Telemedicine Services Reimbursement Policy: Temporary Addendum for Horizon Medicare Advantage

Effective Date:

March 1, 2020

EFFECTIVE IMMEDIATELY through at least December 31, 2023 as declared by the Governor, in an effort to connect Medicare Advantage members with their providers, Horizon BCBSNJ shall continue our expansion of the use of telemedicine services, for participating providers.

During the current public health emergency, reimbursement for our Medicare Advantage members will include services provided under Centers for Medicare & Medicaid Services (CMS) guidance when provided by our in-network providers through the use of alternative technologies commonly available on smart phones and other devices as listed below:

Telephonic Services (Phone call with audio only)
Telemedicine Services (Both synchronous audio and visual required)
Online Patient Portal Communication (Patient-initiated virtual check-ins)

For all of telehealth services rendered, the provider should bill as follows:

Use CMS designated place of service (POS) ‘02’
Append modifier ‘95’ or ‘GT’ 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.

The telemedicine site of origin guidelines will be waived during this public health emergency; Horizon BCBSNJ will not require a Medicare Advantage members and/or provider to go to a specific location to engage in telehealth.

These expanded services and capabilities are in addition to access that some Horizon BCBSNJ members may currently have on our Horizon CareOnline telehealth platform.

Telemedicine service provisions are limited to those services within a provider’s current scope of practice.

Providers must maintain a complete and accurate record of all telemedicine services performed for Horizon BCBSNJ Medicare Advantage members in accordance with applicable law, rules, and regulations, and Horizon BCBSNJ policies.

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 reimbursement is considered, payment determination is subject to, but not limited to:

Benefit Limitations
The terms of any applicable provider participation agreement;
Routine claim editing logic, including but not limited to incidental or mutually exclusive logic;
Pertinent Horizon BCBSNJ Reimbursement Policies and/or Medical Policies;
Applicable law, regulatory guidance, government mandates.

References:

https://www.phe.gov/emergency/news/healthactions/section1135/Pages/covid19-13March20.aspx‌
https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet

History:

4/25/2021: Addenda updated to reflect guidelines of P.L.2021, c.310