CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Telemedicine / Telehealth coverage and billing rules

Defines reimbursement requirements, coverage scope, provider types, coverage limitations, exclusions, claim submission and coding/billing instructions for telemedicine services for Commercial, INTEGRITY, and Medicaid lines in Rhode Island.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyTelemedicine / Telehealth coverage and billing rules

Policy CodePolicy N/A

Change TypeFormat / effective date noted

Effective DateDec 31, 2018

Next Review Date

Key ActionReport POS 02 and include modifier 952 for synchronous realtime audiovisual telemedicine, document medical necessity/licensure/consent, and submit complete claims within 90 days.

POLICY UPDATE CHANGES

Policy effective 12/31/2018.

>50Example CPT/HCPCS codes listed

1/3 daysHospital telehealth visit frequency limit

1/30 daysNursing facility telehealth visit frequency limit

90Claim submission timeframe (days)

Policy Overview

Policy subject: Telemedicine / Telehealth coverage and billing rules for Neighborhood Health Plan of Rhode Island. Scope: applies to Commercial, INTEGRITY, and Medicaid lines as set out by Rhode Island law and applicable contracts.

Background: Telemedicine services include real-time, two-way audiovisual communications and permitted store-and-forward technology where allowed by law and program rules. Services must be medically necessary, performed within scope of state licensure, meet the same standard of care as face-to-face encounters, and follow technology/compliance requirements (HIPAA-compliant, encryption, secure access and informed member consent).

Billing and reimbursement summary: Telemedicine is not a distinct benefit and is reimbursed as the service provided using telemedicine place-of-service and modifier conventions. Providers must bill with the telemedicine Place of Service (POS) 02 and include required modifiers (e.g., modifier 952; GT modifier rules apply to institutional CAH claims) and comply with usual benefit limits, service-specific coverage rules, authorization requirements, coding standards, and claim timeliness (submit within 90 days).

Payer metadata and effective date: Payer = Neighborhood Health Plan of Rhode Island. Policy effective date: 2018-12-31.

Coverage Criteria and Limits

General Medical Necessity and Licensure

Coverage provided when ALL of the following are met:

ALL of the following

Services must be medically necessary to qualify for reimbursement.
Services must be performed within the scope of state licensure as defined by the Rhode Island Department of Health.
Service-specific criteria, benefit limitations, and authorization requirements may apply (refer to Clinical Medical Policies and service-specific Coverage and Reimbursement policies).
Communication exchanged must be sufficient in amount and nature to meet the service as if rendered face-to-face.

Technology and Compliance Requirements (Medicaid & Commercial)

To be considered compliant telemedicine technology must meet ALL of the following:

ALL of the following

Utilize HIPAA-compliant real-time, two-way secure audiovisual video conferencing or store-and-forward technology (per Telemedicine Coverage Act).
Use encryption software for data transmission.
Have a secure access portal with multi-level authentication, individual user credentials, and defined user access.
Providers are required to obtain informed member consent and describe potential benefits, risks, and consequences of telemedicine.
Treatment must meet the same standard of care as a face-to-face encounter and be an appropriate substitute.

Originating Site and Medicare INTEGRITY Requirements

Medicare beneficiaries eligible for telehealth only if originating site and site type meet criteria:

ALL of the following

Originating site must be located in a county outside of a Metropolitan Statistical Area (MSA) or meet other Medicare geographic rules.
Allowed originating site types include Office of a physician or practitioner; Critical Access Hospital (CAH); Hospital (inpatient or outpatient); Rural Health Clinic (RHC); Federally Qualified Health Center (FQHC); hospital-based or critical access hospital-based renal dialysis center; Community Mental Health Center (CMHC); Skilled Nursing Facility (SNF).

Allowed Provider Types

Coverage for telemedicine limited to the following provider types (lists differ slightly by INTEGRITY vs Medicaid/Commercial):

ONE of

Clinical nurse specialist (CNS)
INTEGRITY and Medicaid/Commercial lists include CNS
Clinical social worker (CSW)
Nurse Midwife
Nurse practitioner (NP)
Physician assistant (PA)

Coverage Limitations (Frequency)

ALL of the following

Subsequent hospital services: limited to 1 telehealth visit every 3 days.1 per 3 days
Subsequent nursing facility care services: limited to 1 telehealth visit every 30 days.1 per 30 days

Coverage Exclusions

Telemedicine services are NOT covered when ANY of the following apply:

ANY of the following

Asynchronous 'store-and-forward' technology is non-covered for INTEGRITY members except in federal demonstration programs in Alaska or Hawaii.
Telemedicine services provided to a member at an independent renal dialysis facility.
Audio-only telephone conversation.
Email message.
Facsimile transmission.

