ModifiedPremera BluecrossPolicy N/A

Telehealth/Telemedicine services reimbursement

Defines when the Plan recognizes and reimburses telehealth/telemedicine services submitted on a professional claim across Premera Blue Cross and affiliated lines of business, and describes acceptable modalities, documentation, billing modifiers and place of service requirements.

Policy Summary

PayerPremera Bluecross

PolicyTelehealth/Telemedicine services reimbursement

Policy CodePolicy N/A

Change TypeCodes added, codes removed, Washington-specific clarifications

Effective DateN/A

Next Review DateN/A

Key ActionAppend the appropriate telehealth modifier and Place of Service code and document member consent for audio-only encounters where required.

SourceLink

POLICY UPDATE CHANGES

Added new CPT codes effective January 1, 2025 for audio and video communications (98000-98007) and audio-only communications (98008-98016).

The legacy audio-only codes 99441-99443 and G2012 were terminated effective December 31, 2024 and removed from the policy.

Clarified Washington-specific requirements and definitions for 'established relationship' for audio-only services and their effective/termination dates.

Moved Telehealth Modifiers and Place of Service code sections into the Codes/Coding Guideline section and updated descriptions for POS code '10' (home) and POS '02'.

Removed certain Exception statements regarding same-day telehealth visit reimbursement rules and PHE-related new patient billing flexibilities.

multipletelehealth modalities

Q3014originating site fee

98000-98007

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

98008-98016new audio-only CPT codes

99441-99443, G2012terminated audio-only codes

established-relationshipWA-specific rules

When Telehealth Services Are Covered

Coverage criteria and billing/documentation rules

Telehealth services may be covered when clinically appropriate and properly documented and billed.

An appropriate telehealth modifier and appropriate Place of Service code must be submitted with the procedure code for telehealth services.

All telehealth encounters must be permanently documented/stored in the member's health record and available for audit; documentation should match in‑person visit documentation and include: patient consent, patient location, distant site provider name/location, telehealth modality, participants present, summary of discussion, plan of care, prescriptions/tests/referrals, time spent, and any store‑and‑forward files or interprofessional communications.

If a member is physically hosted at a healthcare facility and assisted to connect, the facility may bill HCPCS Q3014 for an originating site fee; no originating site fee is billed when the member connects from home.

Member consent for audio‑only encounters must be obtained and documented prior to the encounter.

Distant site providers must be licensed and practice within the scope of the state where the member is located; payment is limited to listed provider types when covered.

Store‑and‑forward communications must be secure, HIPAA‑compliant, and do not include telephone, fax or text; S&F records and any patient‑provided files must be maintained in the medical record.

Select CPT code for telehealth E/M services based on total time on the date of encounter or level of medical decision making per CPT guidelines unless the code description specifies otherwise; see Appendix P and CMS telehealth file for additional allowable services.

Recognized telehealth codes and constraints

Codes and time requirements that the Plan recognizes when telehealth services are covered by a member's benefits.

Synchronous audio‑video established patient codes (use time or MDM per code): 98004 (>=10 min), 98005 (>=20 min), 98006 (>=30 min), 98007 (>=40 min; use 99417 for >=55 min).

Synchronous audio‑only new patient codes (require >10 minutes discussion; total time thresholds): 98008 (>=15 min), 98009 (>=30 min), 98010 (>=45 min), 98011 (>=60 min; use 99417 for >=75 min).

Synchronous audio‑only established patient and brief virtual check‑in codes: 98012 (>=10 min), 98013 (>=20 min), 98014 (>=30 min), 98015 (>=40 min; use 99417 for >=55 min), and 98016 (brief virtual check‑in, 5–10 minutes, established patients only).

Online digital (secure messaging) services reported once per 7‑day period with cumulative time thresholds: 99421 (5–10 min), 99422 (11–20 min), 99423 (21+ min) for physicians; 98970–98972 for non‑physician providers. These services are not reported for cumulative time <5 minutes and are not reported on the same date as an office/outpatient visit. Permanent storage of communications is required.

State-specific coverage and coding updates

Washington-specific requirements and exception removals:

For Washington providers, an established relationship is required before providing audio‑only telemedicine: behavioral health requires a prior appointment within 3 years; other services require a prior appointment within 2 years. The prior appointment may be in‑person or via real‑time audio‑video (as specified by the effective time windows), and the provider must have access to prior health records.

An originating site facility fee (HCPCS Q3014) cannot be billed for audio‑only services in Washington.

Certain Public Health Emergency (PHE) era exceptions and same‑day telehealth reimbursement exception statements were removed as of 12/09/25.

