity period

Policy change effective 1/1/2024Beginning January 1, 2024, most specialty services delivered via telehealth will be reimbursed at 85% of in-person rates.

ExceptionsPrimary care and behavioral health services will continue to be reimbursed at 100% of in-person rates unless otherwise specified in provider contract or state regulation.

Background — temporary parityTemporary parity for telehealth rates during the COVID-19 public health emergency has ended; the prepandemic rate differential was restored effective 1/1/2024.

Billing Rule

Claim Adjudication Dependencies

Claims for telemedicine/telehealth are adjudicated based on member eligibility and benefits on the date of service and are subject to coordination of benefits, referral/authorization/notification, utilization management, and provider contractual terms. Claims payment is also subject to claims editing logic, industry-standard coding conventions, and any applicable modifiers and place of service codes. Providers must submit claims with appropriate modifiers and place of service codes. Note that telehealth payment rates may differ from in‑person rates per plan and state rules (e.g., 85% of in‑person rates with certain exceptions per contract or state regulation). In the event of a conflict between this guideline and a provider’s agreement, the provider agreement governs.

Verify member eligibility and benefits for the date of service before billing.
Confirm and obtain any required prior authorization, referrals, or notifications per the member's plan.
Apply appropriate modifiers and place of service codes as specified by current CPT guidance and payer rules.
Be aware of plan-specific telehealth payment differentials and contract terms that may affect payment.
Claims are processed per plan rules, claims editing logic, and the provider contract; contractual terms prevail if conflicts arise.

Also calledAlso referred to as store-and-forward telehealth or noninteractive telecommunication.

Use caseUsed when direct real-time interaction is not required and the clinician reviews transmitted medical information later.

Interactive audio-video telecommunication

DefinitionInteractive audio-video telecommunication is real-time communication between the patient and a distant physician or health care specialist; the patient must be present and participating throughout the communication.

ModalityRequires synchronous audio and video communications equipment to support real-time interaction.

ReportingUsed when the service is performed live with patient participation for evaluation and management or specialist consultation.

Telehealth Provided Other than in Patient's Home — POS 02

POS codePOS 02 — Telehealth Provided Other than in Patient's Home: the location where health services are provided or received through telecommunication technology when the patient is not in their home.

Effective dates notedPolicy documents place-of-service guidance updates with effective dates for lines of business (Commercial/Medicare Advantage and MassHealth) in the publication history.

Claims auditAll claims for telehealth services, including those billed with POS 02, are subject to audit and medical record requests.

Telehealth Provided in Patient's Home — POS 10

POS codePOS 10 — Telehealth Provided in Patient's Home: the location where health services and health-related services are provided or received in the patient's home via telecommunication technology.

AuditabilityClaims for services provided in the patient's home (POS 10) are subject to audit and medical record requests.

Documentation and editsPlace-of-service coding updates and administrative edits are tracked in the policy publication history; providers must follow current POS guidance when filing claims.