Updated Policy During COVID-19 Pandemic

Effective Date: October 1, 2019

Purpose:

The policy sets forth Horizon NJ Health’s reimbursement standards for telemedicine and telehealth (collectively, “telemedicine”) services. This policy applies to any individual or entity that seeks reimbursement from Horizon NJ Health for telemedicine services, including but not limited to individual health care providers; hospitals, clinics, and other facilities; and any entities that employ or contract with individual health care providers who perform telemedicine services.

Scope:

This policy applies to the following Horizon NJ Health Government Programs lines of business:

1. NJ FamilyCare/Medicaid
2. MLTSS

Definitions:

1. “Distant site” means a site at which a health care provider, acting within the scope of a valid license or certification issued pursuant to Title 45 of the Revised Statutes is located while providing health care services by means of telemedicine or telehealth.

2. “Health care provider” means an individual who provides a health care service to a patient, and includes, but is not limited to, a licensed physician, nurse, nurse practitioner, psychologist, psychiatrist, psychoanalyst, clinical social worker, physician assistant, professional counselor, respiratory therapist, speech pathologist, audiologist, optometrist, or any other health care professional acting within the scope of a valid license or certification issued pursuant to Title 45 of the Revised Statutes.

3. “Originating site” means a site at which a patient is located at the time that health care services are provided to the patient by means of telemedicine or telehealth.

4. “Telehealth” means the use of information and communications technologies, including telephones, remote patient monitoring devices, or other electronic means, to support clinical health care, provider consultation, patient and professional health-related education, public health, health administration, and other services in accordance with the provisions of P.L.2017, c.117 (C.45:1-61 et. al.).

5. “Telemedicine” means the delivery of a health care service using electronic communications, information technology, or other electronic or technological means to bridge the gap between a health care provider who is located at a distant site and a patient who is located at an originating site, either with or without the assistance of an intervening health care provider, and in accordance with the provisions of P.L.2017, c.117 (C.45:1-61 et al.). “Telemedicine” does not include the use, in isolation, of audio-only telephone conversation, electronic mail, instant messaging, phone text, or facsimile transmission.

Policy and Procedure:

To be eligible for reimbursement by Horizon NJ Health, telemedicine services must meet all of the following requirements:

1. Telemedicine services must be performed in accordance with all applicable law, rules, regulations, and licensing requirements, including but not limited to the New Jersey Telemedicine and Telehealth Law (P.L. 2017, c.117).

2. Telemedicine services must be performed to the same standard of care as if the services were rendered in person.

3. Telemedicine services must be performed in accordance with all Horizon NJ Health requirements that would apply if the service were performed in person, including but not limited to Horizon NJ Health reimbursement policies, rules, guidelines, and limitations; utilization management requirements; and the terms and conditions of the provider’s network participation agreement.

4. Providers must perform telemedicine services using interactive, real-time, two-way, audio and video communication technologies. Horizon NJ Health will not pay for any telemedicine services performed without the use of video communication.

5. Providers must ensure the interactive, real-time, two-way, audio and video communication technologies uses a secure transmission and otherwise meets all applicable privacy requirements as set forth in applicable law, rules, and regulations (including but not limited to the Health Insurance Portability and Accountability Act (“HIPAA”) and in any applicable Horizon NJ Health policies.

6. The following codes may be eligible for reimbursement by Horizon NJ Health when the services are performed via telemedicine. The inclusion of a specific code below does not guarantee payment. Any code not listed below is ineligible for reimbursement by Horizon NJ Health if the service is performed via telemedicine. In the event a coding authority makes any changes to the codes listed below, this policy is deemed to incorporate such coding changes until such time as Horizon NJ Health updates this policy to address the coding changes.

CPT Codes

99201-99205, 99211-99215, 99231-99233*, 99241-99245, 99251-99255, 99307-99310**, 99354-99357, 99406-99409, 90791-90792, 90832-90834, 90836-90839, 90845-90847, 90951-90952, 90954-90955, 90957-90958, 90960-90961, 90963-90970, 96116, 96150-96154, 96160-96161, 97802-97804, 99495-99498

HCPCS Codes

G0108-G0109, G0270, G0296, G0396-G0397, G0406-G0408, G0420-G0421, G0425-G0427, G0442, G0444, G0506, G0508-G0509

*Subsequent hospital care services (99231-99233) are limited to one visit every three days.
**Subsequent nursing facility care services (99307-99310) are limited to one visit every 30 days.

7. Providers performing telemedicine services from a distant site must bill for such telemedicine services using place of service code “02” and modifier “GT” or “95” as detailed below. Horizon NJ Health will not reimburse for telemedicine services billed using the GQ modifier.

8. Any provider rendering services to the patient in person at the originating site should not use place of service code “02 or modifier “GT” or “95” but instead should use the appropriate codes applicable to the in-person services.

9. Providers performing telemedicine services must apply the same patient cost share (if any) that would apply if the service were rendered in person.

10. Only in-network providers are eligible for reimbursement by Horizon NJ Health for telemedicine services. Horizon NJ Health will not reimburse out-of-network providers for telemedicine services.

11. Providers must maintain a complete and accurate record of all telemedicine services performed for Horizon NJ Health members in accordance with applicable law, rules, and regulations, and Horizon NJ Health policies.

12. Nothing in this policy requires a Horizon NJ Health member to use telemedicine in lieu of obtaining an in-person service.

Limitations and Exclusions:

While reimbursement is considered, any payment determination is subject to:

1. Benefit limitations
2. The provider’s participation agreement
3. Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
4. Applicable law, rules, and regulations and the mandates of any governmental authority

References:
state.nj.us/treasury/pensions/documents/laws/chapter117-2017.pdf