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. Providersare 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: 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.
- Benefit coverage for health services delivered by means of telehealth is the same as coverage for health services delivered by in-person means. 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 reimbursement if listed specifically in the member’s benefit plan as a covered service.
- All services provided must be medically appropriate and necessary. Documentation to support the 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 that the service was performed via telehealth.
- A HIPAA compliant electronic connection must be established and utilized between the distant and originating sites.
- Practitioners at the distant site who may furnish and receive payment for 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:
- Electronic connections that are not conducted over a secure encrypted web site as specified by the Health Insurance Portability & Accountability Act of 1996 Privacy & Security Rules.
- Audio-only telephone, email, or facsimile transmissions
- E-visits
- Prescription renewals
- Scheduling a test or appointment
- Call to nurse line for questions or standing orders
- Clarification of issues from previous visit
- Other non-clinical communication
- Updating individual demographic information
- Reporting test results
- Requesting a referral
- Provider to provider consultation
- Any telephone consultation with another provider in reference to the individual
- Phone, email or interactive video visits not initiated by the member
- Reminders
- Providing educational materials
- Treatment that duplicates services provided by the educational setting and/or are part of scholastic education are non-covered and therefore not allowable via telehealth
Definitions:
Synchronous telehealth-Synchronous telehealth means care delivery that occurs in real time between an individual at an originating site and a health care provider at a distant site, connected by video technology. It may include the use of “peripherals”, meaning medical cameras and equipment to allow specialized examination.
Asynchronous telehealth (also called store-and-forward) – Electronic medical information, imaging, or communication that is transferred, recorded, or otherwise stored to be reviewed at a distant site at a later time by a health care provider or health care facility without the individual present in real time.
Types of asynchronous telehealth include:
- Teleradiology - The practice of a radiologist interpreting radiologic images of internal body parts while not physically present in the location where the images are generated.
- Telehome monitoring - The use of electronic remote monitoring devices for purposes such as blood pressure checks, weight checks via a telescale as well as other remote medical intervention and assessment tools from the convenience of the individual's place of residence.
- E-visits - a form of asynchronous telehealth online electronic medical evaluation that is non-face-to-face using Internet resources in response to a individuals on-line inquiry typically through email or by completion of a questionnaire that enables health providers to interact with individuals through a secured electronic channel.
Direct Supervision- Direct supervision means the supervising provider must be present in the office suite and immediately available to provide assistance or direction to the professional in training.
Distant site – A site at which a health care provider or health care facility is located while providing medical services by means of telehealth.
Originating site - A site at which a individual is located at the time health services are provided to the individual by means of telehealth.
Provider of record (or attending provider) - the principal provider who oversees a individual’s care. The provider of record provides primary and routine care, or oversees hospital care, and coordinates other specialized care for an individual.
Consultation – An evaluation of an individual and resulting opinion or recommendation from a physician or licensed independent practitioner. Consultation evaluation is performed upon the request of a treating provider of record because the consultant has expertise in a specific clinical area beyond the requesting provider’s knowledge. If, after completion of a consultation, the consultant assumes responsibility for management of an individual’s condition, subsequent care codes should be used and not follow-up consultation codes.
Online visit– A member initiated low complexity interactive individual encounter performed through a consumer device via telehealth platforms such as mobile health apps, kiosks, or web-based video available through an electronic health record (EHR) portal.
- Audiovisual (face-to-face) real time online communication
- The individual initiates the encounter
- A low complexity, straight forward decision-making encounter that addresses urgent but not emergent clinical conditions
- It is not anticipated that a follow-up encounter is required
Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information.