Telehealth Guidelines

TriWest’s Telehealth program includes services through VA’s Patient-Centered Community Care (PC3) program and Community Care Network. It is available for eligible Veterans as an option for care in the community for both initial and follow-up appointments, as appropriate.

Important Details

  • Telehealth services may be provided through Patient-Centered Community Care (PC3) and Community Care Network (CCN) utilizing current Medicare guidelines.
  • Providers can bill using the Medicare telemedicine methodology and guidance during COVID-19 to be paid at the face-to-face rate.
  • TriWest will pay the providers’ claims for the telehealth services if there is an authorization on file (except Urgent Care where no authorization is required), the scope of services are appropriate for a telehealth visit (no physical procedures are billed that would require face-to-face delivery of care), and the claim is consistent with Medicare guidance for place of service and modifiers.
  • The CPT codes on the SEOCs do not need to include any additional telehealth specific codes for a telehealth claim to be paid.
  • Telehealth is an option for community care appointments under PC3 and CCN for both initial and follow-up appointments as appropriate for the referred condition. It can be used as needed along with face-to-face care where some physical evaluation or procedures are required.

General Telehealth Information

Q: What is the difference between a telehealth visit, virtual check-in, and e-visit?

Telehealth Visit: The use of interactive audio and video communications in real time between a distant site provider and a patient at home (in-home telehealth) or at a local facility (point-to-point telehealth). This service can be provided for new or established patients.

Virtual Check-Ins: Brief 5-10 minute communications with established patients using various technology devices, such as phone or the transfer of recorded video and images, to determine whether an office visit or other service is necessary.

E-Visits: Communication between established patients and their providers through an online patient portal.

Q: What are the requirements to perform telehealth appointments for Veterans?

To deliver care to Veterans via telehealth, a provider must:

  • Have an approved referral/authorization, excluding Urgent Care
  • Submit a request to TriWest to provide telehealth services (waived during COVID-19 pandemic)
  • Have access to a confidential work space to conduct video conferencing
  • Deliver services through a HIPAA-compliant platform (though strongly recommended, this is currently waived due to COVID-19)
  • Maintain medical documentation for all telehealth services delivered
  • Possess proof of professional liability insurance to include telehealth services as required by state guidelines
  • Have protocols for emergency situations for each Veteran with local emergency contact information prior to delivery of care
  • Establish an alternative plan should there be a failure in the technology, developed at the onset of care.

Q: What happens if a Veteran opts for a face-to-face appointment?

A Veteran can request to receive face-to-face care at any time. A face-to-face visit is not required prior to starting telehealth. If the current provider is unable to provide routine face-to-face visits then a new approved referral/authorization will be required from the referring VA Medical Center.

Q: Is a separate approved referral/authorization required to be on file for telehealth?

No, any service that can be effectively and safely delivered by telehealth can be applied to an approved referral at this time. This may change after COVID-19. Watch for more information from both Medicare and VA.

Q: Can providers that utilize telehealth prescribe medications?

Yes, telehealth providers can prescribe medications subject to TriWest requirements and state and federal guidelines, which currently allow provider discretion on controlled substance prescriptions during COVID-19.

Q: What other guidelines apply to telehealth appointments?

  • The Veteran must be dressed appropriately for the session. Inform the Veteran that this session is no different than that of a face-to-face appointment. Inappropriate clothing or lack thereof will result in termination of the session.
  • All weapons must be secured prior to the session to avoid any confusion or inadvertent cause for alarm.
  • The Veteran must have a space that is private, safe, and secure to perform a telehealth visit. This is to protect the Veteran’s privacy.

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Telehealth Self-Assessment

The self-assessment below assists providers in gauging their comfort level with telehealth practices. Certifications in telehealth studies are not a requirement to use the program.

  1. Have you performed telehealth services in the past?
  2. Do you possess the technical requirements to conduct telehealth effectively? Minimum technical requirements include:
    • Video Camera, microphone or headset with microphone, computer/mobile device
    • Internet connection with sufficient bandwidth to conduct video transfers without delays, minimum of 15 Mbps download speed and 5 Mbps upload speed (Go to speedtest.net to check your connection.)
    • HIPPAA-compliant software platform (waived during COVID-19)
  3. Do you have access to a clean, quiet, confidential work space to conduct video conferencing for telehealth?
  4. Are you aware of your state laws governing your ability to perform telehealth?
  5. Do you have the ability to complete a technical assessment with your Veteran 48 hours before their initial telehealth session? A technical assessment is when the Veteran is introduced to your platform using their personal system. This ensures that the Veteran has the device, Internet speed, and knowledge to utilize the program.
  6. Do you have any certifications or trainings that you would like to include in your telehealth provider profile? (Optional; certifications are not a tele-health requirement.)

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COVID-19 Telehealth Guidelines

Q: Are all providers authorized to use telehealth to treat patients?

TriWest has determined at this time that under the Patient-Centered Community Care (PC3) program and the Community Care Network (CCN), providers who wish to utilize virtual or phone visits to treat patients and provide continued care while staying in compliance with CDC and Medicare guidelines may do so, as long as the provider has an approved referral/authorization for care (except Urgent Care where no prior authorization is required).

VA has provided a waiver for all specialties under PC3 where virtual visits for the initial and subsequent appointments are now allowed in light of the ongoing pandemic. Care should be billed on the claim form as instructed by Medicare during the COVID-19 pandemic.

