Telemedicine policy and billing guide

Washington Apple Health (Medicaid)

Telemedicine

Policy and Billing

January 1, 2023

2 | Telemedicine Policy and Billing

Disclaimer

Every effort has been made to ensure this document’s accuracy. If an actual or

apparent conflict between this document and a Health Care Authority (HCA) rule

arises, the rule applies.

HCA will update this document on an as-needed basis. Due to the nature of

content change on the internet, we do not fix broken links in past versions of our

documents. If you find a broken link, please check the most recent version of the

document. If this is the most recent version, please notify us at

askmedicaid@hca.wa.gov.

About this document

This publication takes effect January 1, 2023, and supersedes earlier versions.

HCA is committed to providing equal access to our services. If you need an

accommodation or require documents in another format, please call 1-800-562-

3022. People who have hearing or speech disabilities, please call 711 for relay

services.

Washington Apple Health means the public health insurance

programs for eligible Washington residents. Washington Apple

Health is the name used in Washington State for Medicaid, the

children’s health insurance program (CHIP), and state-only

funded health care programs. Washington Apple Health is

administered by the Washington State Health Care Authority.

Note: Refer to Apple Health (Medicaid) program guides on

HCA’s website for program-specific telemedicine policy and

information.

How can I get HCA Apple Health provider documents?

To access provider alerts, go to HCA’s provider alerts webpage.

To access provider documents, go to HCA’s provider billing guides and fee

schedules webpage.

3 | Telemedicine Policy and Billing

AMA.

Fee schedules, relative value units, conversion factors and/or related components

are not assigned by the AMA, are not part of CPT, and the AMA is not

recommending their use. The AMA does not directly or indirectly practice

medicine or dispense medical services. The AMA assumes no liability for data

contained or not contained herein.

Further billing guidance

The managed care organizations also have their specific billing instructions at the

links below:

• Molina Healthcare

• Coordinated Care

• United Health Care

• Community Health Plan of Washington

• Amerigroup

Confidentiality toolkit for providers

The Washington State Confidentiality Toolkit for Providers is a resource for

providers required to comply with health care privacy laws. To learn more about

the toolkit, visit the HCA website.

What has changed?

The table below briefly outlines how this publication differs from the previous

one. This table is organized by subject matter. Each item in the Subject column is

a hyperlink that, when clicked, will take you to the specific change summarized in

that row of the table.

Subject Change Reason for Change

Client eligibility Added section To conform to HCA billing

guide publishing

standards and improve

usability

Modifier 95 and

distinguishing

between

facility/nonfacility

Added a box stating that

using modifier 95 and

distinguishing between

facility/nonfacility are not

applicable for behavioral

health providers who use

the guides listed

Not a policy change.

Added to clarify policy.

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Table of Contents

Definitions ............................................................................................................................................ 6

Telemedicine ....................................................................................................................................... 7

Introduction to telemedicine .................................................................................................. 7

Best Practices .................................................................................................................................. 7

Resources ......................................................................................................................................... 8

Client Eligibility................................................................................................................................... 9

How do I verify a client’s eligibility? .................................................................................... 9

Are clients enrolled in an HCA-contracted managed care organization (MCO)

eligible? .......................................................................................................................................... 10

Managed care enrollment ..................................................................................................... 11

Checking eligibility ............................................................................................................... 11

Clients’ options to change plans .................................................................................... 12

Clients who are not enrolled in an HCA-contracted managed care plan for

physical health services ...................................................................................................... 12

Integrated managed care (IMC) ..................................................................................... 12

Integrated Apple Health Foster Care (AHFC) ........................................................... 13

Fee-for-service Apple Health Foster Care .................................................................. 13

American Indian/Alaska Native (AI/AN) Clients ..................................................... 13

What if a client has third-party liability (TPL)? ............................................................. 14

Originating and Distant Sites .................................................................................................... 15

Introduction ................................................................................................................................. 15

Documentation requirements .............................................................................................. 15

Originating site ........................................................................................................................... 16

Payment..................................................................................................................................... 16

Billing .......................................................................................................................................... 17

Distant Site ................................................................................................................................... 17

Payment..................................................................................................................................... 17

Billing .......................................................................................................................................... 18

Audio-only telemedicine............................................................................................................. 20

Documentation requirements .............................................................................................. 20

Procedure codes ......................................................................................................................... 20

Billing .............................................................................................................................................. 20

Store and Forward ......................................................................................................................... 22

Requirements .............................................................................................................................. 22

Teledermatology ........................................................................................................................ 23

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Payment..................................................................................................................................... 23

Coverage ................................................................................................................................... 23

Billing .......................................................................................................................................... 24

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Definitions

This section defines terms used in this document.

