Policy No: 132
Date of Origin: 07/01/2017
Last Reviewed: 04/01/2023
Last Revised: 04/01/2023
Policy applies to: Group and Individual
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 Individual, group (including administrative services only) and Medicare Advantage 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.
Digital Health Products
Technologies, platforms, and systems that engage consumers for lifestyle, wellness, and health-related purposes. Digital therapeutic products differ from digital health products in that they are practitioner-prescribed software that delivers evidence-based therapeutic interventions to prevent, manage, or treat a medical disorder or disease.
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 real-time (synchronous) using telephone or other interactive audio-only telecommunications system.
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 for distant site services performed using audio and video technology. Professional providers should submit claims using modifier 26 (instead of GT) for radiology services.
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.
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. Virtual Care includes all Telehealth, Telemedicine, Store and Forward, Remote Physiologic Monitoring (RPM), and Remote Therapeutic Monitoring (RTM) services between health care professionals and patients or authorized caregiver that are furnished for the purposes of diagnosis, evaluation, or treatment of an illness or injury.
Virtual Health services occur when the physician or other Qualified Health Care Professional and the member are not at the same site.
The plan pays for Virtual Care services such as basic office and other outpatient visits, professional consultation, psychiatric diagnostic interview examination, individual psychotherapy, pharmacologic management, and nutrition therapy, Wellness exams, and end stage renal disease related 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.
Provider is responsible for authenticating the member’s identity and verifying the member is eligible for Virtual Care Benefits prior to the service. Benefits can be verified using the 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.
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.
Digital Therapeutic Products, Medical Policy Manual, M-MED175
Digital Therapeutic Products for Attention Deficit Hyperactivity Disorder, Medical Policy Manual, M-MED175.01
Digital Therapeutic Products for Substance Use Disorders, Medical Policy Manual, M-MED175.02
Your use of this Reimbursement Policy constitutes your agreement to be bound by and comply with the terms and conditions of the Reimbursement Policy Disclaimer.