Q: Which CPT codes are covered by telehealth?

CPT codes will vary depending on the specialty, but any care that can be rendered remotely for the condition referred by the VA is eligible for telehealth and should be billed as instructed by Medicare.

Q: What rules govern telehealth?

Telehealth must be conducted consistent with Medicare and DEA guidelines. Providers must be aware of state and federal laws governing their ability to perform telehealth services in states in which they are not licensed.

Q: How will claims be paid and what documentation is required?

Claims will be paid in the same way they are for traditional face-to-face visits. Ensure you are utilizing the appropriate place of service and modifier that identifies the care was delivered via telehealth. See Medicare instructions for billing during COVID to avoid any claims denials or reduced payments.

Q: Is acupuncture via telehealth covered?

Yes, however you cannot use codes that require needle insertion and only should provide the care via telehealth if the request from the VA was broader than just the delivery of the acupuncture.

Q: Is physical therapy or chiropractic services covered under telehealth?

Chiropractic services would be covered comparably to physical therapy for telehealth in that coverage would be extended for some office visits and codes comparable to monitoring exercise (CPT 97110). CMS has provided information on appropriate telehealth coding. CMS has provided guidance to allow face-to-face levels of reimbursement for telehealth, therefore the face-to-face place of service would be used (e.g., POS 11), and modifier 95 should be used to show it was done via telehealth.

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Claims/Billing for Telehealth Services

CCN Region 4 providers can provide telehealth services and bill TriWest using appropriate telemedicine code(s). VA will reimburse TriWest in accordance with Medicare telemedicine methodology and guidance. Medicare telemedicine methodology and guidance references:

Q: Which Place of Service should be used for billing telehealth visits?

When billing professional claims for telehealth services with dates of services on or after March 1, 2020, and for the duration of the COVID-19 pandemic, bill with the Place of Service normally billed (e.g., outpatient office visit POS 11) along with a modifier 95, indicating that the service rendered was actually performed via telehealth.

Under normal circumstances, the provider would bill with the Place of Service code 2, to indicate the care was rendered via telehealth. To receive payment equivalent to a normal face-to-face visit you will not bill POS 2 and instead will follow Medicare guidance to bill POS 11 as if care was delivered in the office during COVID-19.

Q: Which modifiers are appropriate?

During COVID-19, modifier 95 should be used. Outside of COVID-19 the modifier of GT should be used for synchronous telehealth services.

Q: Can providers bill telehealth services on the UB-04 form for PT/OT/SLP?

Yes. Per CMS guidelines, there are no changes in the UB04 billing practice.

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Telehealth - Behavioral Health

Q: What considerations are made for appointing Behavioral Health?

When appointing for Tele-Behavioral Health, extra considerations should be made. Below are questions TriWest asks Veterans to determine Tele-Behavioral Health capabilities and comfort level:

  • When would you prefer to use Tele-Behavioral Health appointing?
  • Do you have a secure (i.e., password-protected) Internet connection?
  • Do you have either a webcam with a microphone on your computer or front-facing camera on your tablet/smartphone?
  • Are you comfortable, able and willing to download a Tele-Behavioral Health application and/or other Tele-Behavioral Health information to your device?
  • Do you have a room or location in your home that will allow you privacy for your Tele-Behavioral Health session?
    • If Veteran does not have a private location, they are then asked: Are you interested in a point-to-point location?
      • A point-to-point location would involve the Veteran commuting to an originating site (usually a small clinic or health center) and attending a telehealth session there via high speed network with a distance telehealth provider.

Q: What is required for Tele-Behavioral Health claim submission?

Providers can bill using the Medicare telemedicine methodology and guidance. There are no differences for the provision of services or how to bill them when behavioral health care is being delivered.

Q: Which POS code should be used?

There is no difference in behavioral health billing of telehealth care. To receive reimbursement for telehealth services offered between facilities, known as Point-to-Point services, a code of Q3014 should also be submitted. If offering telehealth services into the home, do not bill the Q3014 code.

Q: Can I sign up to deliver telehealth services to Veterans?

Yes, if you have the necessary capabilities required to deliver tele-behavioral health services to Veterans, please send an email indicating your interest to telehealth@triwest.com.

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Urgent Care

Q: Does VA cover telehealth Urgent Care visits?

Yes, VA and TriWest reimburse urgent care services if they are delivered via telehealth by a network Urgent Care provider.

Q: Are there any special steps associated with the telehealth urgent care process?

No. Tele-Urgent Care providers are subject to the same requirements for a face-to-face urgent care appointment. An eligibility check is required in either circumstance to verify Veteran eligibility and to activate the eligibility to fill a prescription that results from the Urgent Care visit in a community network pharmacy. For further details regarding the urgent care process, please see here.

Q: How do I submit a claim for a telehealth urgent care appointment?

There are no differences from billing other telehealth care. Follow Medicare guidance for the appropriate POS for an Urgent Care location and use modifier -95 if delivered into the Veteran’s home.

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Points of Contact for Additional Telehealth Questions

  • General Telehealth Questions
  • Tele-Behavioral Health Questions
  • Claims and Billing Questions
    • Phone: 866-651-4977
  • Customer Service (Claims, Authorization Questions/Support, Provider Portal Registration)
    • Phone: 855-722-2838

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Updated: 7/1/2020 3:54:07 PM