COVID-19 telehealth

Telehealth visits

Telehealth services can be provided if the services:

  • Are safely and effectively delivered via telehealth
  • Meet the code definition that is billed when provided via telehealth
  • Meet existing coverage criteria, including pre-authorization requirements and medical necessity
  • Are conducted using U.S. Department of Health and Human Services’ (HHS’) lead on discretion with respect to HIPAA compliant platform requirements. The following companies offer HIPAA-compliant telehealth platforms:
  • Are conducted by a provider with a current, valid, unrestricted and permanent Idaho, Oregon, Utah or Washington state license (as applicable based on practice location)

Individual and group members

  • For claims to process correctly and for you to receive reimbursement consistent with an in-office visit, you must use:
    • The place of service (POS) where the services would have normally occurred (including POS 11; excluding POS 02).
    • Modifier 95 to indicate that the services were rendered via telehealth.  (This update was made to align to the most recent guidance from CMS.)
  • Telehealth services are covered for our Individual and group (including administrative only services groups who have opted in to the telehealth expansion) members when conducted via audio or video. View instructions for verifying ASO groups who will temporarily cover virtual services to replace in-person visits.
  • The member's coinsurance and deductible will apply to the telehealth service, if applicable. Note: The telehealth visit related to COVID-19 testing will be covered at no member cost share. View information about coverage and claim submission guidelines for COVID-19 testing and treatment.

    • We expanded telehealth to reimburse providers for telehealth services the same as in-person visits. When we implemented this, for members who previously had a telehealth benefit, our systems were configured to apply to the member’s office visit cost share for some office visits and mental health visits rather than their lower telehealth cost share that they had incurred prior to COVID-19. Our systems were updated August 1, 2020 to automatically adjust the impacted claims to correctly apply the telehealth cost share for dates of service prior to August 1, 2020 as well as on going. We are still working to adjust claims for dates of service prior to August 1, so you will not need to resubmit claims. You may need to reimburse members who paid the in-office (higher) cost share for these telehealth services. This will not impact your reimbursement. Note: For ASO groups who have opted in to the expanded telehealth, we will apply the office visit cost share for telehealth visits if directed to do this by the ASO group. Claims that were processed with the telehealth cost share will be reprocessed to apply the office visit cost share. For some groups, the telehealth cost share is higher than the office visit cost share, so you may need to reimburse members who paid a higher cost share.

Medicare Advantage members
To align with the most recent CMS guidance:

  • For claims to process correctly and for you to receive reimbursement consistent with an in-office visit, you must use:
    • The place of service (POS) location where the services would have normally occurred (including POS 11; excluding POS 02).
    • Modifier 95 to indicate that the services were rendered via telehealth.
      • Note: For Medicare Advantage claims that were previously submitted with modifier GT, please rebill these claims using the type of bill that indicates a corrected claim with modifier 95.
  • For the encounter to meet the Medicare telehealth face-to-face requirement, telehealth visits with your Medicare Advantage patients must be conducted using real-time via audio and video, and the use of audio and video must be documented in the patient’s chart note.
  • The member's copay, coinsurance and deductible will apply to the telehealth service, if applicable. Note: The telehealth visit related to COVID-19 diagnostic testing to determine if the virus is currently present will be covered at no member cost share. View information about coverage and claim submission guidelines for COVID-19 testing and treatment.
    • We expanded telehealth to reimburse providers for telehealth services the same as in-person visits. When we implemented this, for members who previously had a telehealth benefit, our systems were configured to apply to the member’s office visit cost share for some office visits and mental health visits rather than their lower telehealth cost share that they had incurred prior to COVID-19. Our systems were updated August 1, 2020 to automatically adjust the impacted claims to correctly apply the telehealth cost share for dates of service prior to August 1, 2020 as well as on going. We are still working to adjust claims for dates of service prior to August 1, so you will not need to resubmit claims. You may need to reimburse members who paid the in-office (higher) cost share for these telehealth services. This will not impact your reimbursement.
  • Telehealth services can be provided to Medicare Advantage PPO members by out-of-network providers.

Risk adjustment
CMS has indicated that providers can include diagnosis codes on telehealth claims for risk adjustment purposes. For risk adjustment, telehealth visits must be conducted using audio and video.

If captured using audio and video, member reported blood pressure readings will count toward gap closures and be included in risk adjustment.

