Policy No: 132
Date of Origin: 07/01/2017
Last Reviewed: 03/01/2022
Last Revised: 03/01/2022
This policy applies to Providers. All terms described in this policy are subject to applicable state and federal laws. In the event of any discrepancy between the terms of this policy and the requirements of state or federal law, the law governs.
We are temporarily expanding medical and behavioral health telehealth services to our members.
View our Telehealth visits section of our Coronavirus (COVID-19) update and resources for more information.
ANSI ASC X12 837
ANSI ASC X12 837: The Health Insurance Portability and Accountability Act (HIPAA) requires that all health insurance payers in the United States comply with the electronic data interchange (EDI) standards for health care as established by the Secretary of Health and Human Services (HHS). Medical claims that providers submit to payers are in electronic format of the HIPAA 837 standard.
- 837P (Professional): The standard format used by health care professionals and suppliers to transmit health care claims electronically.
837I (Institutional): The standard format used by institutional providers to transmit health care claims electronically.
Transmission of a Member's health care information over secure connection enabling a member-to-provider or provider-to-provider interaction that is not simultaneous or concurrent in time and where the participants are separated by distance. The interaction must result in medical diagnosis or management of the Member and the technology cannot include the use of audio-only telephone, fax or standard email.
Medically Necessary health care services and supplies rendered or furnished by a Provider that are eligible for benefit consideration under a Member Agreement.
Site at which the Provider delivering the Virtual Care is located at the time of the service.
- Providers location must be listed on the provider's enrollment file
Provider must be licensed and enrolled in the state(s) the Provider and Member are physically located
The member has had at least one in-person appointment within the past year with the physician or other provider rendering the services, with a provider employed at the same clinic as the provider, or with a locum tenens or other provider who is the designated back up or substitute provider for the provider rendering services who is on leave and is not associated with an established clinic.
Face-to-face interaction when a Member and a Provider are physically in the same location.
Used to indicate services furnished using audio-only communication technology. This must be appended to any procedure using Audio-only Technology even if the provider has the capability of Audio/Video Technology.
While the Centers for Medicare & Medicaid (CMS) no longer requires modifier GT for professional services, please continue to use this with place of service POS 02 or POS 10 when submitting claims to our health plan. Professional providers should submit claims using modifier 26 (instead of GT) for radiology services. For the distant site, the GT modifier must be submitted with ‘telehealth and telemedicine' services. Generally, interactive audio and video communications must be used to permit real-time communication between the distant site provider and the member. The member must be present and participating in the visit.
This modifier must be submitted with ‘Store and Forward' services. Generally, asynchronous telecommunications must be used to permit non-real-time communication between the distant site provider and the member.
A person eligible to receive health care benefits for Covered Services under a Member Agreement.
A contract or plan underwritten or administered in whole or in part, by payer, which sets forth the terms and conditions under which a Member is entitled to receive benefits for Covered Services.
Physical location of the Member at the time the service is provided.
Place of Service (POS) 02 - Telehealth Provided Other than in Patient's Home
To be used on professional claims when the member is located in a health care facility for health services and when also receiving health services from a distant site provider through telecommunication technology. Modifier GT is required with POS 02.
Place of Service (POS) 10 – Telehealth Provided in Patient’s Home
To be used on professional claims when the member is located in their home or a location that is not a health care facility when receiving health services from a distant site provider through telecommunication technology. Modifier GT for synchronous services or modifier GQ for asynchronous services is required with POS 10.
A physician (person who is legally qualified to practice medicine in the state where he or she practices) or other qualified health care professional.
Store and Forward Technology
Use of an Asynchronous Interaction to transmit a Member's medical information from an Originating Site to a Provider at a Distant Site, which results in medical diagnosis and management of the Member, and does not include the use of audio-only telephone, fax, or email.
Store and Forward Services
The Provider's professional services of diagnosis and medical management of the Member that result from the use of Store and Forward Technology.
Live real-time communication through interactive technology that enables a Member and a Provider who are separated by distance to interact simultaneously.
Services provided by Synchronous Interaction audio (telephonic), Synchronous Interaction audio/video communications, or Store and Forward Technology. The Provider and Member, or the Providers participating are separated by distance. The service provided is evaluation and management focused. When specified in this policy, other types of services may be applicable. Requirements concerning the establishment of the Provider-Member relationship are subject to applicable state laws.
For example: Member receives Virtual Care from Provider for an immediate health concern. Provider diagnoses a low-level condition, gives Member medical advice and calls in a prescription. Provider can bill for the service.
This policy describes reimbursement requirements for Virtual Care Services including Telehealth, Telemedicine, and Store and Forward Services.
Providers are responsible for ensuring the security and privacy of information, including, but not limited to, HIPAA, community standards, and best practices for security and privacy, recording consent, Protected Health Information (PHI) storage and storage disclosure.
Providers must ensure access to Virtual Care services is inclusive for those patients who may have disabilities or limited-English proficiency and for whom the use of telemedicine technology may be more challenging.
Reimbursement for billable services is determined by the Provider’s contract and the Member Agreement.
In order for Virtual Care to be eligible for reimbursement the following must be met:
- Services are initiated by or at the request of a Member or authorized caregiver seeking access to a Provider from a Distant Site.
