CurrentNevada Health AuthorityPolicy N/A

TELEHEALTH SERVICES

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This policy governs Medicaid and Nevada Check Up coverage, reimbursement, limitations, and prior authorization for telehealth services. It applies to participating providers and establishes requirements for originating and distant sites, telehealth modalities, eligible and non-covered services, and facility-fee reimbursement.

Policy Summary

PayerNevada Health Authority

PolicyTELEHEALTH SERVICES

Policy CodePolicy N/A

Change TypeClarified and revised

Effective DateJul 27, 2017

Next Review DateN/A

Key ActionApply the same prior authorization requirements to telehealth services as to services provided in person.

SourceLink

POLICY UPDATE CHANGES

The policy clarifies that an originating site must be an enrolled Medicaid provider to receive a telehealth facility fee.

The telehealth chapter was reorganized and its language, terminology, punctuation, capitalization, and duplications were revised for clarity.

Optional benefitTelehealth benefit status

Enrolled providerRequired originating-site status

1Minimum in-person ESRD visits

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CurrentNevada Health AuthorityPolicy N/A

TELEHEALTH SERVICES

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Sign up for all Nevada Health Authority policy alerts

Know when Nevada Health Authority releases new policies or updates existing guidance.

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Policy Summary

PayerNevada Health Authority

PolicyTELEHEALTH SERVICES

Policy CodePolicy N/A

Change TypeClarified and revised

Effective DateJul 27, 2017

Next Review DateN/A

Key ActionApply the same prior authorization requirements to telehealth services as to services provided in person.

SourceLink

POLICY UPDATE CHANGES

The policy clarifies that an originating site must be an enrolled Medicaid provider to receive a telehealth facility fee.

The telehealth chapter was reorganized and its language, terminology, punctuation, capitalization, and duplications were revised for clarity.

Optional benefitTelehealth benefit status

Enrolled providerRequired originating-site status

1Minimum in-person ESRD visits

Expressly non-covered communication methods

NoneTelehealth-specific prior authorization

Telehealth Coverage Criteria

General Telehealth Coverage

Telehealth services are covered when ALL of the following conditions are met:

ALL of the following

The originating site is located within the State of Nevada.
The service is delivered by a provider of health care to a patient at a different location through information and audio-visual communication technology; standard telephone, facsimile, and electronic mail are excluded.
The service is clinically appropriate and within the health care professional's scope of practice as established by the professional's licensing agency.
The distant-site provider is an enrolled Medicaid provider.
The service complies with the applicable Medicaid Services Manual policy for the specific service.
The service satisfies federal requirements for efficiency, economy, and quality of care.
The participating providers comply with HIPAA and use a medium approved as appropriate for protected health information by the DHCFP HIPAA Security Officer.

Originating-Site Facility Fee

An originating-site facility fee is covered when the following condition is met:

The originating site is an enrolled Medicaid provider.

An originating site that is not enrolled in Medicaid—including a cellular device, home computer, kiosk, or tablet—is not eligible for a DHCFP facility fee.

Synchronous and Asynchronous Services

Telehealth services may be delivered through either of the following recognized modalities:

ONE of the following modalities

Synchronous telehealth: a real-time interaction between a recipient at an originating site and a health care provider at a distant site, with the provider having direct visualization of the patient.
Asynchronous telehealth (Store-and-Forward): transmission of the patient's medical information from an originating site to the distant-site provider without the recipient being present. These services are reimbursable, but are not eligible for an originating-site facility fee.

Behavioral Health Psychotherapy

Psychotherapy delivered through a HIPAA-compliant telecommunication system is covered when ALL of the following conditions are met:

ALL of the following

The service is provided by ONE of the following eligible professionals or staff
- Licensed Clinical Psychologist (LCP).
- Licensed Clinical Social Worker (LCSW).
- Clinical staff employed and determined by a state mental health agency to meet established class specification qualifications of a Mental Health Counselor, Clinical Social Worker, or Psychological Assistant.
The service is psychotherapy; reimbursement may not be sought for medical evaluation and management services.
Refer to MSM Chapter 400, Mental Health and Alcohol and Substance Abuse Services, for medical coverage requirements.

End-Stage Renal Disease (ESRD) Requirements

ESRD visits are covered when ALL of the following requirements are met:

ALL of the following

At least one visit includes an in-person examination of the vascular access site by a provider.
Additional visits may be provided using an interactive audio/video telecommunications system.
The medical record indicates that at least one visit was furnished in person by a provider.
Refer to MSM Chapter 600, Physician Services, for medical coverage requirements.

The following telehealth services are not covered: telephone calls, images transmitted via facsimile machines (faxes), text messages, and electronic mail (email).

Basic skills training and peer-to-peer services provided by a Qualified Behavioral Assistant (QBA) must be provided in person and are not considered appropriate services to be provided via telehealth. QBA provider qualifications are identified in MSM Chapter 400, Mental Health and Alcohol and Substance Abuse Services.

Personal care services provided by a Personal Care Attendant (PCA) must be provided in person and are not considered appropriate services to be provided via telehealth. PCA provider qualifications are identified in MSM Chapter 2600, Intermediary Service Organization, and MSM Chapter 3500, Personal Care Services.