Audio-only telemedicine – The delivery of health care services using audio-only

technology, permitting real-time communication between the client at the

originating site and the provider, for the purposes of diagnosis, consultation, or

treatment.

Distant site – The site at which a physician or other licensed provider, delivering

a professional service, is physically located at the time the service is provided

through telemedicine.

Face-to-face – The client could be receiving the care in person or via audio-

visual technology.

Facility – See the Site-of-Service Payment Differential section in HCA’s Physician-

related services/Health care professional services billing guide.

Hospital – A facility licensed under chapter 70.41, 71.12, or 72.23 RCW.

In person – The client and the provider are in the same location.

Medicaid agency or agency – The Washington State Health Care Authority.

Medically necessary – See WAC 182-500-0070.

Nonfacility – See the Site-of-Service Payment Differential section in HCA’s

Physician-related services/Health care professional services billing guide.

Originating site – The physical location of a client receiving health care services

through telemedicine.

Store and forward technology – Use of an asynchronous transmission of a

covered person's medical or behavioral health information from an originating

site to the health care provider at a distant site which results in medical or

behavioral health diagnosis and management of the covered person and does

not include the use of audio-only telephone, facsimile, or email.

Telemedicine – The delivery of health care services using interactive audio and

video technology, permitting real-time communication between the client at the

originating site and the provider, for the purpose of diagnosis, consultation, or

treatment. Telemedicine includes audio-only telemedicine, but does not include

any of the following services:

• Email and facsimile transmissions

• Installation or maintenance of any telecommunication devices or systems

• Purchase, rental, or repair of telemedicine equipment

• Incidental services or communications that are not billed separately, such as

communicating laboratory results

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Telemedicine

Introduction to telemedicine

Before 2020, the Health Care Authority (HCA) had been encouraging and

allowing healthcare providers to provide telemedicine options for HCA clients for

several years. In response to the COVID-19 pandemic, HCA, working with Apple

Health (Medicaid) managed care organizations, expanded the use of a variety of

telemedicine technologies to meet the health care needs of clients, families, and

providers. In the health care community, the words telehealth and telemedicine

are often used interchangeably. However, for Apple Health, telemedicine is

defined in a very specific way. See Definitions.

Best Practices

When conducting telemedicine services, it is important to ensure that the

standard of care for telemedicine is the same as that for an in-person visit,

providing the same health care service. Refer to the Department of Health for

requirements from various commissions (e.g., Medical Commission, Nursing

Commission, etc.).

Best practices may include, but are not limited to, the following:

• Consider the client’s resources when deciding the best platform to provide

telemedicine services.

• Test the process and have a back-up plan; connections can be disrupted with

heavy volume. Communicate a back-up plan in the event the technology fails.

• Introduce yourself, including what your credential is and what specialty you

practice. Show a badge when applicable.

• Ask the client their name and verify their identity. Consider requesting a photo

ID when applicable/available.

• Inform clients of your location and obtain the location of clients. Include this

information in documentation.

• Inform the client of how the client can see a clinician in-person in the event of

an emergency or as otherwise needed.

• Inform clients they may want to be in a room or space where privacy can be

preserved during the conversation. Explain that personal health information

may be disclosed.

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Resources

There are many resources available for providers to get started with telemedicine.

The following are examples of resources:

• Telehealth Collaborative provider training (required)

• Telemental Health Toolkit from NRTRC

• Washington State Dental Association

• University of Washington Behavioral Health Institute

• Washington state Department of Health

Additionally, many professional societies have telemedicine guidelines that may

provide valuable care-specific information for health care professionals.

Note: Inclusion in the above list does not reflect an endorsement

or verification of complete accuracy by HCA.

