Nebraska Medicaid Program
Coverage & Reimbursement for Telehealth
Definitions and Background
Billing and Reimbursement
- What is telehealth?
Telehealth is an electronic real time synchronous audio-visual contact between a patient and health care practitioner relating to the health care diagnosis or treatment of the patient. The patient is in one location with specialized equipment including a video camera and monitor and the health care practitioner is at another location with specialized equipment. The practitioner and patient interact as if they were having a face-to-face service. (See 471 NAC 1-006.01 and 471 NAC 1-006.02)
- Where are the regulations for the Nebraska Medical Assistance Program's coverage of telehealth?
The regulations for coverage criteria and reimbursement of Medicaid telehealth services are in the Nebraska Administrative Code at 471 NAC 1-006. These regulations can be accessed at www.dhhs.ne.gov/reg/t471.htm. Click on Chapter 1 and scroll down to Section 1-006. This 13-page telehealth section explains the specific requirements related to Medicaid telehealth. Each service covered as a Medicaid telehealth service must otherwise be coverable as a face-to-face service, and all other Medicaid regulations and policies in addition to 471 NAC 1-006 apply to telehealth services.
- Why did Nebraska add telehealth to the Nebraska Medical Assistance Program regulations?
During the 1999 Legislative Session, the Nebraska Unicameral passed legislation implementing the Nebraska Telehealth Act (Neb. Rev. Stat. Sections 71-8501 to 71-8508 [LB 559, Laws 1999]). The intent of the law is to improve access to health care services for those in medically underserved areas of Nebraska. The Act directs the Department to reimburse for telehealth services and transmission charges provided to Medicaid eligible patients effective for dates of service beginning July 1, 2000.
- What is a telehealth service?
For Medicaid payment purposes the service must be a service covered by Medicaid. No new services have been added due to telehealth coverage. A telehealth service is a contact between a patient and a health care practitioner relating to the health care diagnosis or treatment of such patient through telehealth but does not include a telephone conversation, electronic mail message, or facsimile transmission between a health care practitioner and a patient or a consultation between two health care practitioners. (See 471 NAC 1-006.02)
- What is a telehealth site?
This is either a health care facility enrolled with Medicaid and licensed under the Health Care Facility Licensure Act OR a health care practitioner facility whose practitioners are enrolled with Medicaid and credentialed under the Uniform Licensing Law.
- The originating site is considered to be the location of the Medicaid client at the time the service is furnished via telehealth.
- The distant site is considered to be the site where the health care practitioner, providing the professional service, is located at the time the service is provided via telehealth.
- Where can I learn more about the equipment used to provide services via telehealth?
The regulations describe the specific Medicaid technical requirements (See 471 NAC 1-006.04C Telecommunications Technology). For information about equipment, see the numerous web sites devoted to this technology. Other sites of interest include http://telehealth.hrsa.gov, or w ww.americantelemed.org or www.nitc.state.ne.us.
- Who in Nebraska can be contacted about telehealth technical issues ?
The following people have been helpful in the area of telehealth and telecommunication technologies in Nebraska:
Dennis Berens, DHHS Services, Office of Rural Health (402-471-0142; firstname.lastname@example.org) for general information about telehealth across Nebraska;
Dave Glover, consultant to the Nebraska Hospital Association (308-234-6051 or 308-627-2473; email@example.com) for information about the Nebraska Statewide Telehealth Network (also known as the "Nebraska telehealth backbone");
Dave Lawton , DHHS (402-471-0507; firstname.lastname@example.org) about the Health and Human Services telecommunication system; and
Max Thacker, UNMC ITS-Video Services (402-559-7438; email@example.com;) for information about telehealth at the University of Nebraska Medical Center.
- What means of transmitting a service are excluded from coverage?
The Nebraska Telehealth Act specifically excludes the reimbursement of transmission services provided via email, telephone, or facsimile transmission.
- Is a videophone telehealth covered by Medicaid?
No, services cannot be reimbursed and a transmission charge cannot be paid when the service is provided via a videophone. (See 471 NAC 1-006.05F) This includes all transmissions that do not meet the H.320 or H.323 audiovideo standards for real time, two-way interactive audiovisual transmission and that are less than the minimum signal of 384 kbps (kilobits per second) over a dedicated line, an Intranet, or other controlled environment. (See 471 NAC 1-006.01 and 471 NAC 1-006.05).