- Physician or other Qualified Health care professional and the member are not at the same site
- Member is eligible for Virtual Care Benefits. Providers are responsible to verify this and can be verified using Availity Essentials
- Service delivered to a Member must be within the scope of the performing (distant site) provider’s license and in compliance with applicable state laws in the state(s) where the Member is physically located and where the distant site Provider is physically located. This requirement includes satisfaction of the elements of the Member-Provider relationship as determined by the relevant healthcare regulatory board and all applicable law. Please refer to your state licensing board to determine care guidelines when the provider and/or member are in different states, as these requirements vary by state, provider type, and service type. In most, if not all instances, the provider must be licensed in the state the member is physically located at the time of the visit.
- The service replaces the need for an In-Person visit.
- Service does not originate from a related E/M service provided within the previous 7 days.
- Service does not lead to an E/M service or procedure within the next 24 hours or soonest available appointment
- A permanent record of relevant evaluation, management, and follow-up instructions are maintained as part of the Member’s medical record. The record must be available for review or audit by the Member’s health plan at any time. The record-keeping standards that apply to in person visits also apply to virtual care visits.
- Following the Virtual Care session, if the rendering Provider is not the Member’s primary care provider (PCP), the rendering Provider should communicate a summary of the Virtual Care encounter to the Member’s PCP using secure methods (e.g., email/fax, secure email, transmit to EMR), as well as to the Member, unless the Member has requested a limitation on such communication.
- If a Provider offering Virtual Care services does not have an established provider-member relationship with a Member seeking such services, steps should be taken to establish a provider-member relationship through a combination of audio and video communication and not audio-only communication. In all cases, the applicable community standard of care must be satisfied
- Virtual Services using Audio Only technology must have an established relationship between member and Provider.
- Virtual Services using Audio Only technology must have consent obtained prior to first audio-only encounter with a provider and may cover such encounters for a period of up to 12 months. If audio-only encounters continue beyond an initial 12-month period, consent must be obtained from the covered person for each prospective 12-month period. Consent must be documented in the member’s medical record and available for a minimum of five years.
Annual Wellness: G0438, G0439
Evaluation and Management Codes (E&M Codes): 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215 Audio Only: 99441, 99442, 99443, 98966, 98967, 98968
Behavioral Health: 90785, 90791, 90792, 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90840, 90846, 90847, 90853
Diabetes Management: G0108, G0109
Nutrition Therapy: 97802, 97803, 97804
Palliative Care: 99497, 99498
Preventive and similar services are eligible for reimbursement only as services specifically defined by CMS, our health plan's published policies and member benefits or applicable state and federal law as suitable for delivery via Virtual Care and as consistent with all other requirements of this policy.
Smoking and Tobacco use Cessation: 99406, 99407
Virtual Check-in: G2012, G2251, G2252
Other Services: 96156, 96158, 96159, 96164, 96165, 96167, 96168, 96160, 96161
The following services are not covered as services under this scenario:
- E-mail; fax transmission; secure messaging
- Installation or maintenance of any telecommunication devices or systems
- Home health monitoring
- Reporting of test results only
- Request for medication refill
- Follow-up care that does not require shared medical decision making
- Provider-to-Provider interactions
- Asynchronous or "Store and Forward" telecommunication (including transferring data from one site to another through the use of a scanning, camera or similar devices that record (stores) an image that is sent (forwarded) via telecommunication to another site for consultation).
- Radiology interpretations. Claims should be billed with modifier 26.
- Service covering monitoring the Member's clinical status.
- "Health line" type services provided by nurses and other non-physician, non-nurse practitioner providers.
- Triage to assess the appropriate place of service and/or appropriate provider type.
Administrative services including but not limited to, follow-up care that does not require shared medical decision making, or follow-up phone calls that do not replace what would have been a follow-up visit, scheduling, registration, updating billing information, reminders, requests for medication refills or referrals, pre-authorizations, prior authorizations, ordering of diagnostic studies, and medical history intake completed by the Member.
Subject to applicable state laws, the following services are generally not reimbursable Telehealth services under this scenario:
- Follow-up phone calls that do not replace what would have been a follow-up visit.
- Any communications that are used to convey results of test(s).
Originating Site Facility Fee
For the Originating Site Facility to be considered for reimbursement the following must be met:
- Member must be physically located in the Health Care Facility billing as the originating site
- The originating site must be providing health services to the Member
- Originating Site must be an Eligible Health Care Facility as listed below
- Providers billing on ANSI 837P must submit with appropriate place of service, HCPCS Q3014 with no modifier
- Providers billing on ANSI 837I must submit with revenue code 0780 range with HCPCS Q3014 with no modifier
- Originating Site provider included in the eligible originate Site health care facility list
Reimbursement for Virtual Care via Asynchronous interaction are limited to the services specifically contracted for in a Provider’s contract with the Member’s health plan.
Reimbursement for Store and Forward Services is determined by the Member Agreement and Provider contract.
Store and Forward Services are considered for reimbursement when criteria for Virtual Care is met as well as the following:
- Place of Service 10 and modifier GQ is required for all Store and Forward Services billed for distant site professional services
Services are included in the Eligible Store and Forward Services list
E-Consultation (Provider-to-Provider) 99446, 99447, 99448, 99449, 99451, 99452
- Both providers must be at a health care facility
- Greater than 50% of the time must be devoted to medical consultative verbal/secure online discussion.
- Member is aware that the consult occurred. This can be achieved through making the results of the consult available to the Member.
- If more than one telephone/internet contact is required to complete the consultation request (e.g., discussion of test results), the entirety of the service and the cumulative discussion and information review time should be reported with a single code.
E-Visits: 98970, 98971, 98972, 99421, 99422, 99423
Remote Evaluation: 99091, G2010, G2250
The following services are not Covered Services under this scenario:
- Home health