In our continuing effort to simplify the information being distributed by top insurers during this pandemic regarding their current adjusted billing rules, we are providing this summary. It contains information taken directly from each insurer’s website, augmented by our telephone conversations with representatives of the various companies. Additionally, for further clarity we are providing links to the most complete explanations each payer has distributed to date. We have highlighted certain points in bold to facilitate your ability to quickly review the information. We must caution this is a guide based on the most current information available to us.
Please reach out to us if you are in need of immediate assistance to ensure that your revenue stream is maintained during this time. For immediate assistance, contact Louis Burke at 917-838-9510 or via email at LouisB@ecmmgt.com.
AETNA
(Link to AETNA site)
DATE: For the next 90 days, until June 4, 2020
COST SHARING: Aetna will waive member cost sharing for a covered telemedicine visit regardless of diagnosis. Aetna members are encouraged to use telemedicine to limit potential exposure in physician offices. Cost sharing will be waived for all virtual visits provided by in-network providers. Self-insured plan sponsors will be able to opt-out of this program at their discretion.
CODING: For the 90-day period - All telemedicine services not noted below will be covered according to Aetna’s Telemedicine policy which is available to providers on the NaviNet and Availity portals.
For the next 90 days Aetna will cover minor acute evaluation and management services care services rendered via telephone. A visual connection is not required. For general medicine and behavioral health visits – a synchronous audiovisual connection is still required. Aetna’s telemedicine policy is available to providers on the NaviNet and Availity portals.
The following codes require an audiovisual connection: w Modifier 95 or GT where indicated
G2061, G2062, G2063 - Qualified nonphysician healthcare professional online assessment, for an established patient, for up to seven days, cumulative time during the 7 days; 5-10 minutes; 11 – 20 minutes; or 21 or more minutes
98970, 98971, 98972 - Qualified nonphysician health care professional online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10; 11-20; or 21 or more minutes.
99421, 99422, 99423 - Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10; 11-20; or 21 or more minutes.
H0015 GT or 95 - Alcohol and/or drug services; intensive outpatient (treatment program that operates at least 3 hours/day and at least 3 days/week and is based on an individualized treatment plan), including assessment, counseling; crisis intervention, and activity therapies or education
H0035 GT or 95 - Mental health partial hospitalization, treatment, less than 24 hours.
H2012 GT or 95 - Behavioral health day treatment, per hour.
H2036 GT or 95 - Alcohol and/or other drug treatment program, per diem
S9480 GT or 95 - Intensive outpatient psychiatric services, per diem
97151 GT or 95 - Behavior identification assessment, administered by a QHP, face to face with patient and/or guardians administering assessments and discussing findings and recommendations. Includes non-face-to-face analyzing of past data, scoring/interpreting the assessment, and preparing the report/treatment plan.
97155 GT or 95 - Adaptive behavior treatment with protocol modification, administered by QHP, which may include simultaneous direction of a technician working face to face with a patient.
97156 GT or 95 - Family adaptive behavior treatment guidance administered by QHP, with parent/guardian
97157 GT or 95 - Multiple-family group adaptive behavior treatment guidance, administered by QHP, with multiple sets of parents/guardians
The following codes require either an audiovisual connection or telephone:
G2010 - Remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related e/m service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment.
G2012 - Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related e/m service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion.
98966, 98967, 98968 - Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 5-10; 11-20; or 21-30 minutes of medical discussion.
99441, 99442, 99443 - Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10; 11-20; or 20-30 minutes of medical discussion.
90791, 90792; GT or 95 - Psychiatric diagnostic interview examination
90832, 90833, 90834, 90836, 90837, 90838; GT or 95 - Individual psychotherapy
90839, 90840; GT or 95 - Psychotherapy for crisis; first 60 minutes; or each additional 30 minutes
90845; GT or 95 – Psychoanalysis
90846, 90847, 90853; GT or 95 - Family or group psychotherapy
90863; GT or 95 - Pharmacologic management, including prescription and review of medication, when performed with psychotherapy services
96116; GT or 95 - Neurobehavioral status examination
EMPIRE BCBS
(Link to EMPIRE BCBS site)
DATE: For 90 days effective March 17, 2020
COST SHARING:
Effective March 17, Empire began waiving member cost sharing for telemedicine (video + audio) visits, including covered visits for mental health or substance abuse disorders, for our fully insured employer plans, Individual plans, Medicare plans and Medicaid plans where permissible. Self-insured plan sponsors may opt out of this program.