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Client Eligibility

Most Apple Health clients are enrolled in an HCA-contracted managed care

organization (MCO). This means that Apple Health pays a monthly premium to an

MCO for providing preventative, primary, specialty, and other health services to

Apple Health clients. Clients in managed care must see only providers who are in

their MCO’s provider network, unless prior authorized or to treat urgent or

emergent care. See HCA’s Apple Health managed care webpage for further

details.

It is important to always check a client’s eligibility prior to

providing any services because it affects who will pay for the services.

How do I verify a client’s eligibility?

Check the client’s Services Card or follow the two-step process below to verify

that a client has Apple Health coverage for the date of service and that the

client’s benefit package covers the applicable service. This helps prevent

delivering a service HCA will not pay for.

Verifying eligibility is a two-step process:

Step 1. Verify the patient’s eligibility for Apple Health. For detailed

instructions on verifying a patient’s eligibility for Apple Health,

see the Client Eligibility, Benefit Packages, and Coverage Limits

section in HCA’s ProviderOne Billing and Resource Guide.

If the patient is eligible for Apple Health, proceed to Step 2. If the

patient is not eligible, see the note box below.

Step 2. Verify service coverage under the Apple Health client’s

benefit package. To determine if the requested service is a

covered benefit under the Apple Health client’s benefit package,

see HCA’s Program benefit packages and scope of services

webpage.

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Note: Patients who are not Apple Health clients may apply for

health care coverage in one of the following ways:

• Online: Go to Washington Healthplanfinder - select the

"Apply Now" button. For patients age 65 and older or on

Medicare, go to Washington Connections select the “Apply

Now” button.

• Mobile app: Download the WAPlanfinder app – select “sign

in” or “create an account”.

• Phone: Call the Washington Healthplanfinder Customer

Support Center at 1-855-923-4633 or 1-855-627-9604 (TTY).

• Paper: By completing an Application for Health Care

Coverage (HCA 18-001P) form.

To download an HCA form, see HCA’s Free or Low Cost

Health Care, Forms & Publications webpage. Type only the

form number into the Search box (Example: 18-001P). For

patients age 65 and older or on Medicare, complete the

Washington Apple Health Application for Aged, Blind,

Disabled/Long-Term Services and Support (HCA 18-005) form.

• In-person: Local resources who, at no additional cost, can

help you apply for health coverage. See the Health Benefit

Exchange Navigator.

Are clients enrolled in an HCA-contracted managed

care organization (MCO) eligible?

Yes. Most Medicaid-eligible clients are enrolled in one of HCA’s MCOs. For these

clients, managed care enrollment will be displayed on the client benefit inquiry

screen in ProviderOne.

All medical services covered under an HCA-contracted MCO must be obtained

through the MCO’s contracted network. The MCO is responsible for:

• Payment of covered services

• Payment of services referred by a provider participating with the plan to an

outside provider

Note: A client’s enrollment can change monthly. Providers who

are not contracted with the MCO must receive approval from

both the MCO and the client’s primary care provider (PCP) prior

to serving a managed care client.

Send claims to the client’s MCO for payment. Call the client’s MCO to discuss

payment prior to providing the service. Providers may bill clients only in very

limited situations as described in WAC 182-502-0160.

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Note: HCA continues to pay for the following through fee-for-

service (FFS):

- Professional fees for dental procedures using CDT® codes

- Professional fees using CPT® codes only when the provider’s

taxonomy starts with 12

See the Dental-Related Services Billing Guide or the Physician-

Related Services/Health Care Professional Services Billing

Guide, or both, for how to bill professional fees.

Managed care enrollment

Most Apple Health (Medicaid) clients are enrolled in HCA-contracted MCO the

same month they are determined eligible for managed care as a new or renewing

client. Some clients may still start their first month of MC eligibility in the FFS

program because their qualification for MC enrollment is not established until the

month following their Medicaid eligibility determination. Providers must check

eligibility to determine enrollment for the month of service.

New clients are those initially applying for benefits or those with changes in their

existing eligibility program that consequently make them eligible for Apple

Health managed care.

Checking eligibility

• Providers must check eligibility and know when a client is enrolled and with

which MCO. For help with enrolling, clients can refer to the Washington

Healthplanfinder’s Get Help Enrolling webpage.

• MCOs have retroactive authorization and notification policies in place. The

provider must know the MCO’s requirements and be compliant with the

MCO’s policies.

