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    v1.0.28
    OpenPayerPolicy UpdatesAdministrative/Operational PolicyOptum behavioral health telehealth policy update |…
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    CurrentOptumPolicy N/A

    Behavioral Health: Telehealth, Claims and Related Policy Adjustments Following End of the COVID-19 Public Health Emergency

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    Describes how Optum Behavioral Health adjusted telehealth, claims timely filing, HIPAA enforcement discretion, controlled substance prescribing, and certain state-specific provisions following the end of the COVID-19 public health emergency; applies to providers in network and varies by plan type and state.

    Policy Summary
    PayerOptum
    PolicyBehavioral Health: Telehealth, Claims and Related Policy Adjustments Following End of the COVID-19 Public Health Emergency
    Policy CodePolicy N/A
    Change TypePolicy update — informational (no material changes)
    Effective DateN/A
    Next Review DateN/A
    Key ActionObtain authorization for Virtual Partial Hospitalization and Intensive Outpatient Program services per Optum Clinical Guidelines.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    Nov. 1, 2023document current as of

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    May 11, 2023end of national public health emergency referenced
    Dec. 31, 2024most Medicare telehealth flexibilities through
    90 daysNJ telehealth cost-share waiver extends

    Telehealth and Claims Coverage Criteria

    Telehealth coverage criteria and modalities

    Telehealth coverage and modality allowances by service and plan type, subject to state and plan requirements.

    Telehealth flexibilities ended May 12, 2023; state regulations and member benefit plans take precedence over the allowances summarized below.

    Outpatient services

    • Outpatient therapy: audio/visual and telephonic (audio) allowed for commercial and Medicaid where state permits.
    • Medication management/Outpatient evaluation & management (E&M): audio/visual and telephonic (audio) allowed for commercial and Medicaid where state permits.
    Inpatient E&M: audio/visual only for commercial and Medicaid where state permits.
    Applied Behavior Analysis (ABA): limited to supervision of behavior technicians and family training/guidance delivered via audio/visual only.
    Intensive Outpatient Program (IOP): audio/visual only; authorization required per Optum Clinical Guidelines.
    Partial Hospitalization Program (PHP): audio/visual only; authorization required. Optum will continue to authorize Virtual PHP to ensure access despite limited evidence of efficacy.
    Psychological testing and outpatient ECT & TMS: not demonstrated to be effective virtually; therefore NONE (not permitted virtually).
    Medicare-specific: the majority of Medicare telehealth flexibilities remain in place through Dec 31, 2024; Medicare members may receive telehealth at home from any U.S. area and certain visits may be audio-only per HHS guidance.

    Claims, billing, HIPAA and controlled substances coverage nodes

    Claims and billing requirements post-emergency.

    Timely filing (Commercial): timely claim filing requirements for commercial health plans will resume in 2023 per the IRS/DOL regulation related to the national emergency period; Optum will provide additional details when finalized. Note: the IRS/DOL regulation extended the timely-filing pause for an additional 60 days following the last day of the national emergency period.
    Timely filing (Medicare Advantage): standard timely filing requirements apply for Medicare Advantage plans.
    Timely filing (Medicaid): state-specific timely filing and billing rules apply; refer to the applicable state Medicaid website.
    Billing for telehealth: Optum will reimburse clinically appropriate telehealth claims in accordance with the member's benefit plan and applicable state or federal requirements; state mandates and plan requirements take precedence and providers are responsible for following applicable requirements.
    HIPAA-compliant platforms: providers must use HIPAA-compliant platforms starting Aug 10, 2023 (end of HIPAA enforcement discretion transition period). A transition period ran May 12–Aug 9, 2023, during which good-faith use had no financial penalties.