- Can any Medicaid enrolled provider do a service via telehealth?
No, some services are excluded, and thus some providers cannot be paid for a telehealth service. See 471 NAC 1-006.05 for non-covered telehealth services. Providers must be specifically enrolled as a telehealth site with Medicaid to bill for a telehealth service.
- How do I enroll to become a Medicaid-approved telehealth site?
Each telehealth site must enroll with Medicaid – both the originating and the distance site. Each telehealth site a) must meet the definition in regulations, b) must be an enrolled Medicaid provider, and c) must be specifically approved as a telehealth site by submitting a letter containing the items below before billing Medicaid for telehealth services. The telehealth site must be operational before enrolling as a Medicaid telehealth site. Medicaid enrollment is done by sending two copies of a letter that assure the requirements of 471 NAC 1-006.10C are meet . (Draft letters prior to final submission are encouraged.) These requirements are:
- Certifying written quality of care protocols are operational at the sites where telehealth services are provided; ( A telehealth site may enroll with Medicaid even if no practitioners use the site, but the site is open for Medicaid clients to see practitioners at a distant site.);
- Certifying written patient confidentiality protocols are operational at the sites where telehealth services are provided (Protocols do not need to be submitted but should be readily available upon request, such as during a site visit.);
- Listing the facility provider number (facility or group practice number used to bill the transmission costs from that site ), the names of all health care practitioners providing telehealth services and their Medicaid provider identification numbers, (Each telehealth site must notify Medicaid of each practitioner authorized by the site to use its telehealth facilities. NOTE: Some facilities may need to credential practitioners who use their telehealth equipment or who see a patient from a distant site; for example, consult JACHO requirements for hospital to hospital transmissions.) and the services provided(for example -- consultative services, speech therapy services, mental health services, etc.; all services must otherwise be covered by Medicaid. );
- Naming an authorized contact person with his/her phone number; (In addition, an email address for each telehealth contact facilitates communication. At least one contact person should have a working knowledge of Medicaid billing and coding and should be familiar with provider enrollment issues.);
- Documenting that the telehealth technologies meet the standards in 471 NAC 1-006.04C, (NOTE: If teleradiology services are also billed, please certify that the equipment meets the requirements in this section as well.)and
- Attaching a sample copy of the provider’s informed consent form (see 471 NAC 1-006.10A). (Informed consent is a requirement for Medicaid telehealth. Medicaid recommends use of the Medicaid sample consent form with the telehealth site’s logo at the top; this sample form can be mailed or faxed upon request.)
- How do I get on the Medicaid enrolled list of health care practitioners at an approved telehealth site?
You must contact the telehealth contact person at the telehealth site and request that your name, Medicaid provider identification number, and service be submitted to Nebraska Medicaid. The telehealth site must then forward this information to Medicaid in the form of a letter, amending the initial telehealth site enrollment letter.
- Is a separate provider number required for the location of the telehealth site?
No. Except for dentists, a separate provider number is not required for providing services via telehealth. Dental providers may call Diane Schnase, at (402) 471-9188 or email at firstname.lastname@example.org for further information about obtaining a Medicaid telehealth provider number.
- Can out-of-state practitioners provide services via telehealth to clients in Nebraska ?
Yes, out-of-state practitioners may provide services to clients in Nebraska if they comply with Nebraska statutes and regulations. These include licensure, registration, or certification through the Nebraska Department of Health and Human Services - Regulation and Licensure, enrollment with Nebraska Medicaid, and acting within the appropriate scope of practice. State statute specifies that medicine occurs at the client's physical location so the professional physically located out-of-state must maintain a Nebraska license, registration, or certification. Exceptions to these requirements are allowed when conditions in 471 NAC 1-006.10D are met. (See 471 NAC 1-006.03 and 471 NAC 1-006.10D)
- Can out-of-state practitioners provide services via telehealth to Nebraska Medicaid clients when the client is out of Nebraska?