As with face-to-face visits, diagnosis codes included on claims must have sufficient documentation and may be subject to review. Refer to the Risk Adjustment section of our website for additional information about documentation requirements.

Palliative care
As a participating provider, you can conduct advance care planning (ACP) conversations with your patients via telehealth.

In light of the demand triggered by COVID-19 and to better support our Medicare Advantage members, we are now covering goals of care/ACP conversations at no cost share ($0 copay), regardless of the visit type or place of service. This benefit enhancement applies to telehealth (conducted via audio and video) and in-person visits with dates of service on or after January 1, 2020. Any impacted claims submitted this year with CPT 99497 or 99498 will automatically be reprocessed. To ensure members are supported if their health status and/or wishes regarding care planning change, the benefit covers one ACP conversation per day with no annual limit.

BlueCard members
BlueCard members’ telehealth benefits are based on the member’s home plan.

Telehealth benefits
We will continue to cover the medical and behavioral health codes for our Individual, group and Medicare Advantage members, as outlined in our Virtual Care (Administrative #132) reimbursement policy. Claims submitted following the guidelines in this policy, including the use of POS 02, will be paid as they have been. View instructions for verifying members' telehealth benefits.

Teledentistry expansion

Teledentistry services can be provided if:

Member benefits and dental provider reimbursement:

  • Claims performed via teledentistry are considered the same as in-person visits and are paid at the same rate as in-person visits.
  • Standard cost shares and plan limitations apply. Any paid amounts will accumulate to the annual maximum, if applicable.
  • View the member’s plan benefits on the Availity Web Portal.

Telehealth vendors

In addition to local providers, most members have access to one of two national telehealth vendors that can help assess a member’s condition and determine the necessary next steps of care:

  • MDLIVE provides medical and behavioral health care via video or phone visits. It is available to Medicare Advantage members and as a buy up for fully insured large group and administrative services only (ASO) group members. Note: For Medicare Advantage all visits with MDLIVE will be at the member’s primary care provider (PCP) copay.
  • Doctor on Demand provides medical and behavioral health video visits. It is available to Individual, small group, mid-size group and Uniform Medical Plan (UMP) members. It is also offered as a buy up for large and ASO group members.

When members login to their account, they can view their telehealth benefits and access their telehealth vendor.

Note: If a patient’s symptoms might be indicative of COVID-19, the member would still need to be seen in person and tested for the disease.

Advice24

Most members also have access to a 24/7 nurse advice line that they can call for answers to questions about common health concerns.

Secure messaging

Ask a Doctor provides routine medical care virtually by secure messaging (that can convert to video) with a board-certified, U.S.-based provider and is an option for members with mild or no symptoms. It is available to Individual, small, mid-size and large group members.

House calls

DispatchHealth and Heal provide house calls in certain areas.

DispatchHealth
DispatchHealth serves as a mobile urgent care service that provides care in the home setting. It is an option for members who do not have COVID-19 symptoms and are concerned about the risk of exposure in a clinic setting. Note: During the triage process, if DispatchHealth identifies a patient at risk for COVID-19, DispatchHealth will direct the patient to the appropriate testing site.

View the complete list of the conditions and symptoms they treat.

Regence small, mid-size and large group, UMP, ASO and Medicare Advantage plan members have access to DispatchHealth in Idaho (Boise area), Oregon (Portland area) and Washington (Seattle, Tacoma and Olympia areas). View DispatchHealth’s service area and verify access using a ZIP code. Note: The program may not apply to all UMP Plus plans.

You can refer a patient to care by calling the Regence-specific phone number for any of the locations below at 1 (833) 652-0539 or by calling the following phone numbers dedicated to each area:

  • Boise, ID: (208) 298-9893
  • Portland, OR: (503) 917-4904
  • Seattle, WA: (425) 651-2473
  • Tacoma, WA: (253) 341-4072
  • Olympia, WA: (360) 836-4855

Heal
Heal provides primary and urgent care home visits by a physician and laboratory technician. Heal will see members who are suspected of having COVID-19 in their home. Heal may test for COVID-19 and is working with the Washington Health Department to order the test. Heal may also work with our participating labs to order the test. Members can make appointments from 8 a.m. to 8 p.m., seven days a week, 365 days a year. It is currently available to Individual, small, mid-size and large group, UMP (except UMP Plus plans), ASO and Medicare Advantage members in only the greater Seattle, Washington area.