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Clients’ options to change plans

Clients have a variety of options to change their plan:

• Available to clients with a Washington Healthplanfinder account:

Go to the Washington Healthplanfinder website.

• Available to all Apple Health clients:

o Visit the ProviderOne Client Portal website:

o Call Apple Health Customer Service at 1-800-562-3022. The automated

system is available 24/7.

o Request a change online at ProviderOne Contact Us (this will generate an

email to Apple Health Customer Service). Select the topic “Enroll/Change

Health Plans.”

For online information, direct clients to HCA’s Apple Health Managed Care

webpage.

Clients who are not enrolled in an HCA-contracted

managed care plan for physical health services

Some Medicaid clients do not meet the qualifications for managed care

enrollment. These clients are eligible for services under the fee-for-service (FFS)

Medicaid program. In this situation, each Integrated Managed Care (IMC) plan

will have Behavioral Health Services Only (BHSO) plans available for Apple Health

clients who are not in managed care. The BHSO covers only behavioral health

treatment for those clients. Eligible clients who are not enrolled in an HCA-

contracted managed care plan are automatically enrolled in a BHSO, except for

American Indian/Alaska Native clients. If the client receives Medicaid-covered

services before being automatically enrolled in a BHSO, the FFS Medicaid

program will reimburse providers for the covered services. Some examples of

populations that may be exempt from enrolling into a managed care plan are

Medicare dual-eligible, American Indian/Alaska Native, Adoption support and

Foster Care alumni.

Integrated managed care (IMC)

Clients qualified for enrollment in an integrated managed care plan receive all

physical health services, mental health services, and substance use disorder

treatment through their HCA-contracted managed care organization (MCO).

For full details on integrated managed care, see HCA’s Apple Health Managed

Care webpage and scroll down to “Changes to Apple Health managed care.”

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Integrated Apple Health Foster Care (AHFC)

Children and young adults in the Foster Care, Adoption Support and Alumni

programs who are enrolled in Coordinated Care of Washington’s (CCW) Apple

Health Foster Care program receive both medical and behavioral health services

from CCW.

Clients under this program are:

• Under the age of 18 who are in foster care (out of home placement)

• Under the age of 21 who are receiving adoption support

• Age 18-21 years old in extended foster care

• Age 18 to 26 years old who aged out of foster care on or after their 18th

birthday (alumni)

These clients are identified in ProviderOne as

“Coordinated Care Healthy Options Foster Care.”

The Apple Health Customer Services staff can answer general questions about

this program. For specific questions about Adoption Support, Foster Care or

Alumni clients, contact HCA’s Foster Care and Adoption Support (FCAS) Team at

1-800-562-3022, Ext. 15480.

Fee-for-service Apple Health Foster Care

Children and young adults in the fee-for-service Apple Health Foster Care,

Adoption Support and Alumni programs receive behavioral health services

through the regional Behavioral Health Services Organization (BHSO). For details,

see HCA’s Mental Health Services Billing Guide, under How do providers identify

the correct payer?

American Indian/Alaska Native (AI/AN) Clients

American Indian/Alaska Native (AI/AN) clients have two options for Apple

Health coverage:

• Apple Health Managed Care

• Apple Health coverage without a managed care plan (also referred to as fee-

for-service [FFS])

If an AI/AN client does not choose a managed care plan, they will be

automatically enrolled into Apple Health FFS for all their health care services,

including comprehensive behavioral health services. See the Health Care

Authority’s (HCA) American Indian/Alaska Native webpage.

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What if a client has third-party liability (TPL)?

If the client has third-party liability (TPL) coverage (excluding Medicare), prior

authorization must be obtained before providing any service requiring prior

authorization. For more information on TPL, refer to HCA’s ProviderOne Billing

and Resource Guide.

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Originating and Distant Sites

Introduction

Telemedicine is an interaction between a healthcare provider who is physically

located at the distant site and a client who is physically located at the

originating site. This section provides more information on documentation,

payment, and billing requirements attributed to each type of site.

Documentation requirements

Billing site Documentation requirement

Distant site • Specification of the telehealth modality that was used (e.g.,

visit was conducted via HIPAA-compliant real-time

audio/visual)

• Verification that telemedicine was clinically appropriate for

this service

• Whether any assistive technologies (e.g., electronic

stethoscopes, mobile automatic blood pressure device, etc.)

were used

• The location of the client

• The location of the provider (such as billing office, home,

etc.). Include city/state.

