Policy No: 132
Date of Origin: 07/01/2017
Last Reviewed: 07/01/2020
Last Revised: 07/01/2020
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 in-network medical and behavioral health telehealth services to our Individual, group (including administrative services only who have the telehealth benefit) and Medicare Advantage members.
View our Coronavirus (COVID-19) update and resources for information about the temporary expansion of in-network telehealth services for our members.
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.
873I (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 that the services are rendered in
For the purposes of this policy, Virtual Care services are Covered Services when:
- Services are initiated by or at the request of a Member or authorized caregiver seeking access to a Provider from a Distant Site.
- Verify members' benefits using the Availity Portal.
- Service is delivered to a Member by a Provider acting within the scope of his or her license and in compliance with applicable state laws in the state(s) where the Member is physically located while seeking services in the state(s) where the Provider is physically located, if applicable. This requirement includes satisfaction of the elements of the Member-Provider relationship as determined by the relevant healthcare regulatory board and all applicable law.
- The service replaces the need for an In-Person visit.
- 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. Practice Guidelines for Live, On Demand Primary and Urgent Care. Last retrieved on December 13, 2017.
- 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.
- Billed services must be within the Provider's scope of license. Coverage for billed services will be determined by the Member Agreement.
- The Provider is responsible for practicing within the scope of their license and determining the standards for safe and secure delivery of virtual care services, including location of the member and/or provider, and compliance with all applicable laws.
- 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.
Virtual Care via Synchronous Interaction received at an Originating Site where the Member is physically located and the location is not a Health Care Facility.
- This use case falls within the definition of "Telehealth" under this policy.
- The Member is present and able to participate. The Member's identity is authenticated and eligibility is verified.
- If a Provider offering Virtual Care services under this scenario in his or her practice 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.
Telephone assessment and management service by physicians or other qualified health care professionals
Current Procedural Terminology (CPT®) 99441-99443 (with GT modifier)
Telephone assessment and management service by non-physician qualified health care professionals
CPT 98966-98968 (with GT modifier)
Online assessment and management services (using video, Internet) by non-physician qualified health care professionals
CPT 98969 (with GT modifier)
Office or other outpatient visit for the evaluation and management of a new patient (for video visits when appropriate)
CPT 99201-99203 (with GT modifier)
Office or other outpatient visit for the evaluation and management of an established patient (for video visits when appropriate)
CPT 99212-99214 (with GT modifier)
Follow up with member:
If this evaluation does not lead to a visit and does not occur within seven days of a prior related service by the billing practitioner, it may be billed as a standalone service.
HCPCS G2012 (with GT modifier)
For this scenario, E&M codes CPT 99204, 99205, 99211 and 99215 billed with place of service (POS) 02 and modifier GT are not reimbursable for virtual care services.
Psychology services, initial assessment
CPT 90791 (with GT modifier)
Psychiatry services, mental health therapy and psychopharmacology initial assessment
CPT 90792 (with GT modifier)
Psychotherapy, 30 minutes
CPT 90832 (with GT modifier)
Psychotherapy services, mental health therapy and psychopharmacology follow-up visits
CPT 90833 (with GT modifier)
Psychotherapy, 45 minutes
CPT 90834 (with GT modifier)
Psychotherapy, 60 minutes
CPT 90837 (with GT modifier)
Family psychotherapy with member present
CPT 90847 (with GT modifier)
Behavioral health follow-up visits
Advanced care planning, 30 minutes
CPT 99497 (with GT modifier)
Advanced care planning, additional 30 minutes
CPT 99498 (with GT modifier)
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.
Modifier GT must be appended to all codes when the service is conducted via interactive audio and/or video telecommunication systems.
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
- Telemedicine Health Care Common Procedure Coding System (HCPCS) Q3014 (telehealth originating site facility fee)
- 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:
- Medical/behavioral health evaluations that occur within seven (7) days after an In-Person evaluation and management service performed by the same Provider for the same condition, whether Provider-requested or unsolicited Member follow-up.
- Medical/behavioral health evaluations occurring more than once within seven (7) days for the same episode of care and rendered by the same Provider.
- 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).
Providers at the Originating Site
If the originating site is a health care facility:
Providers at the Distant Site must submit the appropriate HCPCS/CPT codes for the services rendered.
Modifier GT must be appended to all codes when the service is conducted via interactive audio and video telecommunication systems.
The following services are not Covered Services under this scenario:
Virtual Care received via Store and Forward Asynchronous Interaction. Please check Availity Portal or Customer Service for benefit coverage information.
Coverage of Store and Forward Services are limited to the services specifically contracted for in a Provider's contract with the Member's health plan.
Providers at the Distant Site must submit the appropriate HCPCS/CPT codes for the services rendered. Modifier GQ must be appended to all codes referenced in this scenario when the service is conducted via Asynchronous Interaction.
Reimbursement for Store and Forward Services is determined by the Member Agreement and Provider contract.
For the following Store and Forward scenarios, the Provider at the Distant Site should not have seen the member In-Person within 14 days. The consult must replace the need for an In-Person visit with the Provider at the Distant Site. If an In-Person visit with the Provider at the Distant Site occurs within 14 days from the Store and forward consult date of service, the consult is not considered to have replaced the need for an In-Person visit.
The Distant Site Provider should have access to the electronic medical record of the Member from the referring Provider.
In order to be reimbursed, the following criteria must be met:
- 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.
Referring or consulting provider at the distant site:
Consultation via Virtual Care includes counseling and/or coordination of care with other Providers or agencies are provided consistent with the nature of the problem(s) and/or family's needs.
CPT 99446 - 99449, 99451, 99452 (with GT/GQ modifier) for services by Providers at Distant Site.
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.
Providers engaging with Member via Store and Forward Asynchronous Interaction.
Remote evaluation and follow up with member
The following service is not a Covered Service under this scenario: