DraftWashington State Health Care AuthorityPolicy N/A

Telemedicine Policy - Apple Health Obstetric Care

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Proposed coverage criteria for obstetric telemedicine services for Apple Health clients, including medical necessity, safety, hybrid-care, provider, documentation, prenatal, postpartum, billing, and audio-only requirements.

Policy Summary

PayerWashington State Health Care Authority

PolicyTelemedicine Policy - Apple Health Obstetric Care

Policy CodePolicy N/A

Change TypeNo material clinical or coverage change

Effective DateN/A

Next Review DateN/A

Key ActionOffer the client in-person services and document that offer in the medical record.

SourceLink

POLICY UPDATE CHANGES

Current remote patient monitoring coverage during pregnancy will not change.

3 visitsPrenatal audio-only limit

1 visitPostpartum audio-only limit

6-12 weeksRequired postpartum visit window

1 readingDiagnostic-test readings reimbursed

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DraftWashington State Health Care AuthorityPolicy N/A

Telemedicine Policy - Apple Health Obstetric Care

Customize your policy alerts

Sign up for all Washington State Health Care Authority policy alerts

Know when Washington State Health Care Authority releases new policies or updates existing guidance.

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Policy Summary

PayerWashington State Health Care Authority

PolicyTelemedicine Policy - Apple Health Obstetric Care

Policy CodePolicy N/A

Change TypeNo material clinical or coverage change

Effective DateN/A

Next Review DateN/A

Key ActionOffer the client in-person services and document that offer in the medical record.

SourceLink

POLICY UPDATE CHANGES

Current remote patient monitoring coverage during pregnancy will not change.

3 visitsPrenatal audio-only limit

1 visitPostpartum audio-only limit

6-12 weeksRequired postpartum visit window

1 readingDiagnostic-test readings reimbursed

Obstetric Telemedicine Coverage Criteria

General obstetric telemedicine requirements

Covered when all of the following requirements are met:

General telemedicine requirements

Medical necessity and quality: Care must meet medical necessity requirements, and telemedicine care must be safe and effective.
Relationship to in-person care: Telemedicine must complement in-person care rather than replace it.
Client preference must be prioritized and respected. The client must be offered in-person services, and the offer must be documented in the medical record.
Provider and records requirements: The telemedicine provider must have a physical location in Washington or an established relationship with a provider that has a physical location in Washington. Records, including imaging and laboratory results, must be accessible to the local treating provider and the local hospital or birth center.
Diagnostic-test interpretation: Payment is made for only one reading or interpretation of diagnostic tests, such as laboratory tests and ultrasounds.one reading or interpretation

Prenatal visits

Prenatal telemedicine care must meet the following requirements:

Initial and transfer-of-care visits: The initial comprehensive prenatal visit must be provided in person. If the client changes providers or transfers care, the first visit with the new provider must also be provided in person.

The initial comprehensive prenatal visit must include a thorough evaluation of the client's physical, behavioral, and social health needs.

Other early pregnancy visits may be completed by audio-only telemedicine or real-time audio/visual telemedicine.

Postpartum visits

Postpartum telemedicine care must meet the following requirements:

Comprehensive postpartum visit: The comprehensive postpartum care visit must be provided in person within 6–12 weeks after delivery.6–12 weeks after delivery

Other postpartum visits may be completed by audio-only telemedicine or real-time audio/visual telemedicine.

Proposed supported telemedicine service areas

Billing guides will identify support for obstetric telemedicine in the following service areas when current evidence supports the value of these services:

Supported service categories

Maternal-fetal medicine, including high-risk obstetric care and specialty consultation.
High-risk conditions: Care for clients with certain high-risk conditions.
Postpartum care: Postpartum visits.
Lactation support.
Behavioral health services.

Audio-only telemedicine

Audio-only care is covered subject to the following utilization limits:

Audio-only utilization limits: Audio-only care is limited to three visits during the prenatal period and one visit during the postpartum period.3 prenatal visits; 1 postpartum visit

Providers may request a limitation extension if the client would benefit from additional audio-only visits.

Telemedicine must complement, not replace, in-person obstetric care. Providers must prioritize and respect client preference, offer in-person services, and document that offer in the medical record.

Payment is made for only one reading or interpretation of a diagnostic test, including laboratory tests and ultrasounds. Additional readings or interpretations of the same diagnostic test are not reimbursed.

Provider Requirements and Billing Actions

Prior Authorization

Audio-Only Limitation Extension

Providers may request an extension of the audio-only visit limit when the client would benefit from additional audio-only visits. The request must support the client-specific need for extending the limit.

Documentation Required

Offer and Document In-Person Care

Prioritize and respect client preference by offering in-person services. Document the offer in the client’s medical record.

Documentation Required

Maintain Accessible Clinical Records

Ensure records, including imaging and laboratory results, are accessible to the local treating provider and the local hospital or birth center. The telemedicine provider must have a physical location in Washington or an established relationship with a provider who does.

Policy Background

HCA proposes a hybrid model for Apple Health obstetric care in which telemedicine complements in-person visits rather than replacing them. The proposal is intended to support access while maintaining medical necessity, safety, care coordination, and health equity. Proposed areas for telemedicine support include maternal-fetal medicine and specialty consultation, care for clients with certain high-risk conditions, postpartum visits, lactation support, and behavioral health.