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Telemedicine and Telehealth Services for AmeriHealth New Jersey Members (Updated May 19, 2020)
Policy #00.10.42c Telemedicine and Telehealth (AmeriHealth New Jersey)
Coverage of Preventive Well Visits through Telemedicine in Response to COVID-19 for AmeriHealth New Jersey Members
The purpose of this News Article is to provide advance notice regarding coverage for telemedicine and telehealth services for our AmeriHealth New Jersey members during the coronavirus disease 2019 state of emergency.
This News Article addressing telemedicine and telehealth services is effective from March 6, 2020 through
the duration of the public health emergency as described in Executive Order 103, and supersedes Policy #00.10.42c Telemedicine and Telehealth (AmeriHealth New Jersey) during this time period.
There is currently an outbreak of respiratory disease caused by a novel coronavirus, which has now been detected both nationally and internationally. The virus has been named “SARS-CoV-2” and the disease it causes has been named “Coronavirus Disease 2019” (COVID-19). The SARS-CoV-2 virus has demonstrated the capability to rapidly spread, leading to significant impacts on healthcare systems and causing societal disruption. The potential public health threat posed by COVID-19 is high globally. To effectively respond to the COVID-19 outbreak, rapid detection of cases and contacts, appropriate clinical management and infection control, and implementation of community mitigation efforts are critical.
In response to the current COVID-19 outbreak, the Centers for Disease Control and Prevention (CDC) recommends that professional providers conduct telephonic and telemedicine services to triage and assess individuals to prevent transmission of the respiratory virus.
The CDC discusses prevention and treatment of COVID-19 on their website at
To help reduce potential exposure, members and providers may utilize telemedicine and telehealth services as appropriate and as available as part of a member’s plan.
Coverage is subject to the terms, conditions, and limitations of the member's contract
The Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition.
This communication does not address services provided through the Company's contracted telemedicine vendor.
In accordance with the member’s benefits, telemedicine and telehealth services are eligible for reimbursement consideration by the Company when all of the following criteria are met:
The services are medically necessary and able to be delivered using one of the following modes of communication:
Two-way audio and video communications
Interactive, synchronous (real-time)
Interactive, synchronous (real-time) in conjunction with store and forward delayed communications
A telephone (i.e., audio telecommunication only/telephone call) or online digital communication
Covered services include, but are not limited to:
Primary medical care
Specialty medical care
Medical nutrition therapy
Skilled nursing (intermittent)
Medical nutrition therapy
State mandates do not automatically apply to self-funded groups; therefore, individual group benefits must be verified.
For products with capitation arrangements, services delivered through telemedicine and telehealth are considered included in capitation with the exception of those services identified in applicable policies identifying fee for service reimbursement. Refer to the appropriate claim payment policies for list of exceptions to capitation arrangements.
The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.
The Company may conduct reviews and audits of services to our members, regardless of the participation status of the professional provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
providers performing telemedicine and telehealth services must report the appropriate modifier (modifiers GT, GQ, or 95) and place-of-service (POS) code 02 (Telehealth) to ensure payment of eligible telemedicine and telehealth services.
Telemedicine and telehealth services performed through a telephone or online digital communication must report the appropriate place of service 02 (Telehealth) to ensure payment. Use of modifiers GT, GQ, or 95 will not be required.
Telemedicine evaluation and management reported by facilities billing on a UB-04 claim form, or the equivalent form 837i, should report revenue code 0780 along with an appropriate evaluation and management procedure code appended by the GT, GQ or 95 modifier, as needed.
Telemedicine ancillary services (e.g. PT/OT/ST) reported by facilities billing on a UB-04 claim form, or the equivalent form 837i, should report the appropriate revenue code along with the corresponding procedure code representing the service provided appended by the GT, GQ or 95 modifier, as needed.
Eligibility, benefits, limitations, exclusions, provider contracts, and Company policies apply.
Dosing and Administration
Black Box Warnings and/or Contraindications
Providers should report only those services that are medically necessary and are able to be delivered through one of the modes of communication detailed in the Coverage Statement above.
NOT ELIGIBLE FOR REIMBURSEMENT
THE COMPANY CONTINUES TO NOT RECOGNIZE THE FOLLOWING PROCEDURE CODES AS TELEMEDICINE. THESE ARE INTERPROFESSIONAL SERVICES/PROCEDURE CODES THAT DO NOT REPRESENT DIRECT COMMUNICATION WITH THE MEMBER. THE FOLLOWING SERVICES REMAIN
99446, 99447, 99448, 99449, 99451, 99452
THE FOLLOWING SERVICE CONTINUES TO BE CONSIDERED A
FOR MEDICAL AND BEHAVIORAL HEALTH SERVICES:
Issued on - 05/19/2020
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