Effective March 19, Empire began waiving cost sharing for in-network provider telehealth visits (by phone or FaceTime/Skype) where medically appropriate if all other requirements for a covered health service are met. Out-of-network telehealth visits are also covered if the member’s benefit plan has out-of-network benefits but may be subject to cost sharing.
Deductible will apply to telehealth and telemedicine visits unrelated to COVID-19 as required for high deductible health plans to preserve tax deductibility of associated HSAs.
This will remain in place for 90 days.
CODING:
Telemedicine (video + audio):
This applies to use of our LiveHealth Online platform, as well as for care received from other providers delivering virtual care through internet video + audio services. Self-insured plan sponsors may opt out of this program. program.
Exceptions include chiropractic services, physical, occupational, and speech therapies. These services require face-to-face interaction and therefore are not appropriate for telehealth. This waiver will remain in place for 90 days.
How are telemedicine services covered?
Empire covers telemedicine e.g., Live Health Online (live video audio) services for providers who have access to those platforms/capabilities and participate in the program.
What codes would be appropriate to consider for a telehealth or a telephonic visit?
Office visit (99201-99215) telehealth claims will require Place of Service (POS) code “02” and either modifier 95 or GT.
Medicare Advantage telehealth claims – Audio Only
99441, 99442, 99443, 98966, 98967, 98968 do not require a telehealth modifier. POS would be the location where the provider initiates such a call.
Note, however, Medicare Advantage coding for either telehealth or audio-only telephonic claims could change in the future based on guidance from CMS.
CIGNA
(Link to CIGNA Site)
DATE: Through May 31, 2020
COST SHARING: Waive customer cost-sharing for office visits related to COVID-19 screening and testing. Waive customer cost-sharing for telehealth screenings for COVID-19 through May 31, 2020. Claims will be processed consistent with these rules beginning April 6, 2020 for dates of service on or after March 2, 2020 and until at least May 31, 2020.
CODING:
Make it easier for customers to be treated virtually for routine medical examinations by providers. In an effort to remove barriers for our customers to access timely and safe care, while ensuring that providers can continue to deliver necessary services in necessary settings,
TELEPHONE ONLY - Providers can also bill code G2012 for a 5-10 minute phone conversation. This will allow for quick telephonic consultations related to COVID-19 screening or other necessary consults, and will offer appropriate reimbursement to providers for this amount of time.
Cigna will not make any requirements as it relates to these services being for a new or existing patient.
Cigna will not make any requirements regarding the type of technology used (i.e., phone, video, FaceTime, Skype, etc. are all appropriate to use at this time).
Cigna will allow providers to bill a standard face-to-face visit for all virtual care services, including those not related to COVID-19. This means that providers can perform services for commercial Cigna customers in a virtual setting and bill as though the services were performed face-to-face.
Providers should bill using a face-to-face evaluation and management code, append the GQ modifier, and use the POS that would be typically billed if the service was delivered face to face. Providers will be reimbursed consistent with their typical face-to-face rates.
DO NOT - Billing a POS 02 or GT/95 modifier for virtual services. This may result in reduced payment or denied claims due to current system limitations. Billing a typical place of service will ensure providers receive the same reimbursement as they typically get for a face-to-face visit.
Mid-level practitioners (e.g., physician assistants and nurse practitioners) can also provide services virtually using the same guidance. Reimbursement will be consistent as though they performed the service in a face-to-face setting.
We are actively working on guidance for e-consults (e.g., provider-to-provider televisits) and inpatient virtual consults, and will share that information when it is available.
We are actively working on billing guidance for urgent care centers, and will share that information when it is available.
Cigna will reimburse virtual physical, occupational, and speech therapy services The following virtual physical, occupational, and speech therapy (PT/OT/ST) services will be allowed through May 31, 2020 when appended with a GQ modifier and billed with a standard place of service code. These services will be reimbursed consistent with the standard fee schedule.
