Updated telehealth services policy

This provider bulletin is an update to the Department of Health Care Services All Plan Letter 23-007 regarding the Departments policies on covered services offered through telehealth modalities. The Department has since updated its Medi-Cal Managed Care (Medi-Cal) telehealth policies, which are reflected through the Department’s Telehealth Policy Paper, Senate Bill No. 184, Assembly Bill No. 32, and in the DHCS Telehealth Provider Manual. Key updates to the Medi-Cal managed telehealth policies are reflected below.

Regarding provider requirements

A healthcare provider rendering Medi-Cal covered benefits and services via telehealth must be:

• Licensed in California or otherwise authorized by section 2290.5(a)(3).
• Enrolled as a Medi-Cal rendering provider or non-physician medical practitioner.
• Affiliated with an enrolled Medi-Cal provider group.

Regarding reimbursable services

Existing covered services, identified by Current Procedural Terminology ^® – 4th Revision (CPT-4) or Healthcare Common Procedure Coding System (HCPCS) codes may be provided through a telehealth modality only if all of the following criteria are satisfied:

• The treating provider at the distant site believes the covered services being provided are clinically appropriate to be delivered through Telehealth based upon evidence-based medicine and/or best clinical judgment.
• The member has provided verbal or written consent. 
• The medical record documentation proves that the covered services delivered through telehealth meet the procedural definition and components of the CPT-4 or HCPCS code(s) associated with the covered service. Providers are not required to: 
  • Document a barrier to an in-person visit for Covered Services provided via telehealth. 
  • Document the cost effectiveness of telehealth to be reimbursed for covered services provided via a telehealth modality.
• The covered services provided via telehealth meet all state and federal laws regarding confidentiality of healthcare information and a member’s right to their own medical information.

Regarding telehealth modifiers 

Providers must designate telehealth modality with an appropriate modifier when billing for telehealth services. For benefits and services provided through synchronous audio-only telecommunications systems (for example, telephone), the provider bills with modifier 93; for synchronous video, modifier 95; and for asynchronous store and forward (including e-consults), modifier GQ).

Establishing new patients through telehealth

A healthcare provider may establish a relationship with a new patient through video visits. A healthcare provider may not establish a relationship with a new patient via audio-only visit, except for in certain circumstances (for example, when the visit is related to sensitive services as defined in subsection (n) of Section 56.06 of the Civil Code, or when the patient requests an audio-only modality or attests they do not have access to video). FQHCs, including Tribal FQHCs, and RHCs may establish new patient relationships through an asynchronous store and forward modality if the visit meets all of the following conditions:

• The member is physically present at a provider’s site, or at an intermittent site of the provider, at the time the covered service is performed.
• The individual who creates the patient’s medical records at the originating site is an employee or subcontractor of the provider, or other person lawfully authorized by the provider to create a patient medical record.
• The provider determines that the billing provider is able to meet the applicable standard of care.
• A member who receives covered services through telehealth must otherwise be eligible to receive in-person services from that provider.

Regarding patient consent

In addition to documenting consent prior to initial delivery of covered services via telehealth, providers are also required to explain the following to members:

• The member’s right to access covered services delivered through telehealth in-person. 
• That use of telehealth is voluntary and that consent for the use of telehealth can be withdrawn at any time by the member without affecting their ability to access Medi-Cal covered services in the future. 
• The availability of non-medical transportation to in-person visits.
• The potential limitations or risks related to receiving covered services through telehealth as compared to an in-person visit, if applicable.