Prior authorization request form Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM EFFECTIVE DATE: 01|01|2022 POLICY LAST UPDATED: 12|21|2021 OVERVIEW To be in alignment with the Centers for Medicare & Medicaid Services (CMS) related to the new/modifications to the Place of Service (POS) code set for telemedicine for Blue Cross & Blue Shield of Rhode Island’s (BCBSRI) Medicare Advantage and Commercial members.
This Policy outlines BCBSRI’s implementation of a new POS code (10) for Telehealth effective April 1, 2022, as well as a change in description for the existing POS code (02) for Telehealth. MEDICAL CRITERIA Not applicable
PRIOR AUTHORIZATION Not applicable POLICY STATEMENT Medicare Advantage Plans and Commercials Products BCBSRI reserves the right to audit medical records as well as administrative records related to adherence to all the requirements of this policy, e.g., to verify the nature of the services provided, the medical necessity and clinical appropriateness to provide such service via telemedicine.
BCBSRI will begin accepting POS 10 on April 1, 2022 for claims adjudication and requires the accurate submission of POS 10 and 02 codes when telemedicine is being rendered to members for claims submitted for dates of service on or after April 1, 2022.
Although POS 10 is effective January 1, 2022, BCBSRI is requesting that providers file/submit claims with POS 02 until March 31, 2022 in order for BCBSRI to have time to update and configure its system to accept and adjudicate claims timely and accurately with POS 10.
COVERAGE Benefits may vary between groups and contracts. Please refer to the appropriate Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for applicable Telemedicine/Telehealth services benefits/coverage. BACKGROUND
The description of POS code 02 has been revised and a new POS code 10 has been created to meet the overall industry needs, as follows:

1. POS 02: Telehealth Provided Other than in Patient’s Home Descriptor: 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.
2. POS 10: Telehealth Provided in Patient’s Home Descriptor: The location where health services and health related services are provided or received through telecommunication technology. Patient is located 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. Payment Policy | Place of Service (POS) 10 Telemedicine

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM CODING
Medicare Advantage Plans and Commercial Products To ensure correct claims processing, claims filed in accordance with this policy must adhere to the coding instructions found below. All providers must file the appropriate CPT codes and applicable modifiers for the telemedicine/telehealth or telephone encounter. 10 Telehealth Provided in Patient’s Home Detailed Place of Service Description:
The location where health services and health related services are provided or received, through telecommunication technology. Patient is located 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. (This code is effective January 1, 2022, and available to Medicare April 1, 2022.) 02 Telehealth provided other than patient’s home. Detailed Place of Service Description: 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. (Effective January 1, 2017) (Description change effective January 1, 2022, and applicable for Medicare April 1, 2022.) Telemedicine Services (audio and visual) Modifier Reminder:
• Place of Service (POS) 10 or 02, whichever is applicable: o Telehealth: The location where health services and health related services are provided or received, through telehealth telecommunication technology. • Modifier 95 Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System; AND Telephone Only Services Modifier Reminder:
• Place of Service (POS) 10 or 02, whichever is applicable with no additional telemedicine modifiers: o Telehealth: The location where health services and health related services are provided or received, through telehealth telecommunication technology; AND Note: Modifier 95 should NOT be submitted as telephone only services are not rendered via a Real-Time Interactive Audio and Video Telecommunications System. RELATED POLICIES Telemedicine/Telephone Services for Commercial Products - Effective 1/1/2021 Telemedicine/Telephone Services for Medicare Advantage Plans during the Public Health Emergency (PHE)

• Effective 1/1/2021 PUBLISHED BCBSRI’s website under Alerts and Update An FAQ document is available on BCBSRI.com REFERENCES https://www.cms.gov/files/document/mm12427-newmodifications-place-service-pos-codes-telehealth.pdf

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 3 (401) 274-4848 WWW.BCBSRI.COM i ii This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specifi c benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association. CLICK THE ENVELOPE ICON BELOW TO SUBMIT COMMENTS