Telehealth visits

Telehealth visits (virtual services) allow members to receive primary, specialist or urgent care using a computer, phone and/or tablet.

All members have access to expanded telehealth (virtual services). In addition, most members have standard telehealth benefits. (See the Standard telehealth section below.)

Telehealth services can be provided if the services:

  • Are safely and effectively delivered virtually
  • Meet existing coverage criteria, including pre-authorization requirements and medical necessity
  • Are rendered by a provider who meets our credentialing criteria, including:

    • Providers must be licensed in both the state where the member is located, as well as the state where the provider is physically located.
    • Providers must physically provide telehealth services within our service area (home or clinic setting).
      • Providers who conduct telehealth services from their homes within our service area can use a registered agent address.
      • Providers who reside outside our service area must conduct telehealth services from a location within our service area (e.g., clinic location).
      • The provider’s address cannot be a P.O. box.

Learn more about our credentialing requirements for providers who conduct telehealth services.

Note: Effective April 1, 2022, through December 31, 2022, telehealth services may be covered pre-deductible for members on a participating administrative services only (ASO) group with a health saving account- (HSA-) eligible plan.

Expanded telehealth

Expanded telehealth

To support our members, we cover expanded telehealth services. See the tab above for standard telehealth services.

Complete telemedicine training: Washington-based telemedicine providers (those who provide clinical services through telemedicine, other than a physician licensed under chapter 18.57 RCW or chapter 18.71 RCW) must complete telemedicine training in accordance with Senate Bill 6061, Telemedicine Training. The training may be provided by the Washington State Telemedicine Collaborative, hospitals and other health care facilities, continuing education courses or health care professional boards or commissions. A health care professional who completes the training must sign and retain an attestation.

Group and Individual members

For dates of service on or after January 1, 2022

Reimbursement

Note: Please continue to refer to the Clinical Edits by Code List and our member’s benefits for non-covered services. Verify member’s benefits using Availity Essentials.

Claims submission

  • Claims for eligible telehealth services must be billed with POS 02 or POS 10, as appropriate, and modifier GT. View the CMS guidelines for the appropriate use of the POS codes.
  • Telehealth services may be conducted via audio or video. Claims for audio-only telehealth services must have modifier FQ appended, in addition to modifier GT. An established provider-patient relationship is required for audio-only services. Member consent must be obtained and documented in the medical record prior to a virtual service performed using audio-only technology.

For dates of service from July 1 through December 31, 2021

Reimbursement

Note: Please continue to refer to the Clinical Edits by Code List and our member’s benefits for non-covered services. Verify member’s benefits using Availity Essentials.

Claims submission

  • Claims for eligible telehealth services must be billed with POS 02 and modifier GT. Modifier 95 will no longer be accepted as an indicator for telehealth services.
  • Telehealth services may be conducted via audio or video.

For dates of service through June 30, 2021

Reimbursement

  • Providers will be reimbursed for expanded telehealth based on Senate Bill 5385, Telemedicine Payment Parity, where applicable.
  • We will cover expanded telehealth (virtual services) that meet the criteria.

Claims submission

For claims to process correctly as expanded telehealth, you must use:

  • The place of service (POS) where the services would have normally occurred (including POS 11; excluding POS 02).
  • Modifier 95 to indicate that the services were rendered via telehealth.

Telehealth services are covered when conducted via audio or video.

  • For fully insured members, some services will be paid based on the telehealth benefit level, including the codes listed in the Virtual Care Administrative #132 reimbursement policy (along with a few additional codes), versus the in-office benefit level.
  • For ASO group members, services will be paid at the in-office benefit level. ASO groups have the option to waive the deductible for expanded telehealth services. To verify if the deductible is waived for expanded telehealth services, contact our Provider Contact Center.
Medicare Advantage members

For dates of service on or after January 1, 2022

Reimbursement

Note: Please continue to refer to the Clinical Edits by Code List and our member’s benefits for non-covered services. Verify member’s benefits using Availity Essentials.

