CurrentWPS Health InsurancePolicy 1018

Virtual Care

This document governs WPS Health Insurance reimbursement and billing requirements for telehealth, telemedicine, and virtual care services for providers submitting UB-04 or CMS-1500 claims across commercial lines of business.

Policy Summary

PayerWPS Health Insurance

PolicyVirtual Care

Policy CodePolicy 1018

Change TypeNo material change

Effective DateMar 23, 2020

Next Review DateJan 1, 2026

Key ActionSubmit telehealth services with place of service 02 or 10 and the appropriate corresponding modifier; document medical necessity and include documentation in the patient medical record.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

All Commercial LOBLines of business covered

POS 02/10Submission POS requirement

GQ, GO, GT, 95, 93Accepted modifiers

~15 sitesDefined originating sites

Telehealth Coverage Criteria

Telehealth coverage criteria

Services are covered when billed and documented per the policy requirements and performed by eligible providers at eligible sites.

Services are submitted using approved claim forms (UB-04 or CMS-1500/electronic equivalent) and billed per policy requirements.

ALL of the following

Telehealth services must be submitted with Place of Service 02 or 10.
Use appropriate telehealth modifier per service: GQ (asynchronous/store-and-forward), GO (acute stroke), GT (interactive audio/video), 95 (real-time interactive audio/video), 93 (real-time interactive audio-only).
Patient must be present and located at an eligible originating site for services billed with modifiers GT, GO, or 95.

Policy Summary

PayerWPS Health Insurance

PolicyVirtual Care

Policy CodePolicy 1018

Change TypeNo material change

Effective DateMar 23, 2020

Next Review DateJan 1, 2026

Key ActionSubmit telehealth services with place of service 02 or 10 and the appropriate corresponding modifier; document medical necessity and include documentation in the patient medical record.

SourceLink

On This Page

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.

ALL of the following

Servicing provider must meet the definition of an eligible provider and be licensed/certified in the state where the patient is physically located at the time services are provided (unless state emergency guidance allows flexibility).
Eligible provider types include
- Physician
- Physician Assistant
- Nurse Practitioner
- Nurse Midwife
- Clinical Nurse Specialist
- Certified Registered Nurse Anesthetist
- Registered Dietitian or nutrition professional
- Certified Genetic Counselor
- Physical Therapist (PT)
- Occupational Therapist (OT)
- Speech Language Pathologist (SLP)
- Chiropractor (DC)
- Clinical Psychologist*
- Clinical Social Worker*
- Licensed Professional Counselor*
- Marriage and Family Therapist*
- Other mental health or substance abuse professional* acting within scope and providing a payable service
Services provided by eligible telehealth providers must fall within the scope of the provider's license/certification.
Note: Psychiatric diagnostic interview examinations may not be billed with medical services or medical evaluation and management services.

Coding and Billing Modifiers

Accepted modifiers for telehealth servicesModifier | mixed

GQ	Services performed via asynchronous telecommunication system
GO	Services performed for evaluation, diagnosis, or treatment of acute stroke
GT	Services performed face-to-face via interactive audio and visual telecommunication system
95	Services performed via real-time interactive audio or visual telecommunication system
93	Services performed via telephone or other real-time interactive audio-only telecommunication system

Patient presence requirement for GT, GO, 95

RequirementPatient must be present and physically located at an eligible originating site when services are billed with modifier GT, GO, or 95.

Applicable modifiersGT, GO, 95 — these modifiers require patient presence at an originating site when used to report telehealth services.

Documentation implicationClaims should document the patient’s presence at the originating site and the originating site type to support billing with GT/GO/95.

Submission and Documentation Requirements

Documentation Required

Submission and documentation requirements for telehealth claims

Submit telehealth services with place of service (POS) 02 or 10 and the appropriate corresponding modifier; document medical necessity and include appropriate documentation in the patient medical record.

Use POS 02 or 10 on claims for telehealth services.
Apply the appropriate modifier (GQ, GO, GT, 95, or 93) per service description.
Ensure services are medically necessary and document clinical rationale in the medical record.
Include all supporting documentation of the telehealth encounter in the patient’s chart.

Key Definitions

Interactive Telehealth (Real-time two-way interaction)

DefinitionReal-time two-way interaction between a patient and a physician or other eligible provider using a nonpublic interactive audio or visual telecommunication system.

ModalityRequires interactive audio and visual communication (synchronous), not store-and-forward or audio-only.

Use in billingReport interactive telehealth services using the appropriate in-person codes with applicable telehealth modifiers per policy.

Asynchronous Telecommunication (Store-and-Forward)

DefinitionThe storing and forwarding of medical information for review by a physician or other eligible provider at a distant site while the patient is not present (also referred to as store-and-forward).

Associated modifierTypically reported with modifier GQ to indicate use of asynchronous telecommunication systems.

LimitationThis mode is asynchronous; it does not meet the real-time interactive telehealth definition and is billed per applicable code descriptions.

Originating site (where the patient is located)

DefinitionPhysical location at which the patient is located during the time telehealth services are provided.

Eligible sites (examples)Physician/practitioner office; hospital (inpatient/outpatient/critical access); skilled nursing facility; renal dialysis center; certain patient homes; CMHC; RHC; FQHC; mobile stroke unit; residential substance abuse treatment facility; schools and educational facilities.

Policy implicationServices billed as telehealth must indicate an eligible originating site to meet coverage and billing requirements.

Distant site (where the provider is located)

DefinitionThe physical location at which the physician or other eligible provider is located during the time telehealth services are provided.

Contrast with originating siteDistant site refers to the provider’s location; originating site refers to the patient’s location.

Billing noteProviders at the distant site must meet eligible provider definitions in policy when billing telehealth services.