• The names and credentials (e.g., MD, ARNP, PA, etc.) of all

provider personnel involved in the telemedicine visit

• The people who attended the appointment with the client

(family, friend, caregiver)

• The start and end times of the health care service provided

by telemedicine or the duration of service when billing is

based on time

• The consent for care via the modality that was used

Originating

site

• Specification of the telehealth modality that was used (e.g.,

visit was conducted via HIPAA-compliant real-time

audio/visual)

• If there are staff involved in providing the service list the

names and credentials (e.g., MD, ARNP, PA, etc.) of all

provider personnel involved in the telemedicine visit

• Any medical service provided (e.g., vital signs, weight, etc.)

• The start and end times of the health care service provided

by telemedicine

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Originating site

Payment

Originating sites that are enrolled with HCA to provide services to HCA clients

and bill HCA may be paid a facility fee for infrastructure and client preparation.

Note:

- An originating site must be located within the continental

United States, Hawaii, District of Columbia, or any United

States territory (e.g., Puerto Rico).

- HCA does not pay an originating site facility fee to the client

in any setting.

Additionally, HCA does not pay an originating site facility fee in the following

situations:

• Audio-only telemedicine

• Store and forward

• If the originating site is:

o The client’s home

o A hospital (inpatient services)

o A skilled nursing facility

o Any location receiving payment for the client’s room and board

o The same entity as the distant site or if the provider is employed by the

same entity as the distant site

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Billing

To bill for an originating site facility fee for an eligible service, please use the

appropriate billing codes as listed below:

Originating site Billing

Critical access hospital Use revenue code 0780 on the

same line as HCPCS code Q3014

FQHC or RHC Use HCPCS code Q3014

Home, or location determined appropriate

by the individual receiving service

Not eligible for an originating

site reimbursement

Hospital inpatient Not eligible for an originating

site reimbursement

Hospital outpatient Use revenue code 0780 on the

same line as HCPCS code Q3014

Other setting Use HCPCS code Q3014

Physician or other healthcare professional

office

Use HCPCS code Q3014

Skilled nursing facility Not eligible for an originating

site reimbursement

Distant Site

Payment

HCA reimburses medically necessary covered services through telemedicine when

the service is provided by a Washington Apple Health provider and is within their

scope of practice.

For kidney centers or ambulatory surgery centers to bill, either the client or the

provider must be physically present at the facility at the time the service was

rendered. See 42 CFR 440.90 for rules related to clinic services.

Note: A distant site must be located within the continental

United States, Hawaii, District of Columbia, or any United States

territory (e.g., Puerto Rico).

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Billing

The payment amount for the professional service provided through telemedicine

by the provider at the distant site is equal to the current fee schedule amount for

the service provided. Submit claims for telemedicine services using the

appropriate CPT® or HCPCS code for the professional service.

Use place of service (POS) 02 or 10 to indicate that a billed service was furnished

as a telemedicine service from a distant site.

Place of

service Description

02 The location where health services and health related services are

provided or received through telecommunication technology.

Patient is not located in their home when receiving health services

or health-related services through telecommunication technology

10 The location where health services and health-related services are

provided or received through telecommunication technology.

Patient is in their home (which is a location other than a hospital or

other facility where the patient receives care in a private residence)

when receiving health services or health-related services through

telecommunication technology.

When billing with POS 02 or 10:

• Add modifier 95 if the distant site is designated as a nonfacility.

• Nonfacility providers must add modifier 95 to the claim to distinguish them

from facility providers and ensure that they receive the nonfacility rate.

Attention licensed behavioral health agencies (BHA)—Using

modifier 95 and distinguishing between facility/nonfacility are

not applicable for behavioral health providers who use the

following guides:

- Service encounter reporting instructions (SERI) guide

- Mental health billing guide (Part 2)

- Substance use disorder (SUD) billing guide

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HCA discontinued the use of modifier GT for claims submitted for professional

services (services billed on a CMS-1500 claim form, when submitting paper

claims). Distant site practitioners billing for telemedicine services under the

Critical Access Hospital (CAH) optional payment method must use modifier GT.