Claims submission

  • Claims for eligible telehealth services must be billed with POS 02 or POS 10, as appropriate, and modifier GT. View the CMS guidelines for the appropriate use of the POS codes.
  • For the encounter to meet the Medicare telehealth face-to-face requirement, telehealth visits with your Medicare Advantage patients must be conducted using real-time via audio and video, and the use of audio and video must be documented in the patient’s chart note. Claims for audio-only telehealth services must have modifier FQ appended, in addition to modifier GT. An established provider-patient relationship is required for audio-only services. Member consent must be obtained and documented in the medical record prior to a virtual service performed using audio-only technology.

For dates of service from July 1 through December 31, 2021

Reimbursement

Note: Please continue to refer to the Clinical Edits by Code List and our member’s benefits for non-covered services. Verify member’s benefits using Availity Essentials.

Claims submission

  • Claims for eligible telehealth services must be billed with POS 02 and modifier GT. Modifier 95 will no longer be accepted as an indicator for telehealth services.
  • For the encounter to meet the Medicare telehealth face-to-face requirement, telehealth visits with your Medicare Advantage patients must be conducted using real-time via audio and video, and the use of audio and video must be documented in the patient’s chart note.

For dates of service through June 30, 2021

Reimbursement

  • Providers will be reimbursed for expanded telehealth (virtual services, i.e., an office call conducted virtually) at the same rate as in-person visits.
  • We will cover expanded telehealth (virtual services) that meet the criteria.

Claims submission

For claims to process correctly as expanded telehealth, you must use:

  • The place of service (POS) location where the services would have normally occurred (including POS 11; excluding POS 02).
  • Modifier 95 to indicate that the services were rendered via telehealth.

For the encounter to meet the Medicare telehealth face-to-face requirement, telehealth visits with your Medicare Advantage patients must be conducted using real-time via audio and video, and the use of audio and video must be documented in the patient’s chart note.

  • Some services will be paid based on the telehealth benefit level, including the codes listed in the Virtual Care Administrative #132 reimbursement policy (along with a few additional codes), versus the in-office benefit level.
  • Telehealth services can be provided to Medicare Advantage PPO members by out-of-network providers.
Standard telehealth

Standard telehealth

Standard telehealth services are identified in our Virtual Care (Administrative #132) reimbursement policy.

If a member has a standard telehealth benefit, we will continue to cover the medical and behavioral health codes, as outlined in our Virtual Care (Administrative #132) reimbursement policy. Telehealth services that are included in the policy will apply to the member’s telehealth benefit, if applicable.

You can view standard telehealth benefits when performing an eligibility and benefits inquiry on Availity Essentials. When selecting the “Professional (Physician) Visit – Office” benefit service type (BST), the “Professional (Physician) Visit – Home” BST result includes the “Professional (Physician) Visit – Office” BST. To view telehealth benefits, scroll down to “Professional (Physician) Visit – Home” in the eligibility and benefits results. You may also need to view the benefit booklet for additional details.

Group and Individual members

For dates of service on or after January 1, 2022

Reimbursement

Providers will be reimbursed for standard telehealth services based on Senate Bill 5385, Telemedicine Payment Parity, where applicable.

Claims submission

  • Follow the guidelines in the Virtual Care Administrative #132 reimbursement policy. Telehealth services can be submitted with POS 02 or POS 10, as appropriate, and modifier GT. View the CMS guidelines for the appropriate use of the POS codes.
  • Claims for audio-only telehealth services must have modifier FQ appended, in addition to modifier GT. An established provider-patient relationship is required for audio-only services. Member consent must be obtained and documented in the medical record prior to a virtual service performed using audio-only technology.

For dates of service through December 31, 2021

Reimbursement

Providers will be reimbursed for standard telehealth services based on Senate Bill 5385, Telemedicine Payment Parity, where applicable.

Claims submission

Follow the guidelines in the Virtual Care Administrative #132 reimbursement policy, including the use of POS 02.