New CPT code ranges for telehealth effective 01/01/2025 (98000–98007 for audio/video and 98008–98016 for audio‑only) should be used; legacy audio‑only codes (99441–99443) and G2012 were terminated effective 12/31/2024 and removed from the policy.

Codes, Modifiers, Time Rules, and Place of Service

Synchronous audio-video E/M CPT codes (effective Jan 1, 2025)CPTCovered

98000	Synchronous audio-video visit for the evaluation and management of a new patient, straightforward; 15+ minutes
98001	Synchronous audio-video visit for the evaluation and management of a new patient, low MDM; 30+ minutes
98002	Synchronous audio-video visit for the evaluation and management of a new patient, moderate MDM; 45+ minutes
98003	Synchronous audio-video visit for the evaluation and management of a new patient, high MDM; 60+ minutes
98004	Synchronous audio-video visit for the evaluation and management of an established patient, straightforward; 10+ minutes
98005	Synchronous audio-video visit for the evaluation and management of an established patient, low MDM; 20+ minutes
98006	Synchronous audio-video visit for the evaluation and management of an established patient, moderate MDM; 30+ minutes
98007	Synchronous audio-video visit for the evaluation and management of an established patient, high MDM; 40+ minutes

Originating site facility codeHCPCSCovered

Q3014

Telehealth originating site facility fee

Place of Service codes for telehealthPOS

02	Telehealth Provided Other than in Patient's Home
10	Telehealth Provided in Patient's Home

Telehealth modifiersModifier

95	Synchronous Telemedicine Service Rendered via a Real-time Interactive Audio and Video Telecommunications System
GT	Via interactive audio and video telecommunication systems
FR	Supervising practitioner present through two-way audio and video communications technology
93	Synchronous telemedicine service rendered via telephone or other real-time interactive audio-only telecommunications system
FQ	Service furnished using audio-only communication technology
GQ	Via Asynchronous telecommunications system
G0	Telehealth for acute stroke services

Synchronous audio-video established patientCPTCovered

98004	Synchronous audio-video E/M for established patient; 10+ minutes when using time or straightforward MDM
98005	Synchronous audio-video E/M for established patient; 20+ minutes when using time or low MDM
98006	Synchronous audio-video E/M for established patient; 30+ minutes when using time or moderate MDM
98007	Synchronous audio-video E/M for established patient; 40+ minutes when using time or high MDM (>=55 minutes use 99417)

Synchronous audio-only new patientCPTCovered

98008	Synchronous audio-only E/M for new patient; >10 minutes discussion, 15+ minutes total time
98009	Synchronous audio-only E/M for new patient; >10 minutes discussion, 30+ minutes total time
98010	Synchronous audio-only E/M for new patient; >10 minutes discussion, 45+ minutes total time
98011	Synchronous audio-only E/M for new patient; >10 minutes discussion, 60+ minutes total time (>=75 minutes use 99417)

Synchronous audio-only established patient & brief check-inCPTCovered

98012	Synchronous audio-only E/M for established patient; >10 minutes discussion, 10+ minutes total time
98013	Synchronous audio-only E/M for established patient; >10 minutes discussion, 20+ minutes total time
98014	Synchronous audio-only E/M for established patient; >10 minutes discussion, 30+ minutes total time
98015	Synchronous audio-only E/M for established patient; >10 minutes discussion, 40+ minutes total time (>=55 minutes use 99417)
98016	Brief virtual check-in for established patient; 5-10 minutes patient-initiated; video not required

Non-physician telephone assessmentCPTCovered

98966	Telephone assessment and management service by qualified non-physician; 5-10 minutes
98967	Telephone assessment and management service by qualified non-physician; 11-20 minutes
98968	Telephone assessment and management service by qualified non-physician; 21-30 minutes

Online digital (secure messaging) servicesCPTCovered

99421	Online digital E/M for established patient; cumulative 7-day time 5-10 minutes (physician)
99422	Online digital E/M for established patient; cumulative 7-day time 11-20 minutes (physician)
99423	Online digital E/M for established patient; cumulative 7-day time 21+ minutes (physician)
98970	Non-physician online digital E/M; cumulative 7-day time 5-10 minutes
98971	Non-physician online digital E/M; cumulative 7-day time 11-20 minutes
98972	Non-physician online digital E/M; cumulative 7-day time 21+ minutes

Store-and-forward / interprofessional consultationsCPTCovered

99446	Interprofessional telephone/internet/EHR assessment & management; 5-10 minutes
99447	Interprofessional consultative E/M; 11-20 minutes
99448	Interprofessional consultative E/M; 21-30 minutes
99449	Interprofessional consultative E/M; 31+ minutes
99451	Interprofessional consultative E/M written report; 5+ minutes
99452	Interprofessional referral service(s) by treating/requesting provider; 30 minutes

