3139 Telehealth, Virtual Patient Communications and Remote Patient Monitoring Policy
Department: Executive Administration Original Effective Date: 02/14/2022
Approved By: Quality Improvement Committee Last Review/Revision Date: 02/28/2022
Printed copies are for reference only. Refer to electronic copy for latest version.
Policy
It is the policy of Vaya Health (“Vaya”) to ensure that Vaya Health Plan members and recipients (referred to in this policy as patients) have broad access to the healthcare services available from Vaya-contracted providers through an electronic communications system, including real-time interactive audio-visual communication and Virtual Communication and Patient Monitoring. Services may be provided to patients via Telehealth when equivalent in-person (face-to-face) services are not available, or if patients prefer this modality. This policy is intended to overcome geographic, transportation, or other barriers, connecting users who are not in the same physical location. Additionally, this policy is intended to provide guidance to contracted providers who submit claims for reimbursement for services delivered via Telehealth from Vaya.
Scope
Telehealth, telemedicine, and telepsychiatry are terms that refer to the exchange of medical information from one site to another through electronic communication to improve a patient’s health. Innovative uses of technology in the provision of healthcare can help people access routine care and minimize the need for people to access care outside of their homes. This coverage policy is designed to supplement the guidelines set forth in NC Medicaid Clinical Coverage Policy (CCP) No. 1-H To the extent this Vaya Health coverage policy is less restrictive than CCP 1-H, this Policy shall pertain. Vaya Health shall submit a revised Telehealth, Virtual Patient Communications and Remote Patient Monitoring Policy to the Department whenever there is a material change to the Policy. New approaches in Telehealth to support providers may be piloted upon the Department’s review and approval.
Definitions
Distant Site is the location from which the provider furnishes the Telehealth, Virtual Communications, or Remote Patient Monitoring services. There are no restrictions on distant sites. Distant sites may be wherever the provider may be located. Provider(s) shall ensure that beneficiary privacy is protected (such as taking calls from private, secure spaces; using headsets). Federally Qualified Health Centers (FQHCs), FQHC Look-Alikes and Rural Health Centers (RHCs) are considered eligible distant sites and shall follow the appropriate coding and billing guidelines identified in CCP 1-H
Version#: 1
Originating Site is the location in which the individual receiving care is located, which may be health care facilities, schools, community sites, the home, or wherever the person may be at the time they receive services via telehealth, virtual communications, or remote patient monitoring. There are no restrictions on originating sites.
Telehealth is the use of two-way real-time interactive audio and video to provide and support health care services when participants are in different physical locations. Telehealth facilitates the assessment, care management, consultation, diagnosis, education, self- management, and treatment of a person’s healthcare between a healthcare provider or practitioner located at a Distant Site and a patient located at an Originating Site. For ease of reference, the term Telehealth as used in this coverage policy is inclusive of both telemedicine and telepsychiatry.
Virtual Communication is the use of technologies other than video to enable remote evaluation and consultation support between a provider and a beneficiary or a provider and another provider. As outlined in CCP-1H and program specific clinical coverage policies, covered virtual communication services include: telephone conversations (audio only); virtual portal communications (secure messaging); and store and forward (transfer of data from beneficiary using a camera or similar device that records (stores) an image that is sent by telecommunication to another site for consultation).
Remote Patient Monitoring is the use of digital devices to measure and transmit personal health information from a patient in one location to a provider in a different location. Remote patient monitoring enables providers to collect and analyze information such as vital signs (blood pressure, heart rate, weight, blood oxygen levels) in order to make treatment recommendations. There are two types of remote patient monitoring: a) SelfMeasured and Reported Monitoring, when a patient uses a digital device to measure and record their own vital signs, then transmits the data to a provider for evaluation; and b) Remote Physiologic Monitoring, when a patient’s physiologic data is wirelessly synced from their digital device where it can be evaluated immediately or at a later time by a provider.
Procedures
Section I: Member and Recipient Eligibility Requirements
1. Medicaid. A Medicaid beneficiary is eligible for this service when the following criteria are met:
A. Member is enrolled as a NC Medicaid beneficiary whose Medicaid eligibility arises from residence in a county located within Vaya Health’s region and is enrolled in Medicaid Direct or the Behavioral Health and Intellectual and/or Developmental Disabilities (I/DD) Tailored Plan (Tailored Plan) managed by Vaya.