Physical Therapy
97161 - PT eval low complex 20 min (Telephonic or virtual)
97162 – PT Eval Moderate Complex 30 MIN
97110 – Therapeutic Exercise (2 units limit)
Occupational Therapy
97165 - OT eval low complex 30 min (Telephonic or virtual)
97166 - OT eval mod complex 45 min
97110 - Therapeutic exercises (2 unit limit)
Speech Therapy
92507 - Speech/hearing therapy
92526 – Oral Function Therapy
While we encourage providers to bill consistent with an office visit – and understand that certain services can be time consuming and complex even when provided virtually – we strongly encourage providers to be cognizant when billing level four and five codes for virtual services. While we will reimburse these services consistent with face-to-face rates, we will monitor the use of level four and five services to limit fraud, waste, and abuse.
Please note that state and federal mandates may supersede the preceding guidelines.
EMBLEM HEALTH
(Link to EMBLEM HEALTH Site)
DATE: Effective until May 31, 2020, but we may extend that date if necessary
COST SHARING: Emblem Health members across all product lines will have no cost-sharing (including copayments, coinsurance, or deductibles) for the diagnostic visit and related lab test for coronavirus (COVID-19).
CODING: EmblemHealth will temporarily allow for limited telehealth services to be provided by telephone only as outlined in the policy below for all EmblemHealth lines of business and all products. This policy applies to EmblemHealth participating providers only.
Telehealth services are live, interactive audio and visual transmissions of a physician-patient encounter from one site to another using telecommunications technology. They may include transmissions of real-time telecommunications or those transmitted by store-and-forward technology.
Telephone calls, which are considered audio only transmissions, per the CPT definition, are non-face-to-face evaluation and management (E/M) services provided to a patient using the telephone by a Physician or Other Qualified Health Care Professional, who may report evaluation and management services.
Telehealth or Telephone services are covered when all of the following criteria are met:
-The patient is present/participates at the time of service.
-Services should be similar to in-person services with a patient.
-Services must be medically necessary and otherwise covered under the member’s benefit booklet or subscriber agreement.
-Services must be within the provider’s scope of license.
-A permanent record of the telephonic communication(s) must be documented/maintained as part of the patient’s medical record. It must be sufficiently documented to support the code used.
-Consistent with CMS, EmblemHealth will allow non-HIPAA compliant technology such as FaceTime and Skype to be used with discretion and patient consent.
-Only the provider rendering the services may submit for reimbursement for telehealth services.
Non-Behavioral Health Providers: PHONE ONLY services provided only during a state of emergency or implementation of this policy by Emblem Health are limited to the following provider types/primary care physician and midlevel primary care providers for Commercial and Medicare Advantage.
The following provider types may render services
-Physician
-Nurse practitioner
-Physician assistant
-Nurse-midwife
-Clinical nurse specialist
-Registered dietitian or nutrition professional
Behavioral Health Providers: PHONE ONLY during a state of emergency or implementation of this policy by Emblem Health
The following providers for Commercial and Medicare Advantage.
-Clinical nurse specialist
-Psychiatrist
-Psychologist
-Clinical social worker
-Licensed Marriage and Family Therapist (not allowed for Medicare)
-Licensed Mental Health Counselor
ALL Applicable Procedure Code requires Place of Service (POS) code 02 for reporting telemedicine and telephone services rendered by a physician or other practitioner.
Please use Place of Service 02 with Modifier GT is required to identify telemedicine services.
Code(s) for Telephone Services:
CPT Code Description 99441 Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5- 10 minutes of medical discussion
CPT CODE Description 99442 Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 11-20 minutes of medical discussion
CPT CODE Description 99443 Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 21-30 minutes of medical discussion Title Last review
CPT CODE G2012 (Medicare only) Brief communication technology-based service, e.g., virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5- 10 minutes of medical discussion
Modifier(s) for Telehealth Services: Must be used for telemedicine services Modifier Description
-CR Catastrophe/Disaster Related (Reporting only)
-GT Via interactive audio and video telecommunication systems. (must be real-time)
-GQ (Medicaid Telephonic only) Via asynchronous telecommunications system
UNITED HEALTHCARE
(Link to UNITED HEALTHCARE Site)
DATE: Until June 18, 2020, UnitedHealthcare will reimburse appropriate claims for telehealth services
COST SHARING: United is waiving cost sharing for COVID-19 testing during this national emergency and we are waiving cost sharing for COVID-19 testing related visits during this same time, whether the testing related visit is received in a health care provider’s office, an urgent care center, an emergency department or through a telehealth visit. This coverage applies to Medicare Advantage, Medicaid and employer-sponsored plans. For other health related telehealth visits, cost sharing and coverage will apply as determined by your health benefits plan, through June 18, 2020.
