Prior authorization request form Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 PAYMENT COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM EFFECTIVE DATE: 01|01|2024 POLICY LAST UPDATED: 02|04|2026 OVERVIEW Telemedicine is a broad term used to describe an array of electronic communications between medical personnel and patients at different locations. It can also be referred to as telehealth. For purposes of this payment policy, “telemedicine services” shall mean healthcare services delivered by means of real time, two- way electronic audiovisual communications, which facilitate the assessment, diagnosis, treatment, and care management of a patient’s health care while such patient is at an originating site and the health-care provider is at a distant site, consistent with applicable state and federal laws and regulations. Telephone services are healthcare services delivered by way of audio only communication between a health- care provider at a distant site and the patient during a real-time or synchronous audio communication only.
While many healthcare services may be performed as telemedicine services, Blue Cross & Blue Shield of Rhode Island (BCBSRI) has determined that the services outlined in this policy are medically appropriate to either be provided via telemedicine or telephone only. This policy is intended to define BCBSRI payment policies and criteria for reimbursement for telemedicine and telephone only services.
This policy is applicable to Commercial Products. See related policies for telemedicine services for Medicare Advantage Plans.
MEDICAL CRITERIA Not applicable
PRIOR AUTHORIZATION
Not applicable
POLICY STATEMENT Commercials Products
Medicare Advantage Plans Telemedicine/Telephone services are covered when all the following criteria are met: 1. The patient is present at the time of service. 2. Services must be equivalent or similar to in-person services with a patient. 3. Services must be medically necessary and otherwise covered under the member’s benefit booklet or Subscriber Agreement. 4. Services must be within the provider’s scope of license. 5. The extent of any evaluation and management services (E&M) provided via telemedicine/Telephone technology is an appropriate substitute for a face-to-face encounter for the service that is being rendered. 6. A permanent record of telemedicine or telephone communications relevant to the ongoing medical care and follow-up of the patient must be maintained as part of the patient’s medical record, following all medical record documentation and coding requirements. 7. For telemedicine (real time, two-way electronic audiovisual communications) services only. Services must comply with the non-public electronic communication requirements defined by CMS and/or as otherwise designated by the State of Rhode Island, which involves both audio and video components. Payment Policy | Telemedicine/Telephone Services for Commercial Products and Medicare Advantage Plans

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 PAYMENT COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

8. Only the provider rendering the services via telemedicine or telephone may submit for reimbursement for services.

9. Telemedicine/Telephone services (as outlined in this Policy) are limited to the following provider types:
   • Adult Intensive Services (AIS)
   • Applied Behavior Analysis (ABA) • Child and Family Intensive Services (CFIT) • Clinical nurse specialist
   • Clinical social worker • Emergency Medicine -Telemedicine services only • Hospital Clinic visits • Intensive Outpatient Program (IOP) • International Board-Certified Lactation Consultant (RLC) • Licensed Behavior Analyst • Licensed Marriage and Family Therapist
   • Licensed Mental Health Counselor • Nurse Midwife
   • Nurse practitioner
   • Nurse practitioner Behavioral Health (NP-BH) • Partial Hospitalization (PHP) • Physical/Occupational/Speech Therapist - Telemedicine services only • Physician assistant
   • Physician assistant Behavioral Health (PA-BH) • Physicians
   • Psychiatrist
   • Psychologist
   • Registered dietician
   • Urgent Care – Telemedicine services only

   Early Intervention Services On June 10. 2020, The Rhode Island Executive Office of Health and Human Services released the COVID- 19 Telehealth Delivery Policy and Procedure Guidance related to Early Intervention Services. Please refer to the Early Intervention Services Mandate policy for a complete listing of all applicable covered codes.

   Excluded Provider Types
   BCBSRI has determined that it is not medically appropriate or reasonable for the following provider types to provide any Telephone and/or Telemedicine services:
   • Acupuncture
   • Ambulance service • Ambulatory surgical facility
   • Audiologist
   • Certified registered nurse first assist • Chiropractors
   • Durable medical equipment supplier • Dental specialties • General hospital
   • Home infusion • Laboratory • Pathology

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 PAYMENT COVERAGE POLICY | 3 (401) 274-4848 WWW.BCBSRI.COM

• Pharmacy
• Public health/welfare agency/immunization providers
• Psychiatric hospital • Skilled nursing facility • Radiologists
• Renal/Dialysis facility • Retail based clinic • Rehabilitation hospital

The following services are excluded from reimbursement:

Services rendered by non-public electronic communication (that are not allowed for telephone only as outlined in this Policy) e.g., telemedicine provided through the following public facing video communication applications (Note: This is not an all-inclusive list): o Facebook Live o Twitch o TikTok

• The technical and overhead component of the facility fee associated with telemedicine/telephone services. Note: These costs are included in the maximum allowable benefit paid to the professional provider for professional telemedicine/telephone services and are not separately billed or reimbursed.
• Any services rendered over the telephone (audio-only) that are not specially allowed under this Policy.
• Any services rendered by email or by fax or other means not identified in this Policy. • Telemedicine/Telephone services that occurs the same day as a face-to-face visit, when performed by the same provider and for the same condition. • Services that consist of triage solely when a separately identifiable evaluation and management service doesn’t occur to assess the appropriate place of service and/or appropriate provider type for a patient to seek and/or receive services. • Patient communications incidental to E&M services, including, but not limited to: reporting of test results (including COVID-19), or provision of educational materials or contacting a patient in follow-up to a prior in-office, telephone or telemedicine visit for a “check in” where a separately identifiable evaluation and management service does not take place. This includes but is not limited to messages received and responded to via online patient portals or other electronic communication with a subscriber/member. • Administrative matters, including but not limited to, scheduling, registration, updating billing information, reminders, requests for medication refills or referrals, ordering of diagnostic studies, and medical history intake completed by the patient. • Any telemedicine or telephonic encounter conducted by office staff, RNs, LPNs, etc. • Any proactive outreach to members who are not in active care by the provider for an acute or chronic condition that requires the intervention of the provider to limit or eliminate the exacerbation of a condition.

Note:
BCBSRI reserves the right to audit medical records as well as administrative records related to adherence to all the 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 and/or telephone as well the appropriateness of the level of evaluation and management coding. Documentation must contain the details of the provider-patient encounter. Special focus will be placed on a review to determine that a claim is not billed at a higher-level

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 PAYMENT COVERAGE POLICY | 4 (401) 274-4848 WWW.BCBSRI.COM

Evaluation & Management code/service when a lower-level code/service is warranted. For Evaluation & Management services which are coded based on time only, BCBSRI specifically requires the time spent during the visit be clearly documented in the medical record to substantiate the E & M code billed for that service.

COVERAGE Benefits may vary between groups and contracts. Please refer to the appropriate Benefit Booklet, or Subscriber Agreement for applicable telemedicine/telephone services benefits/coverage.

Please note cost share can vary depending on whether the service is obtained from BCBSRI’s designated web-based telemedicine service provider or a BCBSRI or BlueCard network provider.

If a BCBSRI member is receiving services from a provider outside of BCBSRI’s network e.g., a BlueCard network provider in another state, the codes and service limitations in this policy do not apply.

REIMBURSEMENT
BCBSRI will reimburse telemedicine or telephone only services/encounters at 100% of the in-office allowable amount along with any applicable cost share amount, effective 1/1/2024 for any clinically appropriate, medically necessary covered health service.

Services performed by Advanced Practitioners will be reimbursed at a reduced proportion of the physician fee schedule as is the practice for in-office services.

BACKGROUND Formally defined, telemedicine is the use of medical information exchanged from one site to another via electronic communications to improve a patient’s clinical health status. Telemedicine includes a growing variety of applications and services using two-way video, smart phones, wireless tools, and other forms of audio-visual telecommunication’s technology.

Starting out over 40 years ago with demonstrations of hospitals extending care to patients in remote areas, the use of telemedicine has spread rapidly and is now becoming integrated into the ongoing operations of hospitals, specialty departments, home health agencies, private physician offices, as well as consumers’ homes and workplaces.