Yes, out-of-state practitioners may provide services to clients receiving treatment outside of Nebraska; all Nebraska Medicaid program policies and procedures must be followed. These include licensure, registration, or certification through the appropriate agency in the state where the service is occurring, enrollment with Nebraska Medicaid, and acting within the appropriate scope of practice. In addition, the service must meet one of the four requirements listed in 471 NAC 1-006.10D. All prior authorization requirements for out-of-state services must be met. (See 471 NAC 1-006.03, 471 NAC 1-006.10D, 471 NAC 1-002.02G, 471 NAC 1-002.02G1, and 471 NAC 1-002.02G2)
- How does telehealth work for Medicaid billing purposes?
(1) The providers of the service and the telehealth site must be enrolled with Medicaid and approved as Nebraska Medicaid telehealth providers; (2) the providers of the covered service must be listed with and approved by the telehealth site; (3) the service must be a covered Medicaid service; and (4) the patient must be eligible for Medicaid on the date of service. Providers of telehealth services should bill for services provided via telehealth according to the same Medicaid requirements for the service as when provided in-person (i.e. coverage, prior authorization). If a service is not covered by Medicaid as a face-to-face service, it is not covered when provided via telehealth. (See 471 NAC 1-006.05A)
- Do I bill differently when I provide a service via telehealth?
Yes, as outlined below:
CMS-1500: When billing for services provided via telehealth on the CMS-1500 or the standard electronic Health Care Claim: Professional transaction (ASC X12N 837), use the standard CPT/HCPCS procedure code for the service with procedure code modifier ‘GT’ to indicate the service was provided via telehealth technologies. The actual transmission cost is billed on a separate line using the specific transmission procedure code T1014 and the units of service are the minutes spent providing the service via telehealth.
CMS-1450: When billing on the CMS-1450 or the standard electronic Health Care Claim: Institutional transaction (ASC X12N 837), the outpatient hospital or home health service is billed on one line using the standard CPT/HCPCS procedure code for the service with procedure code modifier ‘GT’ to indicate telehealth. Use the appropriate revenue code and unit of service for the service. The actual transmission is billed on a separate line using revenue code 78X and the specific transmission procedure code of T1014; the number of units for the transmission (T1014) is the number of minutes spent providing the service via telehealth.
: When billing on the CMS-1450 or the standard electronic Health Care Claim: Institutional transaction (ASC X12N 837), the outpatient hospital or home health service is billed on one line using the standard CPT/HCPCS procedure code for the service with procedure code modifier ‘GT’ to indicate telehealth. Use the appropriate revenue code and unit of service for the service. The actual transmission is billed on a separate line using revenue code 78X and the specific transmission procedure code of T1014; the number of units for the transmission (T1014) is the number of minutes spent providing the service via telehealth.
NOTE: Q2014 Medicare Facility Fee : Medicaid does not cover the Medicare facility fee code Q3014; these costs are covered per 471 NAC 1-006 regulations and are not separately billable to Medicaid. Claims for Medicare/Medicaid dual eligible clients should be billed first to Medicare; Medicaid automatically pays coinsurance and deductibles on crossover claims.
1999 Version 2000 ADA (Dental form): (NOTE: If a dentist chooses to perform services via telehealth, the provider will need to enroll with a new telehealth-specific provider number per 13 above). When billing dental telehealth services use only the 1999 version 2000 ADA Dental Claim Form (only the 1999 version has units of service) or the standard electronic Health Care Claim: Dental transaction (ASC x 12N 837). Use the ADA CDT procedure code for the dental service. The actual transmission cost is billed on a separate line using the specific transmission procedure code T1014; enter the number of minutes of transmission as the quantity.
(NOTE: If a dentist chooses to perform services via telehealth, the provider will need to enroll with a new telehealth-specific provider number per 13 above). When billing dental telehealth services use only the 1999 version 2000 ADA Dental Claim Form (only the 1999 version has units of service) or the standard electronic Health Care Claim: Dental transaction (ASC x 12N 837). Use the ADA CDT procedure code for the dental service. The actual transmission cost is billed on a separate line using the specific transmission procedure code T1014; enter the number of minutes of transmission as the quantity.
- What does Medicaid pay for?