CODING:
Commercial
Telehealth services provided via a real-time audio and video communication system can be billed for members at home or another location. UnitedHealthcare will reimburse telehealth services that are:
1. Originating Site requirements are waived
2. Recognized by CMS and appended with modifiers GT or GQ and,
3. Recognized by the American Medical Association (AMA), included in Appendix P of CPT® and appended with modifier 95. Reimbursable codes can be found embedded in the reimbursement policy at Telehealth and Telemedicine PolicyOpens in a new window.
Medicaid
Telehealth services provided via a real-time audio and video communication system can be billed for members at home or another location. UnitedHealthcare Community Plan will reimburse telehealth services that are:
1. Originating Site requirements are waived
2. Recognized by CMS and appended with modifiers GT or GQ
3. Recognized by the AMA, included in Appendix P of CPT and appended with modifier 95
Medicare Advantage
For all UnitedHealthcare Medicare Advantage plans, including Dual Eligible Special Needs Plans. Telehealth services provided via a real-time audio and video communication system can be billed for members at home or another location.
1. Originating Site requirements are waived
2. All CPT/HCPCS codes, payable as telehealth when billed with Place of Service 02 and the GQ or GT modifiers, as appropriate, under Medicare, will be covered on our Medicare Advantage plans for members at home during this time.
3. Standard plan copays, coinsurance and deductibles will apply.
4. Codes that are payable as telehealth under Medicare Advantage can be found at CMS.GOV
Additionally, for commercial, Medicare Advantage and some Medicaid plans, UnitedHealthcare already reimburses appropriate claims for several technology-based communication services, including virtual check-ins, which may be done by telephone, and e-visits for established patients.
Audio-only Services Billed with E/M Codes
For commercial, Medicaid and Medicare Advantage members, UnitedHealthcare reimburses telehealth services provided through live, interactive audio and visual transmission to existing patients whose medical benefit plans cover telehealth services, unless otherwise permitted by state law. For additional information, visit: Provider Telehealth Policies.
For audio and video telecommunications, during the public health emergency, the requirement for a pre-existing patient relationship has been waived. (NEW PATIENTS ARE COVERED) This applies to all of our Medicare, Medicaid and commercial plan members.
As of March 19, 2020, there is no change to the type of care provider who may submit claims for broad telehealth services. UnitedHealthcare generally follows CMS’ policies on the types of care providers eligible to deliver telehealth services, although individual states may define eligible care providers differently. These include:
-Physician
-Nurse practitioner
-Physician assistant
-Nurse-midwife
-Clinical nurse specialist
-Registered dietitian or nutrition professional
-Clinical psychologist
-Clinical social worker
-Certified Registered Nurse Anesthetists
COVID-19 Virtual Check- Last update: March 26, 2020, 1:30 p.m. CDT
Audio-only Telephone Reimbursement
For commercial, Medicaid and Medicare Advantage members, UnitedHealthcare reimburses the following audio-only or digital services for e-visits:
The patient must generate the initial inquiry, and communications can occur over a 7-day period. For these services, UnitedHealthcare reimburses CPT codes 99421-99423 and HCPCS codes G2061-G2063, as applicable. These services can only be reported when the billing practice has an established relationship with the patient. For these e-visits, the patient must generate the initial inquiry, and communications can occur over a 7-day period. The patient must verbally consent to receive virtual check-in services.
For audio and video telecommunications, during the public health emergency, the requirement for a pre-existing patient relationship has been waived. This applies to all of our Medicare, Medicaid and commercial plan members.