B. Member does not have service restrictions due to their NC Medicaid Program eligibility category that would make them ineligible for this service
2. Non-Medicaid: A State-funded Services recipient is eligible for this service when they are enrolled in the Tailored Plan managed by Vaya.
3. Verification. Provider(s) must verify the member’s or recipient’s eligibility each time a service is rendered.
Version#: 1
Section II: Coverage Exclusions
1. General Coverage Exclusions. Vaya shall not cover procedures, products, and services related to this policy when:
A. The patient does not meet the eligibility or coverage criteria listed herein or in CCP 1-H
B. The procedure, product, or service duplicates another provider’s procedure, product or service
C. The procedure, product or service is experimental, investigational, or part of a clinical trial
D. The patient is confined to a jail, detention center, or prison
E. The provider is not enrolled in NC Tracks; or
F. The provider does not follow applicable NC Medicaid Clinical Coverage Policies for the service provided via Telemedicine.
2. Specific Coverage Exclusions. Vaya shall not cover the following as Telehealth Services:
A. Facility fees for the Originating Site (if the Originating Site is a patient’s home) or the Distant Site. Any Medicaid enrolled provider who provides a beneficiary with access to audio and visual equipment to complete a Telehealth encounter may bill a facility fee when their office or facility is the site at which the beneficiary is located when the service is provided, and the distant site provider is at a different physical location.
B. Telehealth conversations that are not consultation, intervention, and treatment focused
C. Email or facsimile transmission between a health care provider and a beneficiary that is not done within a secure portal as referenced in the definition of Virtual Communication above.
D. Skilled nursing facilities (SNF) shall not bill an originating site facility fee when the SNF Medical Director or a beneficiary’s attending physician is conducting a Telehealth visit.
Section III: Service Requirements
1. General Criteria. Vaya shall cover this service when the service is medically necessary and:
A. The procedure, product, or service is individualized, specific, and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the beneficiary’s needs
B. The procedure, product, or service can be safely furnished and no equally effective and more conservative or less costly treatment is available statewide
C. The procedure, product or service is furnished in a manner not primarily intended for the convenience of the beneficiary, beneficiary’s caretaker, or the provider
D. The patient meets the entrance criteria or continued stay criteria, as applicable, set forth below;
E. The consultation takes place by encrypted (or unencrypted, if specific written or verbal consent is provided by the beneficiary’s guardian) two-way real-time interactive audio-visual communication or Virtual Communication.
2. Specific Criteria
A. Vaya shall cover services delivered via Telehealth, Virtual Communications, and Remote Patient Monitoring services when all the following additional criteria are followed before rendering services via Telehealth, Virtual Communications, or Remote Patient Monitoring:
I. Provider(s) shall ensure that services can be safely and effectively delivered using Telehealth, Virtual Communications, or Remote Patient Monitoring.
II. Provider(s) shall consider a beneficiary’s behavioral, physical and cognitive abilities to participate in services provided using Telehealth, Virtual Communications, or Remote Patient Monitoring.
III. The beneficiary’s safety must be carefully considered for the complexity of the services provided.
IV. In situations where a caregiver or facilitator is necessary to assist with the delivery of services via Telehealth, Virtual Communications, or Remote Patient Monitoring, their ability to assist and their safety must also be considered.
V. Delivery of services using Telehealth, Virtual Communications, or Remote Patient Monitoring must conform to professional standards of care: ethical practice, scope of practice, and other relevant federal, state and institutional policies and requirements, such as Practice Act and Licensing Board rules.
VI. Provider(s) shall obtain and document verbal and written consent. In extenuating circumstances when consent is unable to be obtained, this must be documented.
VII. Beneficiaries are not required to seek services through Telehealth, Virtual Communications, or Remote Patient Monitoring, and upon request shall be allowed access to in-person services.
VIII. Provider(s) shall verify the beneficiary’s identity using two points of identification before initiating service delivery via Telehealth, Virtual Communications, or Remote Patient Monitoring.
IX. Provider(s) shall ensure that beneficiary privacy and confidentiality are protected to the best of their ability.
B. Eligible Services and Providers
A range of services may be delivered via Telehealth, Virtual Communication, and Remote Patient Monitoring to Medicaid Direct beneficiaries and Tailored Plan members. All Telehealth, Virtual Communication, and Remote Patient Monitoring services must be delivered in a manner that is consistent with the quality of care provided in-person. Each set of eligible services has its own set of eligible provider(s) as defined in CCP 1-H or other specific CCPs.
