Telehealth Services Reimbursement and Coverage Policy
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Defines University Health Alliance (UHA/HSA) reimbursement, coverage criteria, limitations, and administrative billing guidelines for telehealth and telemedicine services for covered members and participating providers.
No material clinical or coverage changes in this revision.
Coverage criteria and exclusions
Primary coverage criteria and exclusions
Telehealth services are covered when ALL of the following criteria are met; exclusions and special conditions follow.
ALL of the following
ALL of the following
ALL of the following
- Provider must be Hawaii-licensed when establishing a physician–patient relationship in Hawaii; out-of-state providers may provide services only under conditions set forth in the Medical Benefits Guide.
ALL of the following
ALL of the following
- Service must be medically necessary and would have been covered for an in-person encounter.
- Telehealth encounter must include documented patient evaluation, including history and discussion of physical symptoms adequate to establish a diagnosis and treatment plan; documentation must conform to CPT standards.
ALL of the following
ONE of
- Real-time audio/video conferencing-based communication (synchronous).
- Secure interactive and non-interactive web-based communication (excludes email and text messaging).
- Secure asynchronous information exchange for diagnostic quality images and lab results for interpretation/diagnosis.
- Synchronous e-visits as defined by CMS.
ALL of the following
- Reimbursement to the health professional delivering the clinical service is the same as the current fee schedule amount for the service provided; submit claims with appropriate CPT/HCPCS codes and indicate telehealth Place of Service.
ALL of the following
- When a procedural service is performed, the physician who actually performs the procedure should bill standard procedure codes and benefits will be paid based on the procedural fee schedule.
- A specialist/consultant who monitors/advises on a procedure via video should bill for a consultation (not the procedure); benefits paid based on the consultation fee schedule.
ALL of the following
- An emergency room physician may bill for a consultation if an outlying physician requests a telemedicine consultation; specialists may bill for emergency telehealth services.
- If the patient is subsequently treated in the consulting physician's ED, do not bill both the telemedicine consultation and an ED visit for the same patient on the same date/encounter.
ALL of the following
EXCLUSIONS: any of the following are non-covered
- Issuing a prescription based solely on an online questionnaire (not a telehealth service) is not covered.
- Use of telehealth modality to prescribe controlled substances or medical marijuana is not covered except for established patients with extreme discretion.
- Telemedicine services delivered solely through email and/or text messaging are non-covered.
- Audio-only visits for all diagnoses are non-covered.
ALL of the following
- A physician shall not use telemedicine to establish a physician–patient relationship with a patient in Hawaii without a Hawaii license; once a provider–patient relationship is established, licensed parties may use telemedicine as allowed by law.
ALL of the following
- Telemedicine may be used for out-of-state consultations on a limited basis; prior authorization is required for out-of-state telemedicine consultations.
ALL of the following
- All plan provisions, exclusions, payment guidelines, and negotiated agreements that apply to in-person visits also apply to telemedicine services.
- Telehealth services must comply with applicable federal and state privacy, security, and confidentiality laws.
Place of Service, CPT guidance, and documentation
| 02 | Place of Service (POS) code indicating telehealth |
| 99441-99443 | Telephone evaluation and management (general guidance referenced) |
| 97110 | Therapeutic exercise (example referenced) |
Prior authorization, out-of-state rules, and appeals
Prior authorization for telehealth services
Prior authorization is not required for local (in-state) telehealth visits; however, any service that requires prior authorization when rendered in-person also requires prior authorization when rendered via telehealth.
- Confirm whether the specific service ordinarily requires prior authorization in-person; if so, obtain prior authorization prior to delivering it via telehealth.
Out-of-state telemedicine requires authorization
Prior authorization is required for out-of-state telemedicine consultations; telemedicine may be used for out-of-state consultations only on a limited basis with authorization.
- Obtain prior authorization before providing telemedicine services to members located outside Hawaii.
- Verify that the out-of-state consultation falls within the limited circumstances allowed by the policy.
Reconsideration and retrospective review process
Providers may request reconsideration of medical necessity determinations with supporting documentation; UHA may also perform retrospective review and may require documentation to validate payment determinations.
- If a service is denied for medical necessity, submit a request for reconsideration with supporting clinical documentation as described by UHA.
- Maintain legible medical records of the telehealth encounter and make them available to UHA upon request for retrospective review.
Key definitions and included/excluded modalities
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