Telemedicine is not a separate medical specialty. Telemedicine can be provided by an array of physicians and other medical personnel including many different specialists. It is used as a tool to provide better access to patients where a physician may not be available due to such reasons as distance, wait for an appointment, or lack of geographic specialty access.

In 2016, the Rhode Island General Assembly enacted the Telemedicine Coverage Act, requiring health insurers to cover telemedicine services in all plans with effective dates of January 1, 2018 or later.
Reference § 27-81-1 Title. This act shall be known as, and may be cited as, the "Telemedicine Coverage Act".

Effective 7/6/21, the Rhode Island’s Telemedicine Coverage Act (RIGL 27-81) has been amended to include the use of real time, two-way synchronous audio, video, telephone-audio-only communications or electronic media or other telecommunication technology including, but not limited to: online adaptive interview, remote patient monitoring devices. Health insurers shall not impose a deductible, copayment, or coinsurance requirement for a healthcare service delivered through telemedicine in excess of what would normally be charged for the same healthcare service when performed in person. (Senate Bill No. 4 SUB B as amended & House Bill No. 6032 SUB A as amended).

CODING Commercials Products
Medicare Advantage Plans

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 PAYMENT COVERAGE POLICY | 5 (401) 274-4848 WWW.BCBSRI.COM

The codes in the attached grid below are covered as telemedicine and/or telephone services when filed as noted AND the telemedicine criteria set forth in this policy are met.

Covered Telehealth Services for Commercial Covered Telehealth Services for Medicare Advantage

To ensure correct claims processing: Claims for telemedicine services must be filed with either Place of Service (POS) code and with Modifier 95:
• Place of Service (POS) 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. OR • Place of Service (POS) 10: 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. • Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System • Modifier GT: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System is used for institutional billing for Distant site practitioners billing telehealth under the CAH (Critical Access Hospital) Optional Payment Method II.

Claims for telephone only services must be filed with either Place of Service (POS) code below.
• Place of Service (POS) 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. OR • Place of Service (POS) 10: 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 • Modifier FQ: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio Telecommunications System FQ modifier indicates a service or procedure was provided as part of a federally qualified health center (FQHC) or rural health clinic (RHC) or institutional facility
• Modifier 93: Synchronous Telemedicine Service Rendered Via Telephone or Other Real-Time Interactive Audio-Only Telecommunications System. Modifier 93 is generally applied to professional service codes. Note: Any claim filed with a CPT code NOT listed on the attached grid with place of service 02 or 10, and Modifier 95 or FQ or 93 will deny as invalid place of service as a provider liability.

Note: On June 10. 2020, The Rhode Island Executive Office of Health and Human Services released the COVID-19 Telehealth Delivery Policy and Procedure Guidance related to Early Intervention Services. Please refer to the Early Intervention Services Mandate policy for a complete listing of all applicable covered codes.

RELATED POLICIES Early Intervention Services Mandate Coding and Payment Guidelines and Modifiers

PUBLISHED Provider Update, March 2026 Provider Update, March 2025 Provider Update, September 2024
Provider Update, January 2024

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 PAYMENT COVERAGE POLICY | 6 (401) 274-4848 WWW.BCBSRI.COM

Provider Communication sent May 3, 2023 Provider Update, July 2023 Provider Update, October 2022 Provider Update, May 2022 Provider Update, August 2021 Provider Update, June 2021 Provider Update, December 2020 Provider Update, May 2020 Provider Update, January 2019

REFERENCES

1. Rhode Island General Laws The Telemedicine Coverage Act
   http://webserver.rilin.state.ri.us/Statutes/TITLE27/27-81/INDEX.HTM
2. Senate Bill No. 4 SUB B. http://webserver.rilin.state.ri.us/BillText/BillText21/SenateText21/S0004Baa.pdf
3. House Bill No. 6032 SUB A http://webserver.rilin.state.ri.us/BillText/BillText21/HouseText21/H6032Aaa.pdf i ii
4. MLN Telehealth Services MLN901705 - Telehealth Services (cms.gov)
5. Telehealth FAQs updated 2/4/2026

6. 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-specific 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.

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