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    v1.0.28
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyJefferson Health Plans Telehealth Coverage | OpenP…
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    CurrentPartners Insurance Company Dba Jefferson Health PlansPolicy RB.038.B

    Professional Telehealth Services (Individual and Family Plan)

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    This policy governs reimbursement for professional telehealth services provided to members enrolled in Jefferson Health Plans Individual and Family Plans. It defines eligible telehealth modalities, provider and billing requirements, exclusions, and payment limitations.

    Policy Summary
    PayerPartners Insurance Company Dba Jefferson Health Plans
    PolicyProfessional Telehealth Services (Individual and Family Plan)
    Policy CodePolicy RB.038.B
    Change TypeRevised and reissued
    Effective DateN/A
    Last ReviewApr 8, 2025
    Next Review DateN/A
    Key ActionProviders must fully document telehealth services and identify the telecommunication technology used in the patient's medical record.
    SourceLink
    POLICY UPDATE CHANGES

    The 2025 review and reissue removed codes from the policy.

    The policy statement was updated in the 2025 review and reissue.

    Audio-videoRequired technology for eligible telehealth visits

    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.

    Not requiredPrior authorization for professional telehealth services alone
    Once weeklyExpected maximum frequency for the same episode of care
    S9083 deniedUrgent care center case-rate code when telehealth is performed
    Not payableTelehealth services for providers paid on a capitation basis

    Covered and Excluded Telehealth Services

    Covered professional telehealth visit criteria

    Professional Telehealth Services are covered and eligible for reimbursement when all of the following criteria are met:

    ALL of the following

    • The service is medically necessary.
    • The service is delivered using synchronous interactive audio and video telecommunications systems.
    • The member is present at the time of service in a real-time interaction with the healthcare provider.
    • The service is rendered by an eligible physician, nurse practitioner, certified registered nurse anesthetist, physician assistant, registered dietitian, pharmacist, nurse midwife, or clinical nurse specialist.
    • The provider reports the appropriate evaluation and management service that would have applied if the service had been provided in the office.
    • The provider uses the appropriate telehealth modifier and complies with the provider contract, plan fee schedules, and member benefit plan.

    Excluded or non-separately-payable services

    The following services or payment circumstances are excluded, denied, or not separately payable under this policy:

    ANY of the following

    • Telephone-based evaluations, virtual check-ins, and e-visits are not eligible for reimbursement consideration.
    • Text messages are not Professional Telehealth Services.
    • An urgent care center's S9083 case-rate claim is denied when the service is rendered via telehealth; S9083 is limited to in-person, face-to-face services.
    • Telehealth services for providers paid on a capitation basis are included in capitation and are not separately payable.
    • Professional Telehealth Services billed in hospital-based clinics are not eligible for payment of the facility fee component.

    Coding and Frequency Guidance

    Telehealth modifiersModifier
    93Synchronous telehealth service delivered via telephone or other interactive audio-only systems, as described in the coding section; the policy statement otherwise requires synchronous interactive audio and video for covered telehealth visits.
    95Synchronous telemedicine service rendered via real-time interactive audio and video telecommunications; preferred modifier per the Centers for Medicare & Medicaid Services (CMS).
    GTSynchronous telehealth visit administered in real time through interactive audio and video telecommunications systems.
    Urgent care case-rate exclusionHCPCSNot Covered
    S9083Urgent care center case-rate code; not payable when Professional Telehealth Services are performed and payable only for services rendered in person and face to face.
    Evaluation and management and professional service codingmixedCovered
    No codes listed
    Typical frequency for the same episode of care
    Typical frequencyProfessional Telehealth Services would typically not occur more than once per week for the same episode of care.
    Increased frequencyIncreased frequency may result in an audit.
    Audit considerationProviders may be subject to audit when increased frequency occurs.

    Provider Billing and Documentation Requirements

    Prior Authorization

    Prior Authorization Not Required

    Authorization is not required for Professional Telehealth Services alone.

