Criteria
Administrative Requirements
The practice of health care is deemed to occur in the state where the individual is located. Practitioners providing health care to individuals located in another state are subject to the licensing and disciplinary laws of the state of the individual's location and must possess an active license for their profession in the state of the individual's location.
Providers should meet or exceed applicable federal and state legal requirements of medical/health information privacy, including compliance with the Health Insurance Portability and Accountability Act (HIPAA) and originating site's state privacy, confidentiality, security, and medical retention rules. Providers are referred to 'Standards for Privacy of Individually Identifiable Health Information,' issued by the Department of Health and Human Services (HHS). Guidance documents are available on the HHS Office for Civil Rights Web site at:
http://www.hhs.gov/ocr/hipaa
. An attestation by the provider signifying HIPAA compliance must be available upon request.
The health care provider should review and follow the technical and administrative guidelines published by the American Telemedicine Association for fundamental requirements when providing medical and other healthcare services using telecommunications technologies. When guidelines, position statements, or standards from any professional organization or society exist, health care providers should also incorporate those into practice.
- To qualify as a professional service, actual visual contact (face to face) must be maintained between the health care provider and individual, with the exception of E-visits and Virtual Check-Ins which may be performed with audio only communication when face-to-face communication is unavailable. Providers are required to append modifier 95 when the service was rendered via audio/visual communication to attest actual visual contact (face to face) occurred.
- No benefits are available for services delivered by telehealth that are not covered services when delivered in-person.
- Member initiated online visits through consumer devices via telehealth platforms such as mobile health apps, kiosks, web-based video available through electronic health record (EHR) portals may be eligible for coverage if listed specifically in the member's benefit plan as a covered service.
- A HIPAA compliant electronic connection must be established and utilized between the distant and originating sites. Or when digital online visits are performed. A HIPAA compliant connection must be established between the distant site practitioner and member, through the electronic portal, or as deemed appropriate by CMS.
- Documentation to support the medical necessity and appropriateness of the health service must be included in the clinical record. The medical record must specify the location of the individual and the location of the provider and what mode of telehealth, such as store-and-forward or synchronous telehealth by which the service was provide. A health care provider delivering synchronous telehealth services should either identify the health care provider or facility at the originating site that facilitated the telehealth service or that the service was delivered via an E-visit or a virtual check-in.
- Health care clinics or facilities providing the originating site location must document the individual was present at the originating site to facilitate the health care service was provided by the distant site provider. The health care provider at the distant site must document the individual was present at the originating site for the telehealth services. If a health care provider at the originating site assisted with the encounter this must be documented in the clinical record and provide grounds for the medical appropriateness and necessity of facilitation care at the originating site. The additional healthcare provider services at the originating site would not be considered telehealth services and would be subject to applicable policies.
- Practitioners at the distant site who may furnish covered telehealth services (subject to State law) are those providers licensed, registered or certified by the appropriate state agency where the services are performed and provided in accordance with the provider's scope of licensure as provided by law. Where there is no appropriate state agency, the provider must be registered or certified by the appropriate professional body.