I. Telehealth, including:
a. Office or other outpatient services and office and inpatient consultation codes; and
b. Hybrid Telehealth visit with supporting home visit codes
II. Virtual Communication, including:
a. Online digital evaluation and management codes;
b. Telephonic evaluation and management;
c. Telephonic evaluation and management and virtual communication codes; and
d. Interprofessional assessment and management codes.
III. Remote Patient Monitoring, including:
a. Self-measured blood pressure monitoring; and
b. Remote physiologic monitoring
3. Authorization, Referrals and In-Person Examinations:
A. Unless otherwise required for a specific service, Vaya shall not require prior approval for 1H Telehealth, Virtual Communications and Remote Patient Monitoring
B. Patients are not required to obtain prior authorization or have an initial in-person examination prior to receiving services via Telehealth, Virtual Communications or Remote Patient Monitoring; however, when establishing a new relationship with a patient via these modalities the provider must meet the prevailing standard of care and complete all appropriate exam and documentation requirements dictated by relevant Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) coding guidelines, and adhere to all North Carolina professional licensing requirements where applicable.
4. Eligible Technology
A. Telehealth
I. All Telehealth services must be provided over a secure Health Insurance Portability and Accountability Act (HIPAA) compliant technology with live audio and video capabilities including (but not limited to) smart phones, tablets, and computers.
II. In the absence of availability of HIPAA-compliant video communication technology, providers should work to balance patient care, ethical obligations, and current U.S. Department of Health and Human Services Office for Civil Rights regulations/allowances to determine the best course of action.
III. If during the encounter, the provider or beneficiary experiences a loss of the internet- based video telecommunications signal, the beneficiary and the Distant Site provider should communicate by telephone. Both sides should attempt to make system corrections. If the video connection cannot be reestablished, the telephone may be used to continue the encounter if appropriate for the given clinical situation.
B. Virtual Patient Communications
I. Virtual Patient Communications must be transmitted between a beneficiary and provider, or between two providers, in a manner that is consistent with the CPT definition for those services.
II. Provider(s) shall follow all applicable HIPAA rules.
C. Remote Patient Monitoring
I. Remote Patient Monitoring requires use of a device that is defined by the U.S. Food and Drug Administration (FDA) as a medical device and is in real-time and transmittable.
II. Remote Physiologic Monitoring requires a device that is wirelessly synched where a provider can evaluate the data in real or near-real time.
III. All Remote Patient Monitoring must be conducted in a HIPAA compliant manner, particularly with respect to protecting transmission of patient health data.
5. Review of Records: When possible, a provider at the Distant Site delivering services via Telehealth, Virtual Communications, or Remote Patient Monitoring should review all applicable records (electronic or from a remote site) in advance of Telehealth encounters for existing beneficiaries. The clinician should request access to all laboratory examinations and results necessary for assessment of the beneficiary as clinically indicated.
6. Clinical Coverage Policy and Service Definition Requirements: Telehealth services are subject to the same restrictions set forth in applicable NC Medicaid CCPs and Non-Medicaid Service Definitions as face-to-face
contacts, including, but not limited to allowable providers, multiple service limitations, and prior authorization, unless explicitly waived by Vaya.
7. Primary and Specialty Medical Care: All primary and specialty medical care will follow the requirements as specified in CCP-1H as well as the specific CCPs that pertain to the service.
8. Mental Health and Substance Use Services and I/DD Service Delivery: This Telehealth policy will include the provision of services delivered pursuant to the following CCPs and Service Definitions. Whenever a face-toface contact or intervention is indicated in one of the following, the provider may perform the contact or intervention via Telehealth:
A. Services listed in CCP 8A, Enhanced Mental health and Substance Abuse Services are generally not telehealth eligible, except for components of Mobile Crisis Management, Ambulatory Detoxification and Non-Hospital Detoxification. Also, certain supervision and training requirements may be done virtually as per current CCP 8A provisions The following services are currently allowed to be provided outside of the facility by Telehealth:
I. Psychosocial Rehabilitation
II. Child and Adolescent Day Treatment
III. Partial Hospitalization
IV. Substance Abuse Intensive Outpatient Program
V. Substance Abuse Comprehensive Outpatient Program
VI. Substance Abuse Medically Monitored Community Residential Treatment (allows LCAS and CCS to provide services by Telehealth or telephone in lieu of being provided in person at the facility)
VII. Non-Hospital Medical Detoxification (allows LCAS and CCS to provide services by Telehealth or telephone in lieu of being provided in person at the facility)
Intensive In-Home (real-time, two way interactive audio and video Telehealth)
B. 8C, Outpatient Behavioral Health Services Provided by Direct-Enrolled Providers
C. 8F, Research-Based Behavioral Health Treatment (RB-BHT) for Autism Spectrum Disorder (ASD)
D. 8G, Peer Support Services (PSS) services may be provided by Telehealth or telephonically, audioonly communication but limited to 20% or less of total service time provided per beneficiary per fiscal year.
