Policy Statement
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 Care services occur when the physician or other Qualified Health Care Professional and the member are not at the same site. Virtual Care services are the use of medical or behavioral health information to diagnose and/or treat a Member exchanged from one site to another via a Synchronous Interaction audio-only or audio/video telecommunication system.
The services for both types of encounters are evaluation and management focused. Only services specifically defined by Centers for Medicare & Medicaid (CMS) Telehealth (telemedicine) guidelines, Current Procedural Terminology (CPT) & Healthcare Common Procedure Coding System (HCPCS) guidelines, the North Dakota State Rules and Regulations (NDSRR) or our health plan’s published policies and member benefits as suitable for delivery via Telehealth/Telemedicine are eligible for reimbursement. When specified in this policy, other types of services may be applicable.
Reimbursement for Virtual Care services are based on the CMS Telehealth (telemedicine) guidelines, CPT & HCPCS guidelines, NDSRR or our health plan’s published policies and member benefits as suitable for delivery via Telehealth/Telemedicine are eligible for reimbursement.
Reimbursement guidelines
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.
The plan will consider reimbursement for telehealth/telemedicine services when the following criteria are met:
- Audio only technology is only allowed when the member is in their home (POS 10) and the physician or practitioner has audio-video communication technology available, but the member does not have or does not consent to using audio-video communication technology.
- The place of service (POS) must reflect the location of the patient when receiving the Telehealth/Telemedicine services.
- POS 02: Services provided other than in patient’s home. Use this POS when the originating site is a health care facility. Not reimbursable for audio only services.
- POS 10 (effective 1/1/2022): Services provided in patient’s home. Use this POS when the originating site is not a healthcare facility.
- Telehealth identifying modifiers must be used to reflect the technology used to deliver the service. If one of these modifiers is not submitted on the claim line, the claim may be rejected.
- Modifier 93/FQ: This modifier must be used when services are performed using audio-only technology.
- Modifier 95/GT: This modifier must be used when services are performed using audio and video technology.
Separate Reimbursement may be allowed for the following services
Remote Physiological Monitoring (RPM):
Remote Physiologic Monitoring (RPM) is used by providers to access data remotely in order to appropriately manage a disease. These monitoring services measure responses to therapy delivered via a device or software. Examples of RPM include but are not limited to glucose monitoring, oximetry, blood pressure, or cardiac monitoring.
Separate payment may be allowed for remote medical intervention and assessment tools for data collected from the patient’s residence. Providers should refer to the appropriate year’s CPT manual for coding guidelines and plan medical policies for additional requirements.
Originating Site Telehealth services:
The originating site is where the member is located during a telemedicine visit. For the originating site Facility Fee to be considered for reimbursement, the following must be met:
- The Member must be physically located in the Health Care Facility billing as the originating site.
- Claims should be submitted using the same date of service for the originating and distant site.
- Service must include audio and video in order for an originating site facility fee to be reimbursed (facility fee billings for audio-only are not reimbursable).
- The originating site must be providing health services to the Member.
- Providers billing on ANSI 837P must submit with appropriate place of service, HCPCS Q3014 with no modifier. It is not appropriate for place of service 02 or 10 to be used when billing facility fee.
- Providers billing on ANSI 837I must submit with revenue code 0780 range with HCPCS Q3014 with no modifier.
Note: Separate payment for the originating site location where the patient is participating with a distant site practitioner will not be reimbursed if it is the patient’s home, community setting, or other non-provider owned location. (Place of service (POS) 10)
Distant Site Telehealth Services:
The distant site location is where the Provider delivering the Telehealth service is located at the time of the service.
- Separate payment will be made for distant site locations when the patient is present at an originating site.
- Separate payment will be made when the patient is at home using a consumer device via telehealth platforms such as mobile health apps, kiosks, or web-based video available through an electronic health record (EHR) portal to obtain a patient and practitioner face-to-face telehealth services.
- Modifiers must be added 95 (audio-visual) or 93/FQ (audio only) to attest the visit was provided synchronous or asynchronous.
- Modifier 93/FQ: This modifier must be used when services are performed using audio-only technology.
- Modifier 95/GT: This modifier must be used when services are performed using audio and video technology.
Note: Effective June 20, 2026, providers must report distant site telehealth services with POS 02 or 10 and the appropriate telehealth modifier to identify the type of telehealth service provided.
Online Digital E-visit or Brief Virtual Check-in
Online Digital E-visit (98970, 98971, 98972, 99421, 99422, 99423) or Brief Virtual Check-in (98016, 98966, 98967, 98968, G2010, G2251, G2252):
The online digital e-visit or brief virtual check-in is communication via telephone or other telecommunication device to decide whether an office visit or other service is needed. A remote evaluation of recorded video and/or images submitted by an established patient. Does not require the use of audio or video technology and is expected to be patient-initiated.
- Modifier 93/95/FQ/GT – Providers must include the appropriate telehealth modifier.
- POS is 10.
- Service was not initiated from a related E/M service provided within the previous 7 days.
- Service did not lead to a related E/M service or procedure within the next 24 hours or soonest available appointment.
Note: If the billing provider submits an Online Digital Visit, Brief Virtual Check-In, or an E/M service without modifier 25 with a date of service within seven days from another Online Digital Visit, Virtual Check-In, or an E/M service the first claim received will receive reimbursement. The second claim without a modifier 25 will be rejected as the service has been unbundled.
Store and Forward
Store and Forward services are asynchronous services performed through a patient portal, healthcare application or other HIPAA-compliant platform. There is no interactive real-time audio/video or audio-only services performed using Store and Forward services. The service must be initiated by the member or authorized caregiver seeking diagnosis and treatment for the member. These services must replace the need for an in-person visit.
The following are billing requirements for Store and Forward services:
- The place of service (POS) must reflect the location of the patient when receiving Store and Forward services.
- POS 02: Services Provided other than in patient’s home. Use this POS when the originating site is a health care facility.
- POS 10: Services Provided in patient’s home. Use this POS when the originating site is not a healthcare facility.
- Modifier GQ must be used to reflect services performed as asynchronous. If modifier GQ is not submitted on the claim line, the claim may be rejected.
Store and Forward Services are not reimbursed for the following:
- Store and Forward service that originates from a related E/M service provided within the previous 7 days. Service is considered reimbursed as part of the E/M the service originated from and is not separately payable.
- Store and Forward service that leads to an E/M service or procedure within the next 24 hours or soonest available appointment. Service is considered reimbursed as part of the E/M service and not separately payable.
- Services delivered within the post-operative/global period of a procedure are considered part of the global payment for the procedure and not reimbursed separately.
Additional requirements for Telehealth Services
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 Telehealth 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.
References
Cross References
- Adm 122 – Care Management Services
- Adm 136 – Palliative Care
- MED175 – Digital Health Products
- 01 – Digital Therapeutic Products for Attention Deficit Hyperactivity Disorder
- 02 – Digital Therapeutic Products for Substance Use Disorders
