Neighborhood Health Plan RI telehealth Coverage Update

Telemedicine Coverage Criteria

General Telemedicine Coverage Criteria

Covered when ALL of the following are met:

Core coverage conditions: Service is medically necessary; delivered via HIPAA-compliant real-time two-way audiovisual communication (or store-and-forward where permitted by program); performed within the scope of state licensure; communication content is sufficient to meet the same key components as the equivalent face-to-face service; for Medicaid/Commercial, informed member consent describing benefits, risks, and consequences is obtained; treatment meets the same standard of care and is an appropriate substitute for a face-to-face encounter.

References Telemedicine Coverage Act for Medicaid/Commercial; program-specific limitations and prior authorization rules may apply.

INTEGRITY Coverage Criteria and Limits

INTEGRITY-specific coverage limitations (Medicare-like):

INTEGRITY originating site and provider type limits: Telemedicine coverage requires an interactive audio-and-video telecommunications system that permits real-time communication; originating site must be an approved location (physician/practitioner office; hospital inpatient or outpatient; Critical Access Hospital; Rural Health Clinic; Federally Qualified Health Center; hospital-based or CAH-based renal dialysis center; Skilled Nursing Facility; Community Mental Health Center); beneficiaries must be located in eligible geographic areas (county outside an MSA or a rural HPSA in a rural census tract); coverage limited to listed provider types (clinical nurse specialist, clinical social worker, nurse midwife, nurse practitioner, physician assistant, physician, clinical psychologist, registered dietician, certified registered nurse anesthetist).

Store-and-forward is non-covered for INTEGRITY; telemedicine services provided at independent renal dialysis facilities are excluded.

Medicaid/Commercial Technical & Provider Criteria

Medicaid and Commercial technical and provider requirements:

Technical and provider requirements: Services must use HIPAA-compliant real-time two-way secure audiovisual technology or, where permitted by program, store-and-forward technology that at minimum uses encryption for data transmission and a secure access portal with multi-level authentication, individual user credentials, and defined user access; providers must be operating within the scope of state licensure; coverage limited to specified provider types (clinical nurse specialist, clinical social worker, licensed marriage and family therapist, licensed mental health counselor, nurse midwife, nurse practitioner, physician assistant, physician, psychiatrist, psychologist, registered dietician).

Providers are required to obtain informed member consent describing benefits, risks, and consequences of telemedicine.

Frequency Limits

Utilization limits:

Visit frequency limits: Subsequent hospital telehealth services are limited to 1 telehealth visit every 3 days; subsequent nursing facility telehealth services are limited to 1 telehealth visit every 30 days.Hospital: 1 per 3 days; Nursing facility: 1 per 30 days

Coverage and payment conditions

Covered when ALL of the following general payment and coverage conditions are met:

General conditions: Claims are subject to Neighborhood benefit coverage and member eligibility; subject to claims payment edit rules, coding and documentation guidelines, authorization policies, provider contract agreements, and applicable state and federal regulations; providers must maintain documentation to support claims and services are subject to audit.

This policy is informational only; service-specific benefit limitations and prior authorization requirements may apply—refer to plan-specific Prior Authorization Reference or Utilization Management.

Excluded modalities and sites: asynchronous 'store and forward' technology is non-covered for INTEGRITY members except when permitted in Federal telemedicine demonstration programs in Alaska or Hawaii, and telemedicine services provided to a member at an independent renal dialysis facility are excluded. These exclusions can trigger claim denials when billed for INTEGRITY members.

No additional explicit exclusions are specified within the cited policy text. Claims and coverage remain subject to member benefit, eligibility, coding and documentation rules, authorization policies, contract terms, and applicable state and federal regulations; all services billed are subject to audit.

Non-covered modalities: audio-only telephone conversations, email messages, facsimile transmissions, and automated computer programs used to diagnose or treat ocular/refractive conditions are explicitly listed as non-covered and should not be billed as telemedicine services.

The cited portions of the document do not include explicit 'not medically necessary' rulings for specific services. Instead, the policy notes that coverage is informational and that payment depends on benefit coverage, eligibility, coding/documentation, authorization, contracting, and regulatory requirements; determinations of medical necessity will therefore depend on those rules and supporting documentation.

