Telemedicine Services Reimbursement Policy: Temporary Addendum for Horizon BCBSNJ Commercial/ASO plans and products
March 1, 2020
EFFECTIVE IMMEDIATELY through at least December 31, 2023 as declared by the Governor, in an effort to connect members with their providers, Horizon BCBSNJ shall continue our expansion of the use of telemedicine services, for providers, during the current public health emergency, COVID-19. Horizon BCBSNJ shall reimburse the following services in addition to those allowed under the existing Telemedicine Services reimbursement policy.
The following alternative technologies commonly available on smart phones and other devices may be utilized during this public health emergency:
- Telephonic Services (Phone call with audio only)
- Telemedicine Services (Both synchronous audio and visual required)
- Online Patient Portal Communication (Patient initiated virtual check-in for established patients only)
For all of telehealth services rendered, the provider should:
- Use CMS designated place of service (POS) ‘02’ ,or, ‘11’
- Append modifier ‘95’ or ‘GT’ where applicable to the appropriate procedure codes listed here.
- Follow current coding guidelines set forth by the American Medical Association, Current Procedural Terminology Professional Edition and associated publications and services
Qualified telemedicine services are those provided by a health care provider including: Audiology/tinnitus assessments, Behavioral Health Assessments, Behavioral Health Counseling, Behavioral Health OBAT/MAT services, Hearing aid checks (binaural and monaural), Occupational Therapy (OT) Evaluations, Physical Therapy (PT) Evaluations, Self-Management Education services and Speech Therapy services. Per P.L.2021, c.310 a “health care provider" means an individual who provides a health care service to a patient, and includes, but is not limited to, a licensed physician, nurse, nurse practitioner, psychologist, psychiatrist, psychoanalyst, clinical social worker, physician assistant, professional counselor, respiratory therapist, speech pathologist, audiologist, optometrist, or any other health care professional acting within the scope of a valid license or certification issued pursuant to Title 45 of the Revised Statutes.
- Telemedicine service provisions are limited to those services within a provider’s current scope of practice.
- For telemedicine services rendered by providers participating in the Horizon BCBSNJ Commercial Network, payment will be made at the same rate as that of the existing Professional Agreement Allowances.
- Providers must maintain a complete and accurate record of all telemedicine services performed for Horizon BCBSNJ Commercial members in accordance with applicable law, rules, and regulations, and policies.
- These expanded services and capabilities are in addition to access that some Horizon BCBSNJ members may currently have on our Horizon CareOnline telehealth platform.
- Prior Authorization/Medical necessity review is required to determine if level of care services are meet the Medical Necessity Criteria (MCG/ASAM). The provider must deliver the same services via telehealth that would be delivered in-person according to established clinical guidelines. Behavioral Health services that can be delivered via telehealth and that require prior authorization are: ABA/DIR, Intensive Out-patient, PHP, Psychological & Neuropsychological Testing.
- Behavioral Health Out-patient Counseling does not require prior authorization.
Limitations and Exclusions:
While eligibility for reimbursement is provided under applicable Federal and State laws, regulatory guidance or government mandates, payment determination is subject to, but not limited to:
- Benefit Limitations
- The terms of any applicable Horizon BCBSNJ Provider Participation Agreement;
- Routine claim editing logic, including but not limited to incidental or mutually exclusive logic;
- Pertinent Horizon BCBSNJ Reimbursement and/or Medical Policies
4/25/2021: Addenda updated to reflect guidelines of P.L.2021, c.310