Our commercial and Medicare Advantage plans currently reimburse for “virtual check-in” patients to connect with their doctors remotely. These services are for established patients, not related to a medical visit within the previous 7 days and not resulting in a medical visit within the next 24 hours (or soonest appointment available). These services can be billed when furnished through several communication technology modalities, such as telephone (HCPCS code G2012) or captured video or image (HCPCS code G2010).
Medicaid Virtual Check-In Reimbursement
Effective immediately through June 18, 2020, our Medicaid plans will reimburse for “virtual check-in” patients to connect with their doctors remotely. These services are for established patients, not related to a medical visit within the previous 7 days and not resulting in a medical visit within the next 24 hours (or soonest appointment available). These services can be billed when furnished through several communication technology modalities, such as telephone (HCPCS code G2012) or captured video or image (HCPCS code G2010).
COVID-19 Electronic Visits - Last update: March 26, 2020, 1:30 p.m. CDT
UnitedHealthcare will reimburse for patients to communicate with their doctors using online patient portals, using CPT codes 99421-99423 and HCPCS codes G2061-G2063, as applicable.
Our Medicare Advantage, Medicaid and commercial plans currently reimburse for “e-visits” for patients to connect with their doctors remotely. These services are for established patients, not related to a medical visit within the previous 7 days and not resulting in a medical visit within the next 24 hours (or soonest appointment available).
UnitedHealthcare commercial, Medicare Advantage and some Medicaid plans pay for e-visits in all types of locations, including the patient’s home, and in all areas (not just rural). Established patients may have non-face-to-face, patient-initiated communications with their doctors, without going to the doctor’s office, by using online patient portals.
These services can only be reported when the billing practice has an established relationship with the patient. For these e-visits, the patient must generate the initial inquiry, and communications can occur over a 7-day period. For these services, UnitedHealthcare reimburses CPT codes 99421-99423 and HCPCS codes G2061-G2063, as applicable. The patient must verbally consent to receive virtual check-in services.
Until June 18, 2020, UnitedHealthcare will extend this reimbursement to all Medicaid plans.
HORIZON BCBS
(Link to HORIZON BCBS Site)
DATE: This is effective immediately and, along with all previously announced COVID-19 related adjustments and cost-sharing waivers, is in effect through June 30, 2020, unless extended.
COST SHARING: Providing telephonic care with no costs to members
Horizon BCBSNJ is waiving member cost sharing for covered telemedicine visits, which now include common video platforms like Facetime and Skype as well as telephone-only, with in-network health professionals. Members seeking care from out-of-network providers may still get covered services from their preferred health care professional using these platforms or phone, but they remain responsible for out-of-network cost-sharing payments according to the terms of their individual policies.
CODING:
These changes take effect immediately for Horizon BCBSNJ’s fully insured members, including those covered through Medicaid, Medicare, Individual and Small Group policies. The State Health Benefits Program (SHBP) and School Employees’ Health Benefits Program (SEHBP) have also agreed to these changes. Other self-insured health plans are responsible for the specific plan designs they choose to offer to their employees, and we will continue to work with them to administer their plan designs as directed.
Effective immediately, Horizon BCBSNJ is:
-Relaxing its telemedicine rules to allow members to receive covered services by telephone
--Applies to covered services delivered by video or telephone from in-network and out-of-network health care professionals.
-Ensuring provider reimbursements are consistent with existing policies.
--For covered services rendered by common video platforms, providers will be reimbursed at the same rates as if the service was provided in office.
Mental health service professionals are reminded that Horizon BCBSNJ maintains an open network for mental health professionals and these professionals are encouraged to join our network.
Eligible Providers:The above applies to all covered services including those provided by primary care doctors, specialists, therapists, LCSWs, mental health professionals or urgent care doctors.
Audio-only telehealth services for the following codes for:
-99441
-99442
-99443
Horizon BCBSNJ will accept claims for telemedicine services when modifiers 95 or GT are appended to CPT® or HCPCS codes that ordinarily describe face-to-face services including but not limited to:
-Professional services related to diagnosis or treatment of COVID-19
-Routine care
-Therapy
-Mental health care
Regardless of the coding paradigm, Horizon BCBSNJ will pay up to the allowed amount, and providers may not collect member cost share that would otherwise be collectible.
