CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Telemedicine Services Payment Policy – Archive 3

Defines reimbursement, coverage applicability, provider types, technology/security requirements, claim submission and coding rules for telemedicine services for Commercial, INTEGRITY, and Medicaid lines (excludes Extended Family Planning). Applies telemedicine reimbursement rules consistent with Rhode Island law and state contracts.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyTelemedicine Services Payment Policy – Archive 3

Policy CodePolicy N/A

Change TypeFormatting update; coding and scope updates earlier in 2020

Effective DateDec 31, 2018

Next Review Date

Key ActionUse POS 02 on claims and include modifier '95' for synchronous audiovisual telemedicine; submit complete claims within 90 days and document equivalence to face-to-face care.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes were made in the most recent update; only formatting edits were recorded on 05/07/20.

04/13/20: Update: Add code Q3014.

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

12/31/18: Policy effective.

POS 02Telehealth POS required

95Required modifier for synchronous telemedicine

Q3014Originating site facility fee code added

2 limits

Frequency limits (hospital / nursing facility)

Policy Overview

Policy defines telemedicine as real-time, two-way audiovisual communications, including the application of secure video conferencing or store-and-forward technology, to facilitate assessment, diagnosis, treatment, and care management while the patient is at an originating site and the provider is at a distant site. The policy applies to Commercial, INTEGRITY, and Medicaid lines of business and is consistent with the Rhode Island Telemedicine Coverage Act and State of Rhode Island government program contracts. The policy excludes Extended Family Planning (EFP) and reflects the effective and update history of the policy (effective 12/31/2018 with subsequent revisions).

Scope summary: Defines reimbursement, coverage applicability, allowed provider types, technology and security requirements, claim submission and coding rules for telemedicine services for Commercial, INTEGRITY, and Medicaid lines of business (excludes Extended Family Planning), and aligns telemedicine reimbursement rules with Rhode Island law and state contracts.

Policy Header

Effective Date2018-12-31

Last Review2020-05-07

Next ReviewN/A

Policy TitleTelemedicine Services Payment Policy (Archive 3)

PayerNeighborhood Health Plan of Rhode Island

Policy NumberN/A

StatusCURRENT

Coverage Rules & Prerequisites

General Reimbursement and Coverage Prerequisites

Services payable when ALL of the following are met:

ALL of the following

Service is medically necessary.
Service performed within the scope of state licensure as defined by the Rhode Island Department of Health.
Service meets service-specific criteria, benefit limitations, and prior authorization requirements that may apply (refer to Prior Authorization Reference page and Clinical Medical Policies).
Contact Utilization Management at (401) 459-6060 for details.
Communication must be of amount and nature sufficient to meet key components/requirements of the equivalent face-to-face service.

Claim Submission, Coding & POS/Modifier Rules

Claim Submission and Coding Requirements

Billable services are subject to contractual agreements. The following outlines Neighborhood's claim submission and coding requirements for telemedicine services:

Timely Filing: Providers are required to submit complete claims for payment within 90 days of the date services are provided to members, unless otherwise specified by contract. Late submissions may be denied per contract.

Place of Service (POS): Claims must include POS 02 to indicate the service was delivered via telemedicine.

Modifier 95: Claims must include modifier '95' defined as synchronous telemedicine service rendered via real-time interactive audio and video telecommunication system.

GT Modifier (professional vs institutional): Professional claims for telehealth services no longer require the GT modifier to be billed as of 1/1/2018. Institutional claims for telehealth services billed under Critical Access Hospital (CAH) require the GT modifier.

Documentation, Prior Auth & Operational Steps

Documentation Required

Medical Necessity and Equivalence to Face-to-Face

Document that the telemedicine communication was of the amount and nature sufficient to meet the key components of the equivalent face-to-face service and that treatment met the same standard of care. Obtain and document informed member consent that describes potential benefits, risks, and consequences of telemedicine. Ensure documentation supports medical necessity and scope of licensure.

Document sufficiency of audiovisual communication to meet face-to-face key components.
Document medical necessity and that service was within scope of state licensure.
Obtain and document informed member consent including benefits, risks, and consequences.

Prior Authorization

Prior Authorization May Apply

Code List: Telemedicine-relevant CPT/HCPCS

Telemedicine-relevant CPT/HCPCS codes (may apply; inclusion does not guarantee coverage)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 E/M (add-on)
90834	Psychotherapy, 45 minutes with patient
90836	Psychotherapy, 45 minutes with patient when performed with E/M (add-on)
90837	Psychotherapy, 60 minutes with patient
90838	Psychotherapy, 60 minutes with patient when performed with E/M (add-on)
90845	Psychoanalysis
90846	Family psychotherapy (without patient), 50 minutes

1–10 of 111

1/12

Definitions

Originating siteLocation of an eligible Medicare beneficiary at the time the telemedicine service is furnished (approved originating sites include physician office, hospital, CAH, RHC, FQHC, renal dialysis center, SNF, CMHC).

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

POS 02Place of Service code indicating the service was delivered via telemedicine (use POS 02 on the claim).

Technology examples include HIPAA-compliant real-time, two-way secure audiovisual video conferencing and store-and-forward technology. The policy requires encryption, a secure access portal with multi-level authentication and individual user credentials, and informed member consent. The policy applies to services governed by the Rhode Island Telemedicine Coverage Act and to state contracts (including requirements for originating sites and interactive audio/video for INTEGRITY/Medicare beneficiaries).