Telehealth audio/video and audio-only CPT codesCPT

98000-98007	New CPT codes for audio and video communications effective 01/01/2025
98008-98016	New CPT codes for audio-only communications effective 01/01/2025
99441-99443	Audio-only telephone E/M codes (terminated 12/31/2024; removed)
G2012	Virtual check-in code (terminated 12/31/2024; removed)

Time or MDM-based code selection

Guiding principleSelect CPT code based on either the level of medical decision making (MDM) or the total time on the date of the encounter unless the code description states otherwise.

When code description differsIf a code description explicitly prescribes selection criteria, follow the code description rather than defaulting to time or MDM.

Apply CPT Codebook guidanceFollow CPT Codebook guidelines for time and MDM calculations when choosing the appropriate E/M or telehealth code.

Code selection basis

What Providers Must Do

Prior Authorization

Washington audio-only established relationship requirement

Providers must comply with state-specific telehealth requirements for establishing provider–patient relationships and obtaining patient consent where applicable. In Washington state, for audio-only telemedicine the provider must have an established relationship with the patient before providing audio-only services. An established relationship may be met if either: the patient has had, within the past three years, at least one in-person appointment or at least one real-time interactive audio-and-video appointment with the provider (or with a provider employed at the same medical group, same clinic, or same integrated delivery system); OR the patient was referred to the provider providing audio-only telemedicine by another provider who, within the past three years, has had an in-person or real-time interactive audio-and-video appointment with the patient and has provided relevant medical information to the audio-only provider.

Washington-specific requirement effective Jan 1, 2023: established relationship required for audio-only services
Established relationship may be satisfied by prior in-person visit OR prior real-time audio+video visit within past 3 years
Referral by another provider who has an established relationship and provided relevant medical information also satisfies requirement

Key Terms

Audio Only telemedicine

DefinitionAudio-only telemedicine: delivery of healthcare services using audio-only technology permitting real-time communication for diagnosis, consultation, or treatment; excludes facsimile or email.

Modalities excludedAudio-only does not include fax or email communications.

Use casesUsed for real-time diagnosis, consultation, or treatment between a patient at the originating site and a distant site provider.

Distant Site

DefinitionDistant Site: the site/location where the provider or specialist providing the professional service at a distance is located (consulting site).

Provider requirementsDistant site providers must be licensed and operate within the scope of practice where the member is located.

Policy Summary

PayerPremera Bluecross

PolicyTelehealth/Telemedicine services reimbursement

Policy CodePolicy N/A

Change TypeCodes added, codes removed, Washington-specific clarifications

Effective DateN/A

Next Review DateN/A

Key ActionAppend the appropriate telehealth modifier and Place of Service code and document member consent for audio-only encounters where required.

SourceLink

On This Page

Store‑and‑forward / interprofessional consultation codes and minimum times: 99446 (5–10 min), 99447 (11–20), 99448 (21–30), 99449 (31+), 99451 (written report, >=5 min), 99452 (referral service, 30 min).

Brief virtual check‑in constraints

98016 is patient‑initiated, for established patients only (5–10 minutes), and must not originate from a related E/M within the previous 7 days nor lead to an E/M within the next 24 hours.

Audio‑only telephone assessment by non‑physician codes and time thresholds: 98966 (5–10 min), 98967 (11–20 min), 98968 (21–30 min); these audio‑only codes are not to be used solely for prescription renewals, triage to set up an office visit within 24 hours, appointment or test scheduling, or record updates.

Primary basis for code selectionUse level of medical decision making or total time on the date of service as the basis for selecting the CPT code unless the code description specifies otherwise.

ExceptionsWhere a code description explicitly defines selection criteria, that description takes precedence over the general time/MDM rule.

Documentation requirementDocument time and elements of MDM in the medical record to support the selected code per CPT guidance.

Online digital services reporting frequency

Reporting frequencyReport online digital (secure messaging) E/M codes once per 7-day period for the cumulative time associated with the patient-initiated service.

Minimum time thresholdDo not report online digital services for cumulative service time less than 5 minutes.

Same-day restrictionDo not report these online digital codes on the same date of service as an office visit or outpatient facility visit procedure code.

Record retentionOnline digital encounters require permanent storage of the encounter in the medical record.

Brief virtual check-in constraints

Patient and visit typeService is patient-initiated and reported for established patients only.

Duration5–10 minutes of medical discussion (brief virtual check-in).