A service must otherwise be covered under Medicaid and may be reimbursed at either the originating or distance site or both. However, some services are excluded or limited (please see 471 NAC 1-006.05B and 471 NAC 1-006.05C through 1-006.05J.) Payment for telehealth services is set at the Medicaid rate for the comparable face-to-face service and constitutes the total payment for the service, other than the allowable transmission cost. The transmission fee for a covered services is reimbursed with exceptions as found in 471 NAC 1-006.09.
- Is there a distance requirement for coverage of telehealth?
Services will not be reimbursed when the client has access to a comparable service within 30 miles of his or her place of residence. This requirement does not apply in emergency or hardship situations or when a nursing facility resident would require ambulance transportation to a non-emergency medical service. (See 471 NAC 1-006.05E)
- Are there any special requirements when a service is provided via telehealth?
Yes, these requirements include:
- the client must give informed consent specific to telehealth (see example of a telehealth consent form in appendix 471-000-10 and see regulations at 471 NAC 1-006.10A),
- support must be available at the client site (see 471 NAC 1-006.10B),
- each telehealth site must comply with specific quality assurance requirements (see 471 NAC 1-006.10C), AND
- the clinical record must document how services were provided (see 471 NAC 1006.10 F).
- Can any covered service be reimbursed when provided via telehealth?
No, certain services must be provided face to face. Please review the specific exclusions listed in regulation at 471 NAC 1-006.05. Exclusions include:
- Mandatory periodic physician visits for nursing facility clients,
- Rural Health Clinic, Federally Qualified Health Center, and Tribal 638 Clinic encounter services (see 471 NAC 1-006.07 through 1-006.09),
- Durable medical equipment,
- Services requiring the hands-on involvement of the provider (i.e., surgery, eyeglass fittings, and Community Treatment Aide services).
- Will Medicaid reimburse for prescriptions over the Internet?
No. Neither the cost of the prescription or the practitioner services may be covered. (See 471 NAC 1006.05H)
- What is the reimbursement rate for a service provided via telehealth?
Telehealth services are paid at the same rate as a face-to-face service and include the total component for the service (see 471 NAC 1-006.11A). The Practitioner Fee Schedules can be found at http://dhhs.ne.gov/medicaid/Pages/med_practitioner_fee_schedule.aspx.
- What is the reimbursement rate for a telehealth transmission?
The telehealth transmission is reimbursed at eight cents per minute. This rate is based on the highest Universal Services Fund subsidized monthly rate and the expected usage availability. (see 471 NAC 1-006.11B)
- What is the minimum number of minutes that can be billed for a telehealth transmission?
Transmission costs are not covered when transmission time is negligible. The minimum amount of time that can be billed for transmission time is five minutes. (see 471 NAC 1-006.06B)
- Can a transmission charge be billed when the physician is not in attendance, but the office staff provides a service to the client?
If the service would be reimbursed when provided face to face, it can be reimbursed when provided via telehealth (an example would be a low level E & M visit), and a transmission charge can also be billed.
- Can a hospital bill a room charge when the client is in an outpatient room for a telehealth service?
No. If a client is seen only for telehealth transmission services and no billable diagnosis or treatment service occurs in the hospital outpatient setting, the hospital can only bill for the telehealth transmission. Telehealth "facility costs" (e.g., room, staff, equipment) are included in the cost reports.
- Will Nebraska Medicaid reimburse for mileage to transport a client to a telehealth site?
Yes, transportation services may be paid if the client is eligible for transportation to medical appointments AND if the transportation would be reimbursed if the service were provided face-to-face.
- What if the client has private insurance?
Medicaid is the payer of last resort; therefore, the provider must bill the private insurance first. If the service is denied by private insurance, Medicaid will review the denial and claim information to determine if the service and transmission costs are payable. (see 471 NAC 1-006.10E2)
- What if the client has Medicare?
All Medicare covered services must be billed to Medicare first. Medicaid pays only co-insurance and deductibles for Medicare covered services, including the Q3014 service. (Please see #17 above regarding non-coverage of Q3014 for Medicaid clients with no Medicare coverage.)
- Who do I contact regarding telehealth Medicaid enrollment and coverage?
Regarding Medicaid telehealth site enrollment and questions, you may contact Diane Schnase at (402) 471-9188 or email@example.com.