Home Health Services must be provided in person and are not considered appropriate services to be provided via telehealth when provided by a Registered Nurse (RN), Physical Therapist (PT), Occupational Therapist, Speech Therapist, Respiratory Therapist, Dietician, or Home Health Aide. Applicable provider qualifications are identified in MSM Chapter 1400, Home Health Agency (HHA).

Private Duty Nursing services provided by an RN must be provided in person and are not considered appropriate services to be provided via telehealth. Applicable provider qualifications are identified in MSM Chapter 900, Private Duty Nursing.

Asynchronous telehealth services are not eligible for an originating-site facility fee.

Provider and Billing Requirements

Prior Authorization

Apply Service-Specific Prior Authorization Rules

Apply the prior authorization requirements for the individual service being delivered via telehealth. Telehealth itself does not automatically require prior authorization, but services that require authorization when furnished in person require the same authorization when furnished via telehealth.

Refer to the applicable Medicaid Services Manual (MSM) medical coverage policy for service-specific authorization and coverage requirements.

Documentation Required

Photograph Adequacy

Use photographs that are specific to the patient's condition and adequate to render or confirm a diagnosis or treatment plan. Dermatologic photographs, such as images of a skin lesion, may satisfy the single-media-format requirement.

Reject or do not rely on photographs that are nonspecific, clinically inadequate, or insufficient to support diagnosis or treatment planning.

Telehealth Overview

Telehealth uses telecommunications to substitute for an in-person encounter in professional consultations, office visits, office psychiatry services, and a limited number of other medical services. Covered services may be delivered through real-time interaction or store-and-forward transmission, when clinically appropriate, within the provider’s scope of practice, and using HIPAA-compliant technology.

Key Telehealth Definitions

Telehealth

DefinitionDelivery of service from a health care provider to a patient at a different location through information and audio-visual communication technology.

TechnologyTelehealth must use information and audio-visual communication technology.

Excluded methodsStandard telephone, facsimile, and electronic mail are not included as telehealth.

Originating site

DefinitionThe location where a patient receives telehealth services from a health care provider located at a distant site.

Communication systemServices are received through a HIPAA-compliant telecommunications system.

Policy Summary

PayerNevada Health Authority

PolicyTELEHEALTH SERVICES

Policy CodePolicy N/A

Change TypeClarified and revised

Effective DateJul 27, 2017

Next Review DateN/A

Key ActionApply the same prior authorization requirements to telehealth services as to services provided in person.

SourceLink

On This Page

Denial Risk

ESRD In-Person Requirement

ESRD visits must include at least one in-person examination of the vascular access site by a provider. Interactive audio/video telehealth may be used for additional visits, but it cannot replace the required in-person vascular-access examination.

Schedule and complete the required in-person vascular-access examination.
Use telehealth only for additional ESRD visits after the in-person requirement is met.

Denial Risk

Avoid Core Telehealth Eligibility Failures

Confirm all telehealth eligibility and billing conditions before submitting a claim. Coverage may be denied when the originating site is outside Nevada, the originating site is not an enrolled Medicaid provider for a facility fee, or the distant-site provider is not an enrolled Medicaid provider.

An originating site must be located within Nevada.
A non-enrolled originating site—including a cellular device, home computer, kiosk, or tablet—is not eligible for an originating-site facility fee.
Eligible IH, FQHC, and RHC facilities may bill an encounter instead of an originating-site facility fee when applicable; billing must follow the required originating and distant encounter coding rules.
Asynchronous/store-and-forward services are reimbursable but are not eligible for an originating-site facility fee.
Telehealth must be clinically appropriate, within the provider's scope of practice, and delivered through a HIPAA-compliant system; standard telephone, fax, text message, and email are not covered telehealth modalities.
Services designated as requiring in-person delivery—including specified QBA, PCA, home health, and private duty nursing services—are not appropriate for telehealth and are not covered when furnished that way.

Documentation Required

Document the ESRD In-Person Visit

Document in the medical record that at least one ESRD visit was furnished in person by a provider, including the required vascular-access examination. Additional visits may be provided through interactive audio/video telehealth.

The record must clearly identify the in-person visit and provider.
Refer to MSM Chapter 600, Physician Services, for applicable medical coverage requirements.

Facility fee condition

The originating site must be an enrolled Medicaid provider to receive coverage for a telehealth facility fee.

Distant site

DefinitionThe location where a health care provider provides telehealth services to a patient located at an originating site.

Provider requirementThe distant-site provider must be an enrolled Medicaid provider.

Patient locationThe patient receiving services is located at an originating site.

Synchronous telehealth

DefinitionA real-time interaction between a recipient at an originating site and a health care provider at a distant site.

Interaction typeThe interaction occurs in real time.

Patient visualizationThe provider has direct visualization of the patient.

Asynchronous telehealth

DefinitionStore-and-forward transmission of a patient's medical information from an originating site to a distant-site provider.

Recipient participationThe recipient is not present at the time of transmission.

Facility fee statusAsynchronous telehealth services may be reimbursed but are not eligible for an originating-site facility fee.