June 1, 2016
Last Revised Date:
May 20, 2019
Provides guidelines for telemedicine services, and identifies when these services may be eligible for reimbursement by the Health Plan. This policy applies to telemedicine services payable to either individual professional practitioners who delivered the reimbursable services, or the facility or organization that employs the individual professional practitioner who delivered the reimbursable services, and is distinct from any existing Horizon BCBSNJ approved telemedicine vendor arrangements (i.e., American Well).
All products are included, except
- Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap).
- Medicare Advantage (MA)*.
All Insured and Administrative Services Only (ASO) accounts are included.
* The guidelines of this reimbursement policy do not apply to claims for telemedicine services provided to members enrolled in Horizon BCBSNJ Medicare Advantage (MA, plans, however, effective since 1/1/2019, Horizon MA members have access to telemedicine services as part of their Supplemental Benefits when such services are rendered through telemedicine vendor, American Well.
- Asynchronous also known as “store and forward” or “non-interactive telecommunication” means the acquisition and transmission of images, diagnostics, data, and medical information either to, or from, and originating site or to, or from, the healthcare provider at a distant site which allows for the patient to be evaluated without being physically present.
- Distant site means a site which a health care provider, acting within the scope of a valid license or certification, is located while providing health care services by means of HIPAA-compliant telemedicine.
- Originating site means a site at which a patient is located at the time that health care services are provided to the patient by means of telemedicine.
- Synchronous means live, two-way interaction between a person and a provider using audiovisual telecommunications technology.
- Telemedicine is the delivery of healthcare services using HIPAA compliant and secure electronic communications, information technology, or other electronic or technological means to bridge the gap between a health care provider who is located at a distant site and a patient who is located at an originating site, either with or without the assistance of an intervening health care provider for the purpose of diagnosis, consultation, and/or treatment of a patient. Telemedicine does not include the use, in isolation, of audio-only telephone conversation, electronic mail, instant messaging, phone text, or facsimile transmission.
Horizon BCBSNJ shall identify telemedicine services when modifiers 95 or GT are appended to CPT® or HCPCS codes that ordinarily describe face-to-face services including but not limited to, office or other outpatient visits, inpatients visits, or individual psychotherapy services.
Reimbursement for telemedicine services may be available as follows:
- Real time (synchronized) telemedicine services meet all the requirements of a face-to-face consultation or contact between a health care provider and patient.
- Telemedicine service is limited to services involving the use of interactive, real-time, two-way audio-video communication technologies for the purpose of diagnosis, consultation, or treatment in accordance with the member’s contract.
- The provider of telemedicine services shall be:
- Validly licensed, certified, or registered to provide such services in the State of New Jersey, or licensed in the state where the patient is physically located at the time of the telemedicine encounter.
- Subject to regulation by the appropriate New Jersey State licensing board or professional regulatory entity
- Act in compliance with existing requirements requiring the maintenance of liability insurance; and
- Subject to the New Jersey jurisdiction if either the patient or the provider is located in New Jersey at the time services are provided
- Professional services rendered via interactive communication technologies as part of a Health Plan’s benefits are only eligible for reimbursement to the distant site provider rendering the telemedicine services. Any originating site provider rendering in-person services should report the appropriate code for the in-person services.
Based upon our criteria, Horizon BCBSNJ shall consider reimbursement for telemedicine services when modifiers 95 or GT are appended to CPT® or HCPCS codes that ordinarily describe face-to-face services including but not limited to, office or other outpatient professional visits, inpatient professional visits, or individual psychotherapy services.
CMS place of service code 02 will not be applied to this policy as Horizon BCBSNJ still considers modifiers 95 and GT valid HIPAA compliant modifiers.
Providers who utilize telemedicine systems must consider security, patient confidentiality, and privacy. A secured electronic channel is required to be utilized by a telemedicine provider. All transactions and data communication must be in compliance with the Health Insurance Portability and Accountability Act (HIPAA).
Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system.
Please refer to Appendix P within the American Medical Association’s Current Procedural Terminology (CPT®) code manual to review the CPT codes for which a "95" modifier can be used to indicate that the service was provided via a real-time, interactive audio and video telecommunications system.
Via interactive audio and video telecommunications systems
The following lists of codes is provided as an informational tool only, to help identify some of the applicable CPT® codes/code ranges and HCPCS codes that may be utilized in reporting telemedicine services. The inclusion of a specific code does not indicate eligibility for coverage in all situations.
- CPT Codes
90785, 90863, 96116, 90791-90792, 90832-90838, 90839-90840, 90845-90847, 90951-90961, 90963-90966, 90967-90970, 96150-96154, 96160-96161, 97802-97804, 99201-99205, 99211-99215, 99231-99233, 99241-99245, 99251-99255, 99307-99310, 99354-99357, 99406-99407, 99408-99409, 99495-99496, 99497-99498
G0108-G0109, G0270, G0296, G0396-G0397, G0406, G0407, G0408, G0420-G0421, G0425-G0427, G0438-G0439, G0459, G0473, G0506, G0508-G0509, G0513-G0514, S0199
The following services are not eligible for reimbursement under this policy:
- Non-direct patient services (e.g. coordination of care rendered before or after patient interaction) will not be considered for reimbursement.
- Claims submitted with modifier GQ, which signifies services provided via asynchronous telecommunications system, as these services do not include direct in-person patient contact.
- Any service that is not eligible for separate reimbursement when rendered to the patient in-person.
- Presentation/origination site facility fee (HCPCS code Q3014).
- CPT codes 99441-99444.
Health care providers providing telemedicine services shall be subject to the same standard of care or practice standards as are applicable to in-person settings.
Documentation in the medical record must be maintained and must support the services rendered.
Utilization review by Horizon BCBSNJ may be performed.
By coding and billing modifier 95 or GT with a covered procedure code, the provider is certifying that the patient was present at an originating site when the provider furnished the telemedicine service.
Horizon BCBSNJ is authorized to charge a deductible, copayment, or coinsurance for a heath care service delivered through telemedicine provided that the amount charged does not exceed the charge for an in-person consultation.
For telemedicine services rendered by providers participating in the Horizon BCBSNJ Network, payment will be made at the same rate as that of the existing Professional Agreement Allowances.
In instances where the provider is not participating, member liability shall be up to the provider’s charge. Nothing in this Policy shall require a Horizon Covered Person to use Telemedicine or Telehealth in lieu of receiving in-person service from an in-network provider.
The CPT codes and nomenclature used in this Policy are subject to revision and/or change by the American Medical Association. In the event of such changes, the Policy will continue to be in force, albeit applied to the new or amended coding so issued until such time as the Policy is reviewed and updated to reflect the new or amended coding.
Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:
- Employer Group or Individual benefits
- Provider Participation Agreements
- Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
- Mandated or legislative required criteria will always supersede.
2/1/2016: Policy Approved
2/26/2016: Per DOBI request, changed all references to Telemedicine Services to Services on Telemedicine Platform.
6/27/2017: Updated policy to include 2017 AMA modifier 95 and inserted table with services applicable to modifier 95. Added language around HIPAA-compliant technology and provider subjectivity to utilization and medical records review. Clarified applicability of CMS place of service value 02. Removed references to “Horizon approved programs.”
04/23/2018: Entire Policy updated to reflect the NJ State Legislative language and applicable definitions. Re-titled policy. Added CPT/HCPCS 90785, 96160, 96161, G0296, G0506. Deleted HCPCS/CPT codes G0436, G0437. Included modifier table.
5/20/2019: Clarified MA coverage. Added content to Procedure section. Added Appendix P note to modifier table. Included HCPCS code for presentation/origination site facility fee. Added procedure codes 90845-90847, 90966, 99495-99496, G0513-G0514. Deleted procedure codes G0466-G0470.