Policy Type: Revised
Applies To: In-network Texas providers rendering telemedicine or telehealth services to members of fully-insured commercial medical plans subject to Texas Insurance Code (TIC) Chapter 1455.
Policy Implementation: Date of service
Effective Date: January 1, 2018
Revision Date: See Policy Revision Date
Applicable Insurance Code Section(s): TIC Sections 1455.001 - 1455.006; Texas Occupational Code Section 111.004
Payment policies are intended to ensure that providers are paid based on the code that most accurately describes the procedure performed, and may use CPT/HCPCS, CMS or other coding methodologies. Coding methodology, industry-standard payment logic, regulatory requirements, benefits design and other factors are considered in developing payment policies.
This policy addresses Texas Health + Aetna Life Insurance Company and Texas Health + Aetna Health Inc.’s guidelines regarding payment for telehealth and telemedicine services in Texas.
Services provided through telemedicine are considered as if they were provided face-to-face if the relevant standard of care requirements are met. Services are considered eligible if they are otherwise eligible under the plan. There are no CPT codes specific to telemedicine services.
Providers must bill with Place of Service 02 (Telehealth services) and/or modifier GT (via an asynchronous telecommunications system) or 95 (via a synchronous interactive audio and video telecommunications system) with an eligible CPT/HCPCS code. When physicians or healthcare professionals report modifier GT, they certify that they rendered services to a patient via an interactive audio and visual telecommunications system. HCPCS also eligible for coverage: 0188T, G0406, G0425, G0459, G0508, Q3014, S9110 and T1014.
We are not required to cover telehealth by only synchronous audio or asynchronous telecommunication interaction, including:
Telecommunication systems that store medical information such as diagnostic images or video and forward it from one site to another for the physician or health care practitioner to view in the future at a site different from the patient. This is a non-interactive telecommunication because the physician or health care practitioner views the medical information without the patient being present.
Synchronous Interactive Audio and Video Telecommunication, Interactive Audio and Visual Transmissions and Audio-Visual Communication Technology:
Real-time interactive video teleconferencing that involves communication between the patient and a distant physician or health care practitioner who is performing the medical service. The physician or health care practitioner actually sees the patient throughout the communication, so that two-way communication (sight and sound) can take place.
A health service, other than a telemedicine medical service, delivered by a health professional licensed, certified or otherwise entitled to practice in Texas and acting within the scope of the health professional's license, certification or entitlement to a patient at a different physical location than the health professional using telecommunications or information technology.
Telemedicine medical service:
A health care service delivered by a physician licensed in Texas or a health professional acting under physician delegation and supervision of physician licensed in Texas and acting within the scope of the physician's or health professional's license to a patient at a different physical location than the physician or health professional using telecommunications or information technology.
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