Policy Revision History

12/31/18added

Policy effective.

03/03/20revised

Policy update, added Medicaid wording, Medicare coding, and format change.

04/13/20revised

Update: Add code Q3014 (telehealth originating site facility fee).

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyTelemedicine Services Payment Policy – Archive 3

Policy CodePolicy N/A

Change TypeFormatting update; coding and scope updates earlier in 2020

Effective DateDec 31, 2018

Next Review Date

Key ActionUse POS 02 on claims and include modifier '95' for synchronous audiovisual telemedicine; submit complete claims within 90 days and document equivalence to face-to-face care.

SourceLink

On This Page

Technology and Security Requirements (Medicaid & Commercial)

To be compliant, telemedicine services must meet ALL of the following:

ALL of the following

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

INTEGRITY (Medicare-specific) Originating Site and Eligibility

Medicare beneficiaries eligible for telehealth only when ALL of the following apply:

ALL of the following

Beneficiary presented from an originating site located in a county outside an MSA OR a rural HPSA located in a rural census tract.
ALL of the following
- Originating site is one of
  - Office of a physician or practitioner
  - Hospital (inpatient or outpatient)
  - Critical Access Hospital (CAH)
  - Rural Health Clinic (RHC)
  - Federally Qualified Health Center (FQHC)
  - Hospital based or CAH based renal dialysis center
  - Skilled Nursing Facility (SNF)
  - Community Mental Health Center (CMHC)
Use of interactive audio and video telecommunications system permitting real-time communication between distant site provider and originating site beneficiary.

Covered Provider Types

Coverage for telemedicine is limited to the following provider types (by line of business).

INTEGRITY (Medicare) allowed provider types

Clinical nurse specialist (CNS)
Clinical social worker (CSW)
Nurse Midwife
Nurse practitioner (NP)
Physician assistant (PA)
Physician
Clinical Psychologist
Registered dietician
Certified registered nurse anesthetist

Medicaid and Commercial allowed provider types

Clinical nurse specialist (CNS)
Clinical social worker (CSW)
Licensed Marriage and Family Therapist (LMFT)
Licensed Mental Health Counselor (MHC)
Nurse Midwife
Nurse practitioner (NP)
Physician assistant (PA)

Coverage Exclusions

Telemedicine is NOT covered when ANY of the following apply:

ANY of the following

For INTEGRITY members: Asynchronous 'store and forward' technology (permitted only in federal demonstration programs in Alaska or Hawaii).
Telemedicine services provided to a member at an independent renal dialysis facility (INTEGRITY exclusion).
For Medicaid and Commercial: Audio-only telephone conversation.
For Medicaid and Commercial: Email message.
For Medicaid and Commercial: Facsimile transmission.
For Medicaid and Commercial: Automated computer program used to diagnose and/or treat ocular or refractive conditions.

Coverage Limitations

When covered, the following frequency limits apply:

ALL of the following

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

Adjustments, Corrections, Reconsiderations: All adjustments, corrections, and reconsideration requests must include the required forms and comply with National Claims Standards.

Coding Standards Requirement: Coding must meet standards defined by the American Medical Association's CPT Editorial Panel (CPT), ICD-10-CM, and HCPCS Level II.

Billing Rule

Place of Service and Modifier Requirements

Place of Service and Modifier Requirements: When billing telemedicine services, ensure the claim includes POS 02 and modifier 95. Use modifier GT only for institutional CAH claims as required.

Required: POS 02 (Telehealth Place of Service)
Required: Modifier 95 (Synchronous telemedicine via real-time interactive audio and video)
GT modifier: Not required on professional claims as of 1/1/2018; required on institutional CAH claims

Billing Rule

Timely Claim Filing

Timely Claim Filing: Submit complete claims within 90 days of the date of service unless a different contractual timely-filing limit applies. Claims submitted after the timely filing limit may be denied or adjusted.

Denial Risk

Noncompliant Technology or Modality

Noncompliant Technology or Modality — Denial Risk: Claims for services delivered using technology that does not meet HIPAA-compliant, secure real-time audiovisual standards or using excluded modalities (for example, audio-only telephone, email, fax, or noncompliant store-and-forward where not permitted) are subject to denial.

Denial conditions include use of non–HIPAA-compliant platforms or failure to use encryption and secure access controls (multi-level authentication, individual user credentials).
Excluded modalities that may be denied: audio-only telephone, email, facsimile transmission, and automated diagnostic programs where specified as non-covered.
Providers must obtain informed member consent and use compliant technology per state law; failure to document consent or use compliant systems may result in denial.

Service-specific prior authorization requirements may apply. Refer to Neighborhood's Prior Authorization Reference page and Clinical Medical Policies for details. Contact Utilization Management at (401) 459-6060 for authorization questions and additional details.

Refer to Prior Authorization Reference page and Clinical Medical Policies for service-specific requirements.
Contact Utilization Management at (401) 459-6060 for details.

Billing Rule

Frequency Limits for Subsequent Care

Frequency limits: Subsequent hospital services billed via telehealth are limited to 1 telehealth visit every 3 days. Subsequent nursing facility care services billed via telehealth are limited to 1 telehealth visit every 30 days.

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

Registered dietician