CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Telemedicine Services Payment Policy 04.13.20 To 05.06.20

Defines reimbursement, coverage requirements, coding, billing modifiers, provider types, originating site rules, exclusions, and claim submission requirements for telemedicine services for Commercial, INTEGRITY, and Medicaid lines (excluding EFP) in Rhode Island.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyTelemedicine Services Payment Policy 04.13.20 To 05.06.20

Policy CodePolicy N/A

Change TypeCoding and wording updates

Effective DateDec 31, 2018

Next Review Date

Key ActionUse Place of Service (POS) 02 on claims and include modifier '95' for synchronous real-time audio/video telemedicine; contact Utilization Management for prior authorization and document informed member consent.

SourceLink

POLICY UPDATE CHANGES

04/13/20: Update to add code Q3014.

03/03/20: Policy update added Medicaid wording, Medicare coding, and format change.

12/31/18: Policy effective.

1Telehealth POS required (POS 02)

Modifier 95Required professional modifier

Q3014Originating site facility fee code added

90 daysClaim timely filing window

Policy Overview

Background: Telemedicine is defined as delivery of clinical health-care services using real-time, two-way electronic audiovisual communications, and the policy also recognizes the permissibility of store-and-forward technology as allowed by state law. Telemedicine services are treated as the place-of-service equivalent to face-to-face encounters and must meet the same standards of care and documentation as in-person services.

Legal and program references: Coverage is provided consistent with the Rhode Island Telemedicine Coverage Act and applicable State of Rhode Island government program contracts; for INTEGRITY members the policy follows Medicare-like telehealth rules (including originating site restrictions and use of interactive audio-video systems). The document history notes the addition of HCPCS code Q3014 on 04/13/20 and prior updates adding Medicaid and Medicare coding references.

Scope summary: This policy applies to Commercial, INTEGRITY, and Medicaid (excluding Extended Family Planning) and covers reimbursement and coverage requirements, coding and billing modifiers, approved provider types, originating site rules, exclusions, and claim submission requirements for telemedicine services.

Document Header Facts

PayerNeighborhood Health Plan of Rhode Island

Policy TitleTelemedicine Services Payment Policy 04.13.20 To 05.06.20

Policy NumberN/A

Effective Date2018-12-31

Last Review2020-04-13

Next Review

StatusCURRENT

Key ActionUse POS 02 on claims and include modifier '95' for synchronous real-time audio/video telemedicine; obtain and document informed member consent; submit complete claims within 90 days; institutional CAH claims require modifier GT; ensure technology is HIPAA-compliant and meet plan prior authorization/benefit limits as applicable.

Coverage Criteria & Limits

Coding, Modifiers & Claim Submission

Telehealth and Related CPT/HCPCS Codes (informational list of applicable codes)mixed

90791	Psychiatric diagnostic evaluation
90792	Psychiatric diagnostic evaluation with medical services
90832	Psychotherapy, 30 minutes with patient
90833	Psychotherapy, 30 minutes with patient when performed with an E/M service
90834	Psychotherapy, 45 minutes with patient
90836	Psychotherapy, 45 minutes with patient when performed with an E/M service
90837	Psychotherapy, 60 minutes with patient
90838	Psychotherapy, 60 minutes with patient when performed with an E/M service
90845	Psychoanalysis
90846	Family psychotherapy (without the patient present), 50 minutes

1–10 of 111

1/12

Billing Rule

Place of Service and Modifier Requirements

Use Place of Service (POS) 02 on claims for telemedicine and include modifier '95' for synchronous real-time audio/video telemedicine. Professional claims no longer require GT as of 1/1/18; institutional Critical Access Hospital (CAH) telehealth claims require GT.

Professional claims no longer require GT as of 1/1/18
Institutional CAH claims require GT

Billing Rule

Timely Filing

Submit complete claims within 90 days of date of service.

Provider Requirements & Risks

Prior Authorization

Prior Authorization and Benefit Limits

Service-specific prior authorization and benefit limits may apply. Providers should refer to the plan-specific Prior Authorization Reference page and Neighborhood's Clinical Medical Policies, and contact Utilization Management at (401) 459-6060 for details.

Documentation Required

Informed Consent Requirement

Providers are required to obtain informed member consent and document that potential benefits, risks, and consequences of telemedicine were explained and that treatment meets the same standard of care as a face-to-face encounter.

Key Definitions

Definitions

TelemedicineDelivery of clinical health-care services by means of real time, two-way electronic audiovisual communications, including secure video conferencing or store-and-forward technology.

Originating siteLocation of an eligible Medicare beneficiary at time the telemedicine service occurs; for INTEGRITY limited to specific facility types listed in policy.

Modifier 95Synchronous telemedicine service rendered via real-time interactive audio and video telecommunication system.

Service Limits & Exclusions (Operational)

Coverage limits and operational exclusions: For INTEGRITY (Medicare-like) members, originating-site rules apply and coverage limits include subsequent hospital services limited to 1 telehealth visit every 3 days and subsequent nursing facility care limited to 1 telehealth visit every 30 days. INTEGRITY also requires use of an interactive audio-video telecommunications system and limits originating sites to specified facility types (for example, offices, hospitals, CAHs, RHCs, FQHCs, certain dialysis centers, SNFs, and CMHCs).

Exclusions and modality restrictions: Asynchronous 'store-and-forward' telemedicine is non-covered for INTEGRITY members except in specific federal demo programs in Alaska or Hawaii, telemedicine at independent renal dialysis facilities is excluded, and audio-only telephone calls, email, fax, and certain automated diagnostic programs are not covered. For Medicaid and Commercial lines, store-and-forward is permitted only as allowed by state law but technology must meet HIPAA-compliant encryption and access requirements.

Policy Revision Timeline

04/13/20materialLatest

Added HCPCS code Q3014 (telehealth originating site facility fee).

03/03/20non-material

Inserted Medicaid-specific language, Medicare coding references, and reformatted document.

12/31/18added

Policy effective.