Telehealth Service Coverage Guidelines: A Brief Guide
Effective January 1, 2016, the New York telehealth coverage law prohibited commercial insurers and health maintenance organizations from “excluding from coverage a service that is otherwise covered under an enrollee contract because the service is delivered via telehealth.” (NY State Public Health Law § 4406-G, NY State Insurance Law § 3217-H)
This does not include Medicare and self-funded plans. Medicaid has other requirements. WCH Service Bureau helps providers understand Medicare and commercial payer guidelines for coverage of telehealth services:
Medicare
Medicare beneficiaries are eligible for telehealth services only if they are presented from an originating site located in:
- A county outside of a Metropolitan Statistical Area (MSA)
- A rural Health Professional Shortage Area (HPSA) located in a rural census tract
You can access HRSA’s Medicare Telehealth Payment Eligibility Analyzer to determine a potential originating site’s eligibility for Medicare telehealth payment.
Authorized Originating Sites
An originating site is the location where an eligible Medicare beneficiary is when a service is provided via a telecommunications system.
Originating sites authorized by law:
- The offices of physicians or practitioners
- Hospitals
- Critical Access Hospitals (CAHs)
- Rural Health Clinics
- Federally Qualified Health Centers
- Hospital-based or CAH-based Renal Dialysis Centers (including satellites)
- Skilled Nursing Facilities (SNFs)
- Community Mental Health Centers (CMHCs)
Distant Site Practitioners
Practitioners who may furnish and receive payment for covered telehealth services (subject to State law) at a distant site are:
- Physicians
- Nurse practitioners (NPs)
- Physician assistants (PAs)
- Nurse-midwives
- Clinical nurse specialists (CNSs)
- Certified registered nurse anesthetists
- Clinical psychologists (CPs) and clinical social workers (CSWs)
Covered Telehealth Services
As a condition of payment, you must use an interactive audio and video telecommunications system that permits real-time communication between you, at the distant site, and the beneficiary, at the originating site. Asynchronous “store and forward” technology is permitted only in Federal telemedicine demonstration programs in Alaska or Hawaii.
A list of Medicare telehealth services is available on the Medicare Learning Network – Telehealth services site, page 3. Medicare pays the appropriate amount under the Medicare Physician Fee Schedule (PFS) for telehealth services. For full information please visit Medicare Learning Network – Telehealth services.
Some payers, including Oxford Commercial plan, UnitedHealthcare Medicare Advantage Plans and UnitedHealthcare Community Plan, have policies similar to Medicare.
Some Healthfirst plans, including Essential plans, Healthfirst Pro EPO, Pro Plus EPO Plans, and several others, do cover telemedicine, but only via Teladoc telemedicine provider.
Teladoc is a network of licensed primary care physicians who diagnose routine, non-emergency medical problems via the telephone or video. Each physician accepted to join the Teladoc network is hired as a contract employee through Teladoc PA.
Cigna offers telemedicine through American Well and MdLive. EmblemHealth also covers Telemedicine through American Well, a privately held telehealth company based in Boston, Massachusetts that connects patients instantly with doctors over secure video. The company provides immediate urgent care web visits for patients in 46 states.
According to the Empire BlueCross BlueShield Telehealth policy:
Reimbursement for telehealth services may be available when interactive services occur between the patient and the remote provider and the telehealth services are provided through a Health Plan approved telehealth program (e.g., LiveHealth Online) or are mandated by state or federal law.
Telehealth services are to be identified by appending Telehealth modifiers to CPT or HCPCS codes that ordinarily describe face-to-face services, including, but not limited to, office or other outpatient visits, inpatient visits, or individual psychotherapy services.
By coding and billing Telehealth modifiers with a covered procedure code, the provider is certifying that the beneficiary was present at an eligible originating site when the provider furnished the telehealth service. The policy does not, however, provide a description of an eligible originating site.
Verify Telehealth Billing Requirements
Telehealth providers must verify each payer's billing requirements. The best way to know if telemedicine is covered by an insurance policy is to call the payer and verify the following:
- Which services can be completed via telemedicine?
- What are the requirements for the location of the patient or provider?
- Are telehealth services covered when performed “via an asynchronous telecommunications system”?
- Does the reimbursement rate match the face-to-face encounter rate?
- Which providers are eligible (physician, NP, PA)?
- Are there any specific notes that need to be included in the visit documentation?