    Telehealth-Eligible Services and Filing Rules

    Telehealth-eligible service categories (examples)mixed
    Medication Management / Outpatient E&MAudio/Visual and telephonic (audio) allowed for commercial and Medicaid where state permits.
    Inpatient E&MAudio/visual only for commercial and Medicaid where state permits.
    Applied Behavior Analysis (ABA) - supervision & family trainingLimited to supervision of behavior technicians and family training/guidance via audio/visual only.
    Intensive Outpatient Program (IOP)Audio/visual only; authorization required per Optum Clinical Guidelines.
    Partial Hospitalization Program (PHP)Audio/visual only; authorization required and Optum will continue to authorize Virtual PHP.
    Virtual Psychological Testing, Outpatient ECT & TMSNot demonstrated to be effective virtually; therefore not permitted virtually.
    Medicare telehealth flexibilitiesMost flexibilities remain through Dec. 31, 2024; members can receive telehealth at home from any U.S. area; certain visits may be audio-only per HHS guidance.
    Timely filing resumption — commercial
    Policy summaryCommercial timely claim filing requirements that were paused during the national emergency will resume in 2023 per the IRS/DOL regulation; Optum will provide timing details when finalized.
    Regulatory basisResumption follows IRS and Department of Labor/Employee Benefits Security Administration guidance tied to the end of the national emergency and the 60-day extension period.
    Medicare Advantage noteMedicare Advantage continues to follow standard timely filing requirements.
    Medicaid/state rulesMedicaid and other state-specific timely filing rules still apply; providers should refer to state-specific websites for details.
    Billing for telehealthOptum will reimburse clinically appropriate telehealth claims in accordance with the member's benefit plan and applicable state or federal requirements.

    Provider Authorization and Operational Requirements

    Prior Authorization

    Authorization required for Virtual PHP and IOP

    Virtual Partial Hospitalization (PHP) and Intensive Outpatient Program (IOP) services delivered virtually require authorization and must follow Optum Clinical Guidelines and Criteria; Optum will continue to authorize coverage for Virtual PHP to ensure access to care.

    • IOP: audio/visual only; authorization required per Optum Clinical Guidelines.
    • PHP: audio/visual only; authorization required and Optum will continue to authorize Virtual PHP despite limited evidence base to ensure access.

    Transition Periods and Regulatory Flexibilities

    HIPAA enforcement discretion transition period
    Transition period datesTransition period for HIPAA enforcement discretion: May 12, 2023 through 11:59 pm Aug. 9, 2023.
    End of enforcement discretionHIPAA enforcement discretion flexibilities ended May 11, 2023; transition period followed.
    Provider requirements after transitionBeginning Aug. 10, 2023, providers must use a HIPAA-compliant communications platform to conduct telehealth visits; failure may result in financial penalties.
    Good-faith provisionFinancial penalties will not be imposed during the transition period in connection with the good-faith provision of telehealth services.
    Platform optionsProviders are not required to use the Optum Virtual Visits platform; any HIPAA-compliant telehealth platform may be used.
    Policy Summary
    PayerOptum
    PolicyBehavioral Health: Telehealth, Claims and Related Policy Adjustments Following End of the COVID-19 Public Health Emergency
    Policy CodePolicy N/A
    Change TypePolicy update — informational (no material changes)
    Effective DateN/A
    Next Review DateN/A
    Key ActionObtain authorization for Virtual Partial Hospitalization and Intensive Outpatient Program services per Optum Clinical Guidelines.
    SourceLink
    On This Page
    Telehealth and Claims Coverage CriteriaTelehealth-Eligible Services and Filing RulesProvider Authorization and Operational RequirementsTransition Periods and Regulatory Flexibilities
    Provider directory attestation: providers are not required to provide virtual services, but must attest in Provider Express to be listed as offering virtual visits if they provide them.
    State-specific requirements: e.g., New Jersey requires in-network telehealth services be covered without cost-sharing for fully insured commercial plans per state law and timelines; check state-specific guidance.
    Controlled substances prescribing: DEA temporary telemedicine prescribing flexibilities permit prescribing of schedule II–V controlled substances via telemedicine through Dec 31, 2024 per DEA/SAMHSA guidance; certain OUD maintenance/withdrawal prescriptions (schedule III–V) may be permitted via audio-only in accordance with DEA guidance.
    Conflict resolution: provider agreements and member benefit plan terms control if they conflict with the provisions summarized in this document.
    DEA telemedicine prescribing flexibilities — temporary rule
    Scope of temporary DEA ruleTemporary DEA/SAMHSA extension allows prescribing of schedule II-V controlled substances via telemedicine encounters effective Nov. 11, 2023 through Dec. 31, 2024.
    Audio-video prescribingPractitioners may prescribe schedule II-V controlled medications via audio-video telemedicine encounters.
    Audio-only allowance for OUDSchedule III-V narcotic medications for maintenance and withdrawal management treatment of opioid use disorders may be prescribed via audio-only telemedicine encounters per the extension.
    Compliance requirementsPrescriptions must comply with DEA guidance, DEA regulations, and applicable federal and state laws.
    IOP and PHP noteIOP and PHP virtual services require audio/visual delivery and authorization per Optum Clinical Guidelines; Optum will continue to authorize Virtual PHP to ensure access.