Exclusions relative to other visitsNot originating from a related E/M service within the previous 7 days and not leading to an E/M service or procedure within the next 24 hours or soonest available appointment.

Video not requiredVideo technology is not required for the brief virtual check-in service.

Audio-only excluded uses

Prohibited sole usesAudio-only/telephone assessment codes must not be used solely for prescription renewals, appointment scheduling, test scheduling, triaging a patient to set up an office visit within 24 hours, or updating patient record information.

PurposeThese codes are intended for clinical assessment and management, not administrative or scheduling tasks.

Consent requirement for audio-only

Consent requiredMember consent must be obtained prior to the rendering of an audio-only encounter.

DocumentationConsent must be documented in the member's medical record to support use of audio-only codes.

Established relationship time windows (Washington)

Behavioral health window (WA)Washington: behavioral health services require an established relationship defined by a prior appointment within 3 years.

Other services window (WA)Washington: other services require an established relationship defined by a prior appointment within 2 years.

Record access requirementProvider must have access to prior health records or referral information to meet the established relationship requirement.

Policy timing noteThese Washington-specific definitions and termination dates are specified in the policy's state-specific section.

Documentation Required

State-specific telehealth provider actions and consent

Document adherence to state telehealth laws (including Washington House Bills related to audio-only telemedicine) in the patient record and include documentation demonstrating how the established-relationship requirement is met for audio-only encounters. Where state law requires patient consent or notices for telehealth, obtain and document that consent per state requirements. Failure to comply with state-specific telehealth requirements may lead to claim denials, increased audits, contractual penalties, or termination per Plan policy.

Document evidence of prior in-person or audio+video encounter within medical record when billing audio-only services
If providing audio-only services based on a referral, retain documentation of the referring provider’s relevant clinical information and timeline
Obtain and document any state-required patient consent or notice for telehealth encounters

RoleThe distant site is responsible for delivering the telehealth clinical service to the patient remotely.

Originating Site

DefinitionOriginating Site: the site/location where the patient is physically located during the telehealth encounter (e.g., home, clinic, hospital, remote site).

Originating site feeIf the member is physically hosted at a healthcare facility and assisted to connect, that facility may bill HCPCS Q3014 for an originating site fee (not billed when member connects from home in certain state-specific cases).

POS relevanceThe policy references Place of Service codes (including POS 10 for patient home) to identify the patient's physical location during the encounter.

Real-Time Encounters / Video Conferencing

DefinitionReal-Time Encounters / Video Conferencing: secure, real-time interactive audio and video communication over an encrypted, HIPAA-compliant telecommunications system for clinical encounters.

Modality requirementAn interactive audio and video telecommunications system that is HIPAA compliant and encrypted is required for synchronous audio-video services.

Substitution for face-to-faceSynchronous audio-video communications may substitute for a face-to-face encounter for a limited number of services when clinically appropriate.

Store and Forward

DefinitionStore and Forward (S&F): asynchronous transmission of patient images, video clips, audio clips, or clinical data for later review to render a medical opinion or diagnosis.

ExclusionsS&F does not include telephone calls, images transmitted via fax, or text messages.

TypesIncludes provider-generated (interprofessional consults) and patient-generated transmissions; permanent record must be maintained in the medical record.

Selection of code is based on level of medical decision making or total time on date of encounter unless code description states otherwise

Selection ruleSelection of code is based on level of medical decision making (MDM) or total time on the date of encounter unless the code description states otherwise.

CPT Codebook alignmentFollow CPT Codebook guidelines for applying time- or MDM-based selection across telehealth E/M codes.

DocumentationDocument time and MDM elements in the patient record to justify code selection.

A patient-initiated 5-10 minute service for established patients to determine need for a more extensive visit; video not required

Service descriptionA patient-initiated 5–10 minute service for established patients to determine need for a more extensive visit; video not required.

Patient eligibilityReported for established patients only and not originating from related E/M within previous 7 days.

Outcome limitationMust not lead to an E/M or procedure within the next 24 hours or soonest available appointment.

POS 10

DefinitionPOS 10: Place of Service code '10' indicates care rendered to a patient in their home or private residence.

Policy updatePolicy updated to reference POS code '10' to represent member home/private residence for telehealth services.

Audio-only telemedicine

Definition and scopeAudio-only telemedicine: real-time audio-only technology for diagnosis, consultation, or treatment with distinct codes and rules; legacy audio-only codes 99441-99443 and G2012 terminated 12/31/2024.

New codesNew CPT audio-only codes (98008–98016) were added effective 01/01/2025 to replace terminated legacy codes.

Appropriate useAudio-only services require member consent and must meet the policy's clinical and documentation requirements.