Coding & Claim Reporting

Telemedicine Place of Service / Modifiers / Claim rulesmixedCovered

POS 02	Place of Service code to indicate service delivered via telemedicine
Modifier 952	Synchronous telemedicine service rendered via realtime interactive audio and video telecommunication system (claims must include modifier 952)
GT	Former synchronous modifier; professional claims no longer require GT as of 1/1/18; institutional CAH claims require GT

Example Covered CPT/HCPCS codes that may apply to telemedicine (inclusion does not guarantee coverage)CPT

90791	Psychiatric diagnostic evaluation
90792	Psychiatric diagnostic evaluation with medical services
90832	Psychotherapy 30 minutes
90834	Psychotherapy 45 minutes
90836	Psychotherapy 45 minutes with E/M
90837	Psychotherapy 60 minutes
90838	Psychotherapy 60 minutes with E/M
90845	Psychoanalysis
90846	Family psychotherapy without patient present
90847	Family psychotherapy with patient present

1–10 of 104

1/11

Billing Rule

Place of Service and Modifier Requirements

Report Place of Service (POS) 02 on claims to indicate telemedicine; include modifier 952 for synchronous realtime interactive audiovisual telecommunication. Professional claims no longer require GT as of 1/1/18; institutional Critical Access Hospital (CAH) claims require GT.

Affected codes: POS 02
Modifier 952 (synchronous realtime interactive audiovisual)
GT no longer required on professional claims as of 1/1/18
GT still required on institutional CAH claims

Documentation Required

Coding Standards

Coding must meet the authoritative code set standards: CPT (AMA Current Procedural Terminology), ICD-10-CM, and HCPCS Level II. Any adjustments, corrections, or reconsiderations must include required forms and comply with National Claims Standards.

Provider Requirements, Documentation, and Billing Rules

Documentation Required

Medical Necessity and Standard of Care Documentation

Document that the telemedicine service was medically necessary, performed within the provider's scope of state licensure, met the same standard of care as a face-to-face encounter, and that informed member consent (including potential benefits, risks, and consequences) was obtained.

Billing Rule

Claim Timeliness

Submit complete claims for payment within 90 days of the date services are provided.

Denial Risk

Noncompliant Technology or Excluded Modes

Excluded modalities include audio-only telephone, email messages, and facsimile (fax). Claims for telemedicine using these excluded modes or for noncompliant asynchronous store-and-forward where not permitted may be denied.

Excluded: audio-only telephone
Excluded: email message
Excluded: facsimile transmission
Noncompliant asynchronous store-and-forward (where not allowed) may be denied

Prior Authorization

Authorization May Be Required

Service-specific authorizations may apply. Contact Utilization Management at (401) 459-6060 for details and refer to Neighborhood Clinical Medical Policies when no specific policy exists.

Medicare References

Medicare determinations reference: the Medicare Claims Processing Manual (Pub. 100-04), Chapter 12, 0190.3 is cited as the List of Medicare Telehealth Services reference.

Medicare-specific rules: Medicare beneficiary eligibility for telehealth depends on originating site geographic and site-type requirements (detailed under Medicare originating site geographic and site-type rules in the policy's Medicare/INTEGRITY criteria).

Policy Revision History

2018-12-31added

Policy effective 12/31/2018; format change noted

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyTelemedicine / Telehealth coverage and billing rules

Policy CodePolicy N/A

Change TypeFormat / effective date noted

Effective DateDec 31, 2018

Next Review Date

Key ActionReport POS 02 and include modifier 952 for synchronous realtime audiovisual telemedicine, document medical necessity/licensure/consent, and submit complete claims within 90 days.

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OpenPayer

Telemedicine / Telehealth coverage and billing rules

Policy Overview

Coverage Criteria and Limits

Coding & Claim Reporting

Provider Requirements, Documentation, and Billing Rules

Key Definitions

Medicare References

Policy Revision History