Medicare Advantage members

For dates of service on or after January 1, 2022

Reimbursement

Providers will be reimbursed for standard telehealth services based on the facility RVU reimbursement rate.

Claims submission

  • Follow the guidelines in the Virtual Care Administrative #132 reimbursement policy. Telehealth services can be submitted with POS 02 or POS 10, as appropriate, and modifier GT. View the CMS guidelines for the appropriate use of the POS codes.
  • Claims for audio-only telehealth services must have modifier FQ appended, in addition to modifier GT. An established provider-patient relationship is required for audio-only services. Member consent must be obtained and documented in the medical record prior to a virtual service performed using audio-only technology.

For dates of service through December 31, 2021

Reimbursement

Providers will be reimbursed for standard telehealth services based on the facility RVU reimbursement rate.

Claims submission

Follow the guidelines in the Virtual Care Administrative #132 reimbursement policy, including the use of POS 02.

Other telehealth information

Other telehealth information

Reimbursement for HCPCS Q3014

In alignment with CMS’ temporary guidelines (PDF), we allow for outpatient facility billing for HCPCS Q3014 Telehealth originating site facility fee when the originating site for telemedicine is the Medicare Advantage member’s home and the member is registered as an outpatient of the hospital for purposes of receiving telehealth services billed by the provider. Note: For Individual and group members, HCPCS Q3014 is only reimbursable when the member is in the health care facility during the virtual visit.

Options for connecting virtually with your patients

The following companies offer HIPAA-compliant telehealth platforms:

Risk adjustment

CMS has indicated that providers can include diagnosis codes on telehealth claims for risk adjustment purposes. For risk adjustment, telehealth visits must be conducted using audio and video.

If captured using audio and video, member reported blood pressure readings will count toward gap closures and be included in risk adjustment.

As with face-to-face visits, diagnosis codes included on claims must have sufficient documentation and may be subject to review. Refer to the Risk Adjustment section of our website for additional information about documentation requirements.

Palliative care

As a participating provider, you can conduct advance care planning (ACP) conversations with your patients via telehealth.

In light of the demand triggered by COVID-19 and to better support our Medicare Advantage members, we are now covering goals of care/ACP conversations at no cost share ($0 copay), regardless of the visit type or place of service. This benefit enhancement applies to telehealth (conducted via audio and video) and in-person visits. To ensure members are supported if their health status and/or wishes regarding care planning change, the benefit covers one ACP conversation per day with no annual limit.

Teledentistry

Teledentistry

Teledentistry services can be provided if:

Member benefits and dental provider reimbursement:

  • Claims performed via teledentistry are considered the same as in-person visits and are paid at the same rate as in-person visits.
  • Standard cost shares and plan limitations apply. Any paid amounts will accumulate to the annual maximum, if applicable.
  • View the member’s plan benefits on Availity Essentials.
Telehealth vendors

Telehealth vendors

In addition to local providers, most members have access to one of two national telehealth vendors that can help assess a member’s condition and determine the necessary next steps of care:

  • MDLIVE provides medical and behavioral health care via video or phone visits. It is available to Medicare Advantage members and as a buy up for fully insured large group and administrative services only (ASO) group members. Note: For Medicare Advantage all visits with MDLIVE will be at the member’s primary care provider (PCP) copay.
  • Doctor on Demand provides medical and behavioral health video visits. It is available to Individual, small group and mid-size group members. It is also offered as a buy up for large and ASO group members.

When members login to their account, they can view their telehealth benefits and access their telehealth vendor.

Note: If a patient’s symptoms might be indicative of COVID-19, the member would still need to be seen in person and tested for the disease.

Advice24

Most members also have access to a 24/7 nurse advice line that they can call for answers to questions about common health concerns.

Secure messaging

Ask a Doctor provides routine medical care virtually by secure messaging (that can convert to video) with a board-certified, U.S.-based provider and is an option for members with mild or no symptoms. It is available to Individual, small, mid-size and large group members.