The following services, including but not limited to, would not be covered under telehealth:
- Practitioners not using electronic connections conducted over a secure Health Insurance Portability & Accountability Act (HIPAA) connection. BCBSND will allow a non-HIPAA compliant electronic connection to be covered when the method is approved by CMS.
- Audio-only telephone, email, text messages, communication through individual portal, or facsimile:
-
The following services
are
allowed for Audio-Only
- e-visits
- virtual check-ins
- Provider to provider (Inter-professional Consultations) consultation
-
The following Chiropractic Services:
- i. Spinal manipulative therapy
- ii. Manual therapy
- Dental Procedures or diagnostic studies
- Acupuncture
Non-Covered Procedure Codes
G0071 | G0546 | G0547 | G0548 | G0549 | G0550 |
G0551 | G2250 | 99446 | 99447 | 99448 | 99449 |
99451 | 99452 |
Non-Covered Procedure Codes when billed with Place of Service 02 or 10
| 21031 | 0792T | 21440 | 21445 | 40806 | 40819 | 40840 |
| 40842 | 40843 | 40844 | 40845 | 41010 | 41115 | 41520 |
| 41820 | 41821 | 41822 | 41823 | 41830 | 41870 | 41872 |
| 41874 | 41899 | 97810 | 97811 | 97813 | 97814 | 98940 |
| 98941 | 98942 | 98943 | D0120 | D0140 | D0145 | D0150 |
| D0160 | D0170 | D0171 | D0180 | D0190 | D0191 | D0210 |
| D0220 | D0230 | D0240 | D0250 | D0251 | D0270 | D0272 |
| D0273 | D0274 | D0277 | D0310 | D0320 | D0321 | D0322 |
| D0330 | D0340 | D0350 | D0364 | D0365 | D0366 | D0367 |
| D0368 | D0369 | D0370 | D0371 | D0372 | D0373 | D0374 |
| D0380 | D0381 | D0382 | D0383 | D0384 | D0385 | D0386 |
| D0387 | D0388 | D0389 | D0391 | D0393 | D0394 | D0395 |
| D0396 | D0411 | D0412 | D0414 | D0415 | D0416 | D0417 |
| D0418 | D0419 | D0422 | D0423 | D0425 | D0431 | D0460 |
| D0470 | D0472 | D0473 | D0474 | D0475 | D0476 | D0477 |
| D0478 | D0479 | D0480 | D0481 | D0482 | D0483 | D0484 |
| D0485 | D0486 | D0502 | D0600 | D0601 | D0602 | D0603 |
| D0605 | D0606 | D0701 | D0702 | D0703 | D0705 | D0706 |
| D0707 | D0708 | D0709 | D0801 | D0802 | D0803 | D0804 |
| D0999 | D1110 | D1120 | D1206 | D1208 | D1310 | D1320 |
| D1321 | D1330 | D1351 | D1352 | D1353 | D1354 | D1355 |
| D1510 | D1516 | D1517 | D1520 | D1526 | D1527 | D1551 |
| D1552 | D1553 | D1556 | D1557 | D1558 | D1575 | D1999 |
| D2140 | D2150 | D2160 | D2161 | D2330 | D2331 | D2332 |
| D2335 | D2390 | D2391 | D2392 | D2393 | D2394 | D2410 |
| D2420 | D2430 | D2510 | D2520 | D2530 | D2542 | D2543 |
| D2544 | D2610 | D2620 | D2630 | D2642 | D2643 | D2644 |
| D2650 | D2651 | D2652 | D2662 | D2663 | D2664 | D2710 |
| D2712 | D2720 | D2721 | D2722 | D2740 | D2750 | D2751 |
| D2752 | D2753 | D2780 | D2781 | D2782 | D2783 | D2790 |
| D2791 | D2792 | D2794 | D2799 | D2910 | D2915 | D2920 |
| D2921 | D2928 | D2929 | D2930 | D2931 | D2932 | D2933 |
| D2934 | D2940 | D2941 | D2949 | D2950 | D2951 | D2952 |
| D2953 | D2954 | D2955 | D2956 | D2957 | D2960 | D2961 |
| D2962 | D2971 | D2975 | D2976 | D2980 | D2981 | D2982 |
| D2983 | D2989 | D2990 | D2991 | D2999 | D3110 | D3120 |
| D3220 | D3221 | D3222 | D3230 | D3240 | D3310 | D3320 |
| D3330 | D3331 | D3332 | D3333 | D3346 | D3347 | D3348 |
| D3351 | D3352 | D3353 | D3355 | D3356 | D3357 | D3410 |
| D3421 | D3425 | D3426 | D3428 | D3429 | D3430 | D3431 |
| D3432 | D3450 | D3460 | D3470 | D3471 | D3472 | D3473 |
| D3501 | D3502 | D3503 | D3910 | D3911 | D3920 | D3921 |
| D3950 | D3999 | D4210 | D4211 | D4212 | D4230 | D4231 |
| D4240 | D4241 | D4245 | D4249 | D4260 | D4261 | D4263 |
| D4264 | D4265 | D4266 | D4267 | D4268 | D4270 | D4273 |
| D4274 | D4275 | D4276 | D4277 | D4278 | D4283 | D4285 |
| D4286 | D4322 | D4323 | D4341 | D4342 | D4346 | D4355 |
| D4381 | D4910 | D4920 | D4921 | D4999 | D5110 | D5120 |
| D5130 | D5140 | D5211 | D5212 | D5213 | D5214 | D5221 |
| D5222 | D5223 | D5224 | D5225 | D5226 | D5227 | D5228 |
| D5282 | D5283 | D5284 | D5286 | D5410 | D5411 | D5421 |
| D5422 | D5511 | D5512 | D5520 | D5611 | D5612 | D5621 |
| D5622 | D5630 | D5640 | D5650 | D5660 | D5670 | D5671 |
| D5710 | D5711 | D5720 | D5721 | D5725 | D5730 | D5731 |
| D5740 | D5741 | D5750 | D5751 | D5760 | D5761 | D5765 |
| D5810 | D5811 | D5820 | D5821 | D5850 | D5851 | D5862 |
| D5863 | D5864 | D5865 | D5866 | D5867 | D5875 | D5876 |
| D5899 | D5937 | D5982 | D5986 | D5991 | D5995 | D5996 |