E. 8O, Services for Individuals with Intellectual and Developmental Disabilities and Mental Health or Substance Abuse Co-Occurring Disorders
F. 8P, North Carolina Innovations –real-time, two-way interactive audio and video Telehealth for Community Living Supports, Day Supports, Supported Employment, Life Skills Training, Supported Living and Community Networking All State-funded Services unless excluded above
G. In lieu of and Alternative Service Definitions approved for use by Vaya.
9. Non-licensed Staff: This policy will also allow delivery of services via Telehealth by non-licensed staff (QP, BCBA, C-QP, para-professional) to the same extent as licensed staff, as permitted by the CCP applicable to the specific service. For example, if a face-to-face contact in a specific service that falls within the services identified by CCP is permitted to be delivered by a non-licensed staff, it can be delivered via Telehealth under this policy.
10. Emergency and Follow-Up Care: The provider delivering Telehealth Services shall ensure the availability of appropriate follow-up care and if indicated by results of an assessment conducted via Telehealth must have
the capacity for signal for crisis and paramedical support and arrange for transport to an urgent care center or Emergency Department (ED).
11. Responsibility and Requirements of Staff Involved with Telehealth Encounters:
A. To promote trust and rapport with the patient, the provider facilitating the Telehealth service should work to minimize distractions at the Distant Site during the electronic encounter.
B. The provider facilitating the Telehealth service will speak the language of the patient whenever possible. When not possible, the provider shall use an interpreter in the same manner as used in face-to-face treatment.
C. The provider facilitating the Telehealth service will participate in treatment planning and consultation about the patient with members of the treatment team to the same extent as if the service was being delivered face-to-face.
D. If medication is prescribed, the prescriber will ensure timely transmission of prescriptions and verbal orders to pharmacies or input into the Electronic Medical Record if available.
E. Telehealth services shall be provided in an amount, duration, and scope no less than the amount, duration, and scope for the same services provided to beneficiaries under the NC Medicaid Direct program. 42 C.F.R. &v 438.210(a)(2).
F. Providers may use virtual communications to conduct staff supervision and collateral contacts
G. Telehealth services may be used to facilitate access to needed services in a clinically appropriate manner that are not available within Vaya’s Provider Network.
H. Patients may not be required to seek services through Telehealth if they request access to an inperson service through an out-of-network provider.
12. Compliance. Provider(s) shall comply with the following in effect at the time the service is rendered, unless specific provisions have been waived in writing, either via a contract amendment or a communication bulletin from Vaya, the NC Department of Health and Human Services (NCDHHS), or the Centers for Medicare and Medicaid Services (CMS):
A. All applicable written agreements with Vaya and NCDHHS
B. Vaya Health’s Provider Operations Manual and the NC Tracks Provider Claims and Billing Assistance Guide
C. Applicable federal, state and local laws, rules and regulations including, but not limited to, HIPAA and record retention requirements
D. Applicable NC Medicaid Clinical Coverage Policies, guidelines, policies, provider manuals, implementation updates, fee schedules, and bulletins published by CMS, NCDHHS, its divisions, or fiscal contractor(s); and
E. Any other relevant requirements applicable to reimbursement for publicly funded healthcare services.
13. Documentation: Providers must maintain a complete health record that is available to the patient and other treating providers and must document all Telehealth services in accordance with requirements for applicable face-to-face and/or telephonic encounters in applicable CCPs and Service Definitions as well as the NCDHHS Division of Mental Health, Developmental Disabilities and Substance Abuse Services (DMH/DD/SAS) Records Management and Documentation Manual, APSM 45-2.
A. Documentation must clearly indicate that services were furnished via Telehealth, the names of all individuals involved on both sides of the Telehealth encounter (e.g., patient’s name, provider staff,
and the relationship to the patient of any others visible and present), and that all components of the service being billed were provided to the member.
14. Technical Requirements: Telehealth services can be delivered via any HIPAA-compliant, secure technology with audio-visual capabilities, including (but not limited to) smart phones, tablets, and computers.
