Telemedicine Reimbursement Policy: Temporary Update
March 1, 2020
EFFECTIVE IMMEDIATELY through at least December 31, 2023 as declared by the Governor, in an effort to connect members with their providers, Horizon NJ Health shall continue our expansion of the use of telemedicine services, for participating providers, during the current public health emergency, COVID-19. Horizon NJ Health shall reimburse the following services in addition to the existing Telemedicine and Telehealth reimbursement policy:
The following are the telemedicine services that may be utilized during this public health emergency:
- Telephonic Services (Phone call with audio only)
- Telemedicine Services (Both synchronous audio and visual required)
- Online Patient Portal Communication (Patient initiated virtual check-in for established patients only)
For all telemedicine services rendered, the provider should bill as follows:
- Use place of service (POS) ‘02’
- Append modifier ‘95’ or ‘GT’
- Follow current coding guidelines set forth by the American Medical Association, Current Procedural Terminology Professional Edition and associated publications and services
Qualified telemedicine services are those provided by a health care provider including: audiology/tinnitus assessments, behavioral health assessments, behavioral health counseling, behavioral health OBAT/MAT services, hearing aid checks (binaural and monaural), occupational therapy (OT) evaluations, physical therapy (PT) evaluations, self-management education services and speech therapy services. Per P.L.2021, c.310 a “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.
The telemedicine site of origin guidelines will be waived during this public health emergency. Horizon NJ Health will not require a member and/or provider to go to a specific location to engage in telemedicine.
Telemedicine service provisions are limited to those services within a provider’s current scope of practice.
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.
Prior Authorization/Medical necessity review is required to determine if level of care services are meet the Medical Necessity Criteria (MCG/ASAM). The provider must deliver the same services via telehealth that would be delivered in-person according to established clinical guidelines. Behavioral Health services that can be delivered via telehealth and that require prior authorization are: ABA/DIR, Intensive Out-patient, PHP, Psychological & Neuropsychological Testing.
Behavioral Health Out-patient Counseling does not require prior authorization.
Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:
- Benefit limitations;
- The terms of any applicable provider participation agreement;
- Routine claim editing logic, including but not limited to incidental or mutually exclusive logic;
- Pertinent Horizon NJ Health reimbursement policies and/or medical policies;
- Applicable law, regulatory guidance, government mandates, and the terms of the Managed Care Contract between Horizon NJ Health and the New Jersey Department of Human Services, Division of Medical Assistance and Health Services.
American Medical Association, Current Procedural Terminology (CPT®) Professional Edition and associated publications and services
4/25/2021: Addenda updated to reflect guidelines of P.L.2021, c.310