Policy No: 132
Date of Origin: 07/01/2017
Section: Administrative
Last Reviewed: 12/09/2024
Last Revised: 12/09/2024
Approved: 12/12/2024
Effective: 01/01/2025
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.

Virtual Care
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.

Telehealth/Telemedicine:
Telehealth/Telemedicine services are synchronous, real-time services performed via interactive audio/video or audio-only technology received at an Originating Site where the Member is physically located and the provider is located at a separate, distant site.

Services must be initiated at the request of the member or authorized caregiver seeking access to a provider.

Services must replace the need for an in-person visit. The member must be present and able to participate.

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.

Annual Wellness - G0438, G0439

Evaluation and Management Codes (E&M Codes): 98000, 98001, 98002, 98003, 98004, 98005, 98006, 98007, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, G2211

• Audio Only: 98008, 98009, 98010, 98011, 98012, 98013, 98014, 98015, 98966, 98967, 98968
• Home visit: 99347, 99348

• Prolonged Visit: G2212

Behavioral Health - 90785, 90791, 90792, 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90840, 90846, 90847, 90853, G0017, G0018

Care Planning - 99483, 99495, 99496

Chemical Dependency - G0396, G0397, G0442, G0443, G2086, G2087, G2088

Chronic Pain Management - G3002, G3003

CKD Educational Services - G0420, G0421

Crisis Safety Plan Intervention - G0560N

Critical Care Consult - G0508, G0509

Diabetes Management - G0108, G0109

ESRD-Related Services - 90951, 90952, 90954, 90955, 90957, 90958, 90960, 90961, 90963, 90964, 90965, 90966, 90967, 90968, 90969, 90970

HIV prEP: G0011, G0013

Home Health - G0320, G0321

Inpatient Services - G0406, G0407, G0408, G0425, G0426, G0427, G0459

Neurobehavioral Status Examination - 96116, 96121

Nutrition Counseling/Therapy - 97802, 97803, 97804, G0270

Palliative Care - 99497, 99498

Preventive Services:

• including G0513, G0514

• 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.

Psychological/Behavioral Testing & Evaluation - 96127, 96131, 96138, 96139

Smoking and tobacco use cessation - 99406, 99407

Virtual Check-in - 98016, G2251, G2252

Other Services - 96156, 96158, 96159, 96164, 96165, 96167, 96168, 96160, 96161, G0136, G0296, G0444, G0445, G0446, G0447

Eligible Audio-Only Services: 90785, 90791, 90792, 90832, 90833, 90834, 90836, 90839, 90840, 90846, 90847, 90853, 96116, 96121, 96127, 96131, 96138, 96139, 96156, 96158, 96159, 96160, 96161, 96164, 96165, 96167, 96168, 97802, 97803, 97804, 98966, 98967, 98968, 99406, 99407, 99497, 99498, G0108, G0109, G0270, G0296, G0396, G0397, G0406, G0407, G0408, G0420, G0421, G0425, G0426, G0427, G0438, G0439, G0442, G0443, G0444, G0445, G0446, G0447, G0459, G0513, G0514, G2086, G2087, G2088, G2211, G2212

• Remote Monitoring (other) - 0733T 0734T

• RPM non-reimbursable - 99453, 99454, 99457, 99458, G0322 (home health)

• RTM 98978, 0740T, 0741T
• RTM non-reimbursable - 98975, 98976, 98977, 98980, 98981

Care Management Services

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

Palliative Care