    Denial Risk

    Frequency and Audit Risk

    Professional Telehealth Services typically should not occur more than once per week for the same episode of care. Providers may be subject to an audit when increased frequency occurs.

    Documentation Required

    Telehealth Documentation Required

    Fully document the services rendered in the patient's medical record and identify the telecommunication technology used.

    Telehealth Terminology

    E-Visit
    Patient statusThe communication is initiated by an established patient.
    Communication typeIt is a non-face-to-face communication.
    Communication channelThe communication occurs through an online patient portal.
    Interactive telecommunications system
    Required equipmentThe system includes, at a minimum, audio and video equipment.
    Communication capabilityThe equipment permits two-way, real-time interactive communication between the patient and distant-site physician or practitioner.
    Excluded technologies
    Policy Summary
    PayerPartners Insurance Company Dba Jefferson Health Plans
    PolicyProfessional Telehealth Services (Individual and Family Plan)
    Policy CodePolicy RB.038.B
    Change TypeRevised and reissued
    Effective DateN/A
    Last ReviewApr 8, 2025
    Next Review DateN/A
    Key ActionProviders must fully document telehealth services and identify the telecommunication technology used in the patient's medical record.
    SourceLink
    On This Page
    Covered and Excluded Telehealth ServicesCoding and Frequency GuidanceProvider Billing and Documentation RequirementsTelehealth Terminology
    Billing Rule

    Coding and Place of Service

    Report the most appropriate CPT or HCPCS code, the applicable telehealth modifier, and the place of service representing the telemedicine service for payment.

    Billing Rule

    Capitation Payment

    For providers paid on a capitation basis, Professional Telehealth Services are considered included in capitation and are not separately payable.

    Denial Risk

    Urgent Care Case-Rate Exclusion

    Urgent Care Centers are not eligible for payment of case-rate code S9083 when Professional Telehealth Services are performed. The S9083 case rate is payable only for services rendered in person and face to face; eligible UCC Professional Telehealth Services must meet policy criteria and be explicitly included in the provider's contract with the Plan.

    • S9083 — not payable when Professional Telehealth Services are performed.
    Denial Risk

    Hospital-Based Clinic Facility Fee

    When Professional Telehealth Services are billed in hospital-based clinics, the facility fee component is not eligible for payment.

    Denial Risk

    CCI Edits and Plan Audit Authority

    Payment may be impacted by CCI edits. The Plan reserves the right to audit Professional Telehealth Services for compliance with this policy and related state and federal regulations, effectiveness and impact to Plan members, and quality of care.

    Telephones, facsimile machines, and electronic mail systems do not meet the definition of an interactive telecommunications system.
    Professional Telehealth Services
    Service purposeServices are performed using technology to evaluate and communicate with members.
    Provider typeThe services are performed by professional providers.
    Included modalitiesProfessional Telehealth Services are limited to telehealth visits, virtual check-ins, telephone-based evaluations, and e-visits.
    Synchronous interaction
    Interaction timingThe interaction occurs in real time.
    ParticipantsThe interaction is between a patient and a health care provider.
    Provider locationThe health care provider is located at a distant site.
    Telephone-based evaluations
    Encounter typeThe encounter is non-face-to-face.
    Patient statusThe encounter originates from an established patient.
    Service providedA qualified clinician provides evaluation or management of a problem through telephone services.
    Telehealth Visits
    Visit formatThe visit is conducted with a provider.
    Technology requirementThe visit uses a synchronous interactive audio and video telecommunications system.
    Communication modeThe audio and video communication is interactive and occurs in real time.
    Virtual check-ins
    DurationA virtual check-in is a brief five- to ten-minute check-in.
    Communication methodThe check-in occurs by telephone or another telecommunications device.
    Purpose and scopeThe check-in determines whether an office visit or other service is needed for an established patient and may include remote evaluation of recorded video or images submitted by that patient.