| D6010 | D6011 | D6012 | D6013 | D6040 | D6050 | D6051 |
| D6055 | D6056 | D6057 | D6058 | D6059 | D6060 | D6061 |
| D6062 | D6063 | D6064 | D6065 | D6066 | D6067 | D6068 |
| D6069 | D6070 | D6071 | D6072 | D6073 | D6074 | D6075 |
| D6076 | D6077 | D6080 | D6081 | D6082 | D6083 | D6084 |
| D6085 | D6086 | D6087 | D6088 | D6089 | D6090 | D6091 |
| D6092 | D6093 | D6094 | D6095 | D6096 | D6097 | D6098 |
| D6099 | D6100 | D6101 | D6102 | D6103 | D6104 | D6105 |
| D6106 | D6107 | D6110 | D6111 | D6112 | D6113 | D6114 |
| D6115 | D6116 | D6117 | D6118 | D6119 | D6120 | D6121 |
| D6122 | D6123 | D6180 | D6190 | D6191 | D6192 | D6193 |
| D6194 | D6195 | D6197 | D6198 | D6199 | D6205 | D6210 |
| D6211 | D6212 | D6214 | D6240 | D6241 | D6242 | D6243 |
| D6245 | D6250 | D6251 | D6252 | D6253 | D6545 | D6548 |
| D6549 | D6600 | D6601 | D6602 | D6603 | D6604 | D6605 |
| D6606 | D6607 | D6608 | D6609 | D6610 | D6611 | D6612 |
| D6613 | D6614 | D6615 | D6624 | D6634 | D6710 | D6720 |
| D6721 | D6722 | D6740 | D6750 | D6751 | D6752 | D6753 |
| D6780 | D6781 | D6782 | D6783 | D6784 | D6790 | D6791 |
| D6792 | D6793 | D6794 | D6920 | D6930 | D6940 | D6950 |
| D6980 | D6985 | D6999 | D7111 | D7140 | D7210 | D7220 |
| D7230 | D7240 | D7241 | D7250 | D7251 | D7252 | D7259 |
| D7270 | D7272 | D7280 | D7282 | D7283 | D7290 | D7291 |
| D7292 | D7293 | D7294 | D7298 | D7299 | D7300 | D7310 |
| D7311 | D7320 | D7321 | D7340 | D7350 | D7450 | D7451 |
| D7460 | D7461 | D7471 | D7472 | D7473 | D7485 | D7670 |
| D7671 | D7770 | D7771 | D7880 | D7881 | D7921 | D7922 |
| D7939 | D7956 | D7957 | D7961 | D7962 | D7963 | D7970 |
| D7971 | D7972 | D7993 | D7994 | D7995 | D7996 | D7999 |
| D8010 | D8020 | D8030 | D8040 | D8070 | D8080 | D8090 |
| D8091 | D8210 | D8220 | D8660 | D8670 | D8671 | D8680 |
| D8681 | D8695 | D8696 | D8697 | D8698 | D8699 | D8701 |
| D8702 | D8703 | D8704 | D8999 | D9110 | D9120 | D9130 |
| D9410 | D9420 | D9430 | D9440 | D9450 | D9610 | D9612 |
| D9613 | D9630 | D9910 | D9911 | D9912 | D9913 | D9914 |
| D9920 | D9930 | D9932 | D9933 | D9934 | D9935 | D9938 |
| D9939 | D9941 | D9942 | D9943 | D9944 | D9945 | D9946 |
| D9947 | D9948 | D9949 | D9950 | D9951 | D9952 | D9953 |
| D9954 | D9955 | D9956 | D9957 | D9959 | D9961 | D9970 |
| D9971 | D9972 | D9973 | D9974 | D9975 | D9985 | D9986 |
| D9987 | D9990 | D9991 | D9992 | D9993 | D9994 | D9995 |
| D9996 | D9997 | D9999 | 0 | 0 | 0 | 0 |
Any Service Billed with a Place of Service 02 or 10 Requires a 95 Modifier Appended to Attest the Service was Rendered via Face-to-Face Audio/Visual Communication with the Exception of the Following
Procedure Codes:
99454 | 98000 | 98001 | 98002 | 98003 | 98004 | 98005 |
98006 | 98007 | 98008 | 98009 | 98010 | 98011 | 98012 |
98013 | 98014 | 98015 | 98016 | 98966 | 98967 | 98968 |
98970 | 98971 | 98972 | 99091 | 99421 | 99422 | 99423 |
99441 | 99442 | 99443 | 99474 | G2010 | G2012 | G2061 |
G2062 | G2063 | G2251 | G2252 |
For billing and coding information regarded to reimbursement.
Please see BCBSND reimbursement policy.
https://www.bcbsnd.com/providers/policies-precertification/reimbursement-policy/telehealth-services
The following services, including but not limited to, would be covered under telehealth if provided via face-to-face audio/visual communication with the exception of e-visits and virtual check-ins that can be provided as audio-only. Providers must append modifier 95 if the service was rendered via face-to-face audio/visual communication to attest the service was provided face-to-face:
- Electronic connections that are conducted over a secure encrypted web site as specified by the Health Insurance Portability & Accountability Act of 1996 Privacy & Security Rules
- Physical therapy (PT)
- Occupational therapy (OT)
- Speech therapy (ST)
- Behavioral health and substance use disorder treatment/therapies (including group)
- Applied Behavioral Analysis (ABA)
- Diabetes education
- Nutrition counseling
- Lactation counseling
Chiropractic Services included but not limited to: consultations, range of motion assessments, therapeutic exercise prescription, gait training, neuromuscular reeducation, history intake and assessment, with the exception of the noncovered services called out in the prior section.
-
Dental Care; excluding dental procedures
- A dentist may not practice telehealth unless a bona fide dentist-individual relationship is established in person or through telehealth.