Coding, Modifiers, and Claim Rules

Behavioral health CPT codes (partial list)CPT

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

Assorted CPT codes referencedCPT

90838	Psychotherapy, 60 minutes with patient when performed with an E/M service (list separately)
90845	Psychoanalysis
90846	Family psychotherapy (without the patient present), 50 minutes
90847	Family psychotherapy (conjoint psychotherapy) (with patient present), 50 minutes
90863	Pharmacologic management when performed with psychotherapy services (list separately)
90951	ESRD related services monthly, patients <2 years, 4+ face-to-face visits
90952	ESRD related services monthly, patients <2 years, 2-3 face-to-face visits
90954	ESRD related services monthly, patients 2-11 years, 4+ face-to-face visits
90955	ESRD related services monthly, patients 2-11 years, 2-3 face-to-face visits
90957	ESRD related services monthly, patients 12-19 years, 4+ face-to-face visits

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Claim modifiers and POSModifier|POS

Modifier 95	Synchronous telemedicine service rendered via realtime interactive audio and video telecommunication system
GT	Former telehealth modifier; no longer required for professional claims as of 1/1/18; required for institutional CAH claims
POS 02	Place of Service code indicating telemedicine

Covered CPT/HCPCS CodesmixedCovered

99205	Office or other outpatient E/M new patient, comprehensive history/exam, high complexity MDM; typically 60 minutes face-to-face.
99212	Office/outpatient E/M established patient, problem focused history/exam, straightforward MDM; typically 10 minutes.
99213	Office/outpatient E/M established patient, expanded problem focused, low complexity MDM; typically 15 minutes.
99214	Office/outpatient E/M established patient, detailed history/exam, moderate complexity MDM; typically ~25 minutes.
99215	Office/outpatient E/M established patient, comprehensive history/exam, high complexity MDM; typically ~40 minutes.
99231	Subsequent hospital care, problem focused interval history/exam, straightforward/low complexity MDM; typically 15 minutes.
99232	Subsequent hospital care, expanded problem focused, moderate complexity MDM; typically 25 minutes.
99233	Subsequent hospital care, detailed history/exam, high complexity MDM; typically 35 minutes.
99241	Office consultation, problem focused history/exam, straightforward MDM; typically 15 minutes.
99242	Office consultation, expanded problem focused, straightforward MDM; typically 30 minutes.

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inv-14: Claim submission window — Submit within 90 days of service

Claim submission windowSubmit complete claims for payment within 90 days of the date services are provided

inv-15: Typical face-to-face time — Examples by code (99212 ~10 min; 99213 ~15 min; 99214 ~25 min; 99215 ~40 min; 99205 ~60 min; 99245 ~80-110 min)

99212Established patient office/outpatient visit — typically ~10 minutes face-to-face

99213Established patient office/outpatient visit — typically ~15 minutes face-to-face

99214Established patient office/outpatient visit — typically ~25 minutes face-to-face

Provider Requirements, Authorization, and Documentation

Prior Authorization

Authorization and eligibility

Service-specific criteria, benefit limitations, and prior authorization requirements may apply. Verify member eligibility and obtain any required prior authorization before rendering services. Contact Utilization Management at (401) 459-6060 or review Neighborhood's plan-specific Prior Authorization Reference page and Clinical Medical Policies for details.

Prior authorization may be required — check plan-specific prior authorization lists
Claims remain subject to authorization policies and member eligibility

Billing Rule

Excluded modalities and sites for INTEGRITY

Asynchronous 'store and forward' technology is non-covered for Integrity members and is permitted only in Federal telemedicine demonstration programs in Alaska or Hawaii. Telemedicine services provided to a member at an independent renal dialysis facility are excluded.

Background and Scope

Telemedicine services in this policy are defined as clinical services delivered using real-time, two-way HIPAA-compliant audiovisual communications (secure video conferencing) and, where program rules permit, limited store-and-forward technology. Services must meet the same standard of care as equivalent face-to-face encounters, be provided within the scope of state licensure, and include appropriate documentation; for Medicaid/Commercial lines, informed member consent is required.

Definitions and Key Terms

inv-26: Telemedicine / Telehealth — Real-time, two-way audiovisual communications and permitted store-and-forward where allowed

DefinitionReal-time, two-way electronic audiovisual communications (secure video conferencing) to provide or support health-care delivery between a patient at an originating site and a provider at a distant site.

Store-and-forwardPermitted where allowed by program; policy references limited use of store-and-forward technology for applicable lines of business.

Modalities excluded elsewhereAudio-only telephone, email, facsimile, and certain automated computer programs are listed as non-covered modalities in exclusions.

inv-27: Originating site (Medicare/INTEGRITY context) — Location of beneficiary; Medicare-originating site limitations

Originating site (definition)Location of the eligible beneficiary at the time the telemedicine service occurs.

Policy Revision History

05/07/20formatting

Formatting updates to the policy document.

04/13/20coding_addition

Added HCPCS code Q3014 (Telehealth originating site facility fee) to the coding list.

03/03/20policy_update

Policy updated to add Medicaid wording, Medicare coding, and document format changes.

OpenPayer

Telemedicine / Telehealth Coverage Criteria (Real-time audiovisual services)