Commercial

THIS POLICY IS NOT APPLICABLE TO MEMBERS ENROLLED IN AMERIHEALTH PENNSYLVANIA (AHPA) PRODUCTS OR AMERIHEALTH ADMINISTRATORS​ PRODUCTS.​

Coverage is subject to the terms, conditions, and limitations of the member's contract. State mandates do not automatically apply to self-funded groups; therefore, individual group benefits must be verified.

This policy does not describe telemedicine services that are provided by a telemedicine vendor.​

ELIGIBLE FOR REIMBURSEMENT​​

In accordance with the member's benefits, telemedicine and telehealth services as a method of delivery of medical services between a provider and an individual are eligible for reimbursement consideration by the Company when all of the following criteria are met:

• The individual is seeking services from an in-network provider who is licensed in New Jersey.
  
• The services are medically necessary and able to be delivered using one of the following methods:
• Interactive, synchronous (real-time), two-way audio and video communications
• Asynchronous (store and forward) delayed communications​, with the intent to allow the individual to be evaluated by the provider without being physically present. ​
  
• Interactive, synchronous (real-time), two-way audio communications​​​
• ​The encounter takes place via a secure Health Insurance Portability and Accountability Act (HIPAA)--compliant interactive telecommunications system.​
  

• ​Cove​red services include, but are not limited to:
  

• Primary medical care (physical and behavioral)

• Specialty medical care (physical and behavioral)

• Medical nutrition therapy

• Physical therapy

• Occupational therapy

• Speech therapy

• Home care​ services

• Urgent care

• ​A provider determines that an in-person psychiatric evaluation is necessary to meet standard of care requirements regarding the same treatment event,​ or the individual requests an in-person psychiatric evaluation but it is determined that an individual cannot be scheduled for an in-person psychiatric evaluation within 24 hours. In this case, a subsequent, in-person psychiatric evaluation in connection with the same treatment event will be covered, provided that the subsequent in-person psychiatric evaluation is necessary to meet standard of care requirements for that individual.

Telemedicine and telehealth services are not eligible for reimbursement consideration for the following:

• Triage to assess the appropriate place of service.
• The service uses a telecommunication system that does not have HIPAA-compliant encryption.
• Administrative matters, including but not limited to:
• scheduling 
• registration 
• updating billing information 
• reminders 
• requests for medication refills or referrals 
• ordering of diagnostic studies 
• medical history intake completed by the patient
• The originating site-of-service fee or facility fee.
• Communications including, but not limited to, reporting of test results and provision of educational materials. 
• Communications and/or transmission of supporting documentation between consulting provider and treating provider.
• Communications performed solely through electronic mail, instant messaging, phone text, or facsimile transmission.  
  

CAPITATION SERVICES AND REIMBURSEMENT

• For Health Maintenance Organization (HMO) or HMO Point-of-Service (HMO-POS) products with capitation arrangements, services delivered through telemedicine/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 a list of exceptions to capitation arrangements.
• For i​ndividuals enrolled in HMO or HMO-POS products with primary care provider capitation, any capitated services (e.g., laboratory testing, physical therapy, occupational therapy) must be referred to the primary care provider's designated capitated sites.
• Individuals enrolled in HMO or HMO-POS products seeking primary care services through telemedicine/telehealth must obtain services from their selected primary care provider.

REQUIRED DOCUMENTATION

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.

BILLING REQUIREMENTS

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Professional providers performing telemedicine services described must report the appropriate modifier (modifier FQ, GT, GQ, ​93​ or 95) and place-of-service (POS) code 02 ​or 10 to ensure payment of eligible telemedicine services.

 Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.