We encourage all health care professionals, facilities and ancillary providers to continue to work to ensure a high-level of accuracy and compliance with the most current and appropriate coding practices, rules and guidelines.
These changes and all other changes related to COVID-19 are effective until June 30, 2020, subject to extension by Horizon BCBSNJ as the COVID-19 dynamics begin to dissipate.
Published on: March 23, 2020, 12:37 p.m. ET
Last updated on: March 24, 2020, 14:49 p.m. ET
HEALTHFIRST
(Link to HEALTHFIRST Site)
DATE: 3-18-2020 - These changes take effect immediately for 90 days and may be subject to an extension.
COST SHARING: Healthfirst is waiving cost sharing for coronavirus (COVID-19) testing and any telemedicine visits. Providers and facilities are prohibited from billing Healthfirst Child Health Plus, Essential Plan, HFIC, and Qualified Health Plan members any deductible, copayment, coinsurance, or annual deductible for services connected to coronavirus (COVID-19) evaluation or testing performed, in keeping with the state guidelines.
CODING: 3-20-2020 Healthfirst has incorporated changes to our Telemedicine Reimbursement Policy as of 3/17/20. Healthfirst will follow guidance from the Centers for Medicare and Medicaid Services.
Impacted lines of business include: Child Health Plus, Commercial Plan, Essential Plan, Medicaid Please check back regularly for updates.
Telehealth is defined as the use of electronic information and communication technologies to deliver healthcare to patients remotely. Telehealth is designed to improve access to needed services and to improve the health of members. Telehealth is not available solely for the convenience of the practitioner when a face-to-face visit is more appropriate and/or preferred by the member.
A list of telehealth codes appears at the end of the document. Please see below for more information on the telehealth guidelines aligned with CMS.
-The originating site is where the member is located at the time healthcare services are delivered to him/her by means of telehealth.
-The distant site is any secure location within the fifty United States or United States territories where the telehealth provider is located while using telehealth to deliver healthcare services.
-Telehealth applications Telemedicine uses two-way electronic audio-visual communications to deliver clinical healthcare services to a patient at an originating site by a telehealth provider located at a distant site.
-Healthfirst recognizes the CMS-designated practitioners eligible to be reimbursed for telehealth services.
-The totality of the communication of information exchanged between the physician or other qualified healthcare practitioner and the patient during the course of the synchronous telemedicine service must be of an amount and nature that would be sufficient to meet the key components and/or requirements of the same service when rendered via face-to-face interaction.
-Medicaid-Health and Recovery Plan Medicare Advantage Medicaid Advantage Plus (CompleteCare) Qualified Health Plan Telehealth Services
-Telehealth Services Healthfirst will consider for reimbursement telehealth services which are recognized by the CMS and appended with modifier 95, as well as services recognized by the AMA included with modifier 95: Modifier 95
-Synchronous telemedicine service through real-time interactive audio and video telecommunication system. Healthfirst requires modifier 95 for appropriate reimbursement. Place of Service (POS) code to use when billing for telehealth: POS 02: The location where health services and health-related services are provided or received through telehealth telecommunication technology. If telehealth services are billed with modifier 95 but without POS 02, the claim will be denied.
-Modifier 25: Significant, separately identifiable evaluation and management (E&M) service by the same physician or other qualified healthcare professional on the same day as a procedure or other service still can apply
-Telehealth Reimbursement Policy Healthfirst will reimburse participating providers for covered telehealth services in accordance with the fee schedule applicable to the providers' contract. When billing telehealth services, providers must bill with POS code 02 and continue to bill modifier 95.
-Healthfirst recognizes the CMS-designated originating sites considered eligible for furnishing telehealth services to a patient in an originating site.
-The office of a physician or practitioner;
-A hospital (inpatient or outpatient)
-A federally qualified health center (FQHC)
-A skilled nursing facility (SNF)
-A community mental health center
FIDELIS CARE
(Link to FIDELIS CARE Site)
DATE: Effective March 1, 2020
COST SHARING: Fidelis is in the process of updating systems to ensure our members can use telehealth services from participating providers with cost sharing waived (in products that have member cost sharing). Providers rendering care via telehealth are responsible to ensure any copays, coinsurance, or deductible charges are waived for Fidelis Care members at the time of telehealth services.