A. Telehealth services can be conducted via “video cell phone interactions.”
B. In the absence of availability of HIPAA-compliant video communication technology, providers should work to balance patient care, ethical obligations, and current U.S. Department of Health and Human Services Office for Civil Rights regulations/allowances to determine the best course of action.
C. If during the encounter, the provider or patient experiences a loss of the internet- based video telecommunications signal, the patient and the Distant Site provider should communicate by telephone. Both sides should attempt to make system corrections. If the video connection cannot be reestablished, the telephone may be used to continue the encounter if appropriate for the given clinical situation.
15. Informed Consent/ Retention:
A. Audio and video transmission shall not be retained in any medium, including the clinical record, unless there is the consent of the patient or their legally responsible person (LRP). Specific mention of the retention of this transmission will be required on any consent form or script approved for this purpose.
B. All consents for treatment and other procedures applicable to face-to-face encounters must be obtained for Telehealth encounters.
Section IV: Billing Requirements
1. Provider Requirements. To be eligible to bill for services covered under this policy, the provider must:
A. Meet qualification for participation in the NC Medicaid program, and be enrolled in the Medicaid program through NC Tracks
B. Be contracted with Vaya to deliver the service, or bill through an entity that is contracted with Vaya to deliver the service (including an out-of-network contract)
C. Bill only for procedures, products, and services that are within the scope of their clinical practice, as defined by the appropriate licensing entity
D. Bill their usual and customary charges; Vaya shall pay at least the in-person rate for the same services delivered via Telehealth (i.e., payment parity).
E. Report the International Classification of Diseases and Related Health Problems, Tenth Revisions, Clinical Modification (ICD-10-CM) and Procedural Coding System (PCS) to the highest level of specificity that supports medical necessity
F. Report the most specific billing code that accurately and completely describes the procedure, product or service provided, and which determines the billing unit(s) and
G. Use the current ICD-10 edition, Current Procedural Terminology (CPT), Health Care Procedure Coding System (HCPCS), and UB-04 Data Specifications Manual (for a complete listing of valid revenue codes) and any subsequent editions in effect at the time of service. If no such specific CPT or HCPCS code exists, the provider(s) shall report the procedure, product or service using the appropriate unlisted procedure or service code.
2. Allowable Provider Types. Telehealth services may be furnished to patients by valid NC medical or behavioral health licensed staff as specified in CCP-1H and by non-licensed staff (QP, BCBA, C-QP, paraprofessional) to the same extent as licensed staff, as permitted by the CCP applicable to the specific service. For example, if a face-to-face contact in a specific service that falls within the services identified by CCP is permitted to be delivered by a non-licensed staff, it can be delivered via Telehealth under this policy.
3. Payment Parity: Vaya will cover and reimburse all Telehealth interactions at a rate that is equal to in-person care.
4. Claim Type: Provider(s) shall submit claims using one of the following forms/ transaction types:
A. Professional (CMS-1500/837P transaction)
B. Institutional (UB-04/837I transaction)
5. Allowable Codes: Providers may only bill for procedure codes that are specifically listed within the Sites and Services Menu referenced in their contract with Vaya.
6. Modifiers: Provider(s) shall follow applicable modifier guidelines.
A. The GT modifier must be appended to the CPT or HCPCS code to indicate that a service has been provided via “Interactive Telecommunication.”, e.g., audio-visual communication (Webex, Skype, Zoom, Teams, etc.). This modifier is not appropriate for services performed via non-face to face Virtual Communication, e.g., telephonically or through patient portal.
B. Other modifiers must be appended to the CPT codes, as appropriate.
7. Place of Service: Claims for services delivered via Telehealth under this policy can be submitted with a valid Place of Service (POS) code describing the location of the patient when receiving the service billed. Vaya will also accept POS 02-TELEHEALTH.
8. Unlisted Procedure or Service:
A. CPT: The provider(s) shall refer to and comply with the Instructions for Use of the CPT Codebook, Unlisted Procedure or Service, and Special Report as documented in the current CPT in effect at the time of service.
B. HCPCS: The provider(s) shall refer to and comply with the Instructions For Use of HCPCS National Level II codes, Unlisted Procedure or Service and Special Report as documented in the current HCPCS edition in effect at the time of service
Related Documents: (All Hyperlinked)
Forms:
Referenced Policies:
Other:
Accreditation Standards:
NCQA:
URAC:
Supersedes: Not Set