See HCA’s ProviderOne Billing and Resource Guide for more information on

submitting claims to HCA. See HCA’s Inpatient Hospital Services Billing Guide for

more information on billing for services under the CAH optional payment

method.

Follow CMS guidance for modifiers if Medicare is the primary insurance.

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Audio-only telemedicine

Documentation requirements

In addition to the telemedicine requirements previously noted, providers must

obtain consent before rendering the service per RCWs 74.09.325 and 71.24.335.

Consent must be documented in the client record.

Procedure codes

Refer to HCA’s Provider billing guides and fee schedules webpage, under

Telehealth, for a complete list of audio-only telemedicine procedure codes, under

Audio-only telemedicine.

Billing

HCA requires providers to bill audio-only services with the appropriate audio-

only modifiers (93 or FQ). For services that are partially audio/visual and partially

audio-only, a service is considered audio-only if 50% or more of the service was

provided via audio-only telemedicine.

Modifier Description

93 Synchronous Telemedicine Service Rendered Via Telephone or

Other Real-time Interactive Audio-Only Telecommunications

System: Synchronous telemedicine service is defined as a real-time

interaction between a physician or other qualified health care

professional and a patient who is located away at a distant site

from the physician or other qualified health care professional. The

totality of the communication of information exchanged between

the physician or other qualified health care professional and the

patient during the synchronous telemedicine service must be of an

amount and nature that is sufficient to meet the key components

and/or requirements of the same service when rendered via a face-

to-face interaction.

FQ For counseling and therapy provided using audio-only

telecommunications

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Information related to specific service areas and billing guidelines includes the

following:

Billing guide/Resource Modifier

Service Encounter Reporting Instructions (SERI), Substance Use

Disorder (SUD) Billing Guide, and Part II of HCA’s Mental Health

Services Billing Guide

Part I of HCA’s Mental Health Services Billing Guide 93

All other physical health programs 93

Note: For more information, see the Apple Health (Medicaid)

behavioral health policy and billing during the COVID-19

pandemic (FAQ) under Telehealth on HCA’s Provider billing

guides and fee schedules webpage.

22 | Telemedicine Policy and Billing

Store and Forward

Store and Forward is the transmission of medical information to be reviewed later

by a physician or practitioner at a distant site. A client’s medical information may

include, but is not limited to, video clips, still images, x-rays, laboratory results,

audio clips, and text. The physician or practitioner at the distant site reviews the

case without the client present.

Requirements

HCA pays for Store and Forward when all the following conditions are met:

• The visit results in a documented care plan that is communicated back to the

referring provider.

• The transmission of protected health information is HIPAA-compliant.

• Written informed consent is obtained from the client that Store and Forward

technology will be used and who the consulting provider is.

If the consultation results in a face-to-face visit in person or via telemedicine with

the specialist within 60 days of the Store and Forward consult, HCA does not pay

for the Store and Forward consultation.

Note: The originating site for Store and Forward is not eligible to

receive an originating site fee.

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Teledermatology

Payment

HCA pays for Store and Forward for teledermatology. Teledermatology does not

include single-mode consultations by telephone calls, images transmitted via

facsimile machines, or electronic mail.

Coverage

HCA covers the following procedure codes for teledermatology:

E/M service

CPT® code Short description

99241-99243 Office consultation, new or established patient

99251-99253 Initial inpatient consultation

99211-99214 Office or other outpatient visit

99231-99233 Subsequent hospital care

Note:

- For information related to the public health emergency and

e-consults, see HCA’s Telehealth clinical policy and billing on

HCA’s Provider Billing Guides and Fee Schedules webpage,

under Telehealth.

- Teledermatology requires expedited prior authorization

(EPA) # 870001419.

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Billing

Teledermatology services provided via Store and Forward telecommunications

system must be billed with modifier GQ. Bill only the portion(s) rendered from

the distant site with modifier GQ. The sending provider bills as usual with the E/M

and no modifier. The use of modifier GQ does not alter reimbursement for the

CPT® or HCPCS code billed.

You must use POS 02 to indicate the location where health services are provided

through Store and Forward technology. POS 02 code does not apply to the

originating site.

Note: HCA denies claims submitted for Store and Forward

services with POS code 02 if modifier GQ is not included.

HCA may perform a post-pay review on any claim to ensure the above conditions

were met.