CODING: Fidelis Care expanded coverage of telehealth services in 2019 and strongly encourages providers to deliver their services via the telehealth modality wherever reasonably possible in order to support current social distancing and containment strategies. To the extent it is practical, Fidelis Care encourages the use of telehealth to provide COVID-19 related services to members and offers reimbursement for these services across all products
Definition of Telehealth Telehealth is defined as the use of electronic information and communication technologies to deliver health care to patients at a distance. Covered services provided via telehealth include assessment, diagnosis, consultation, treatment, education, care management and/or self-management of a Fidelis Care member.
Fidelis Care will continue to support, promote, and align with rapidly evolving New York State guidance to providers on allowable parameters to render telehealth and telephonic services to our members.
-Providers are required to use Place of Service 02 for telehealth, in combination with the appropriate modifier aligned with the service
-On March 21, 2020 New York State Medicaid issued additional comprehensive updates available here: https://www.health.ny.gov/health_care/medicaid/program/update/2020/index.htm providing clarified and broadened definitions related to telehealth, authorizing telephonic services for reimbursement, and specifying additional reimbursement and coding details specific to NYS Medicaid Fee-for-Service. While Fidelis Care is aligned with coverage described in this update, including aligning with expanded definitions and parameters related to telehealth, the coding and reimbursement referenced is not relevant to our claims processing requirements. Providers should continue to submit telehealth claims to Fidelis Care using their existing procedure codes and ensure Place of Service 02 and appropriate modifiers are included consistent with guidelines described in Section 26 of the provider manual.
Fidelis Care will continue to monitor changes in state and federal regulations related to any expansion of, additional approval, or change in regulation regarding telehealth services.
HUMANA
(Link to HUMANA Site)
DATE: Humana update for telehealth visits – effective March 23, 2020
COST SHARING: To encourage members to seek care safely while protecting the health care workforce, Humana is waiving member cost share for all telehealth services delivered by participating/in-network providers. This includes:
-All telehealth services delivered by participating/in-network providers, either through audio or video
-All telehealth services delivered through MDLive to Medicare Advantage members, and also to Commercial members in Puerto Rico
-All telehealth services delivered through Doctor on Demand to Commercial members
-Please do not collect traditional member responsibility for these services from any Humana member, as it will result in avoidable refund transactions and may inhibit members from seeking needed care
CODING: To support providers with caring for their Humana patients while promoting both patient and provider safety, we have updated our existing telehealth policy. At a minimum, we will always follow CMS telehealth or state-specific requirements that apply to telehealth coverage for our insurance products. This policy will be reviewed periodically for changes based on the evolving COVID-19 public health emergency and updated CMS or state specific rules1 based on executive orders. Please refer to the applicable CMS or state specific regulations prior to any claim submissions, and check this page regularly for the latest information.
Temporary expansion of telehealth service scope and reimbursement rules
-To ease systemic burdens arising from COVID-19 and support shelter-in-place orders, Humana is encouraging the use of telehealth services to care for its members. Please refer to CMS, state, and plan coverage guidelines for additional information regarding services that can be delivered via telehealth
-In response to this emergency, Humana will temporarily reimburse for telehealth visits with participating/in-network providers at the same rate as in-office visits. In order to qualify for reimbursement, telehealth visits must meet medical necessity criteria, as well as all applicable coverage guidelines
-Humana understands that not all telehealth visits will involve the use of both video and audio interactions. For providers or members who don’t have access to secure video systems, we will temporarily accept telephone (audio-only) visits. These visits can be submitted and reimbursed as telehealth visits.
-Please follow CMS or state-specific guidelines and bill as you would a standard telehealth visit.
-Both participating/in-network primary and specialty providers can render care using telehealth services, provided that CMS and state-specific guidelines are followed
For telehealth visits with a specialist, members are encouraged to work with their primary care physician to facilitate care coordination
Check CMS Telemedicine Fact Sheet for guidelines or the applicable state-specific for most updated list of distant site practitioners
Additional Resources:
CMS Telehealth Services Fact Sheet
Medicare Telemedicine Health Care Provider Fact Sheet
