DMHC issues new guidance on billing for telehealth services

April 08, 2020
Area(s) of Interest: Payor Issues and Reimbursement 

On March 18, 2020, the Department of Managed Health Care (DMHC) announced health plans would be immediately required to reimburse providers for telehealth services, including telephonic visits, at the same rate as those provided in-person, when medically appropriate. In essence, if the service is one that would otherwise have been provided in-person but is now being provided via telehealth the plans should reimburse as though it was provided in-person.

On April 7, 2020, DMHC issued a follow-up All Plan Letter (APL) and an FAQ that provides specific guidance on billing for telehealth services. According to the new APL (20-013), practices should document telehealth visits as if they had occurred in person, select the most appropriate CPT code, bill with place of service 02 to indicate it was provided via telehealth, and use modifier 95 for synchronous telemedicine or GQ for asynchronous telemedicine.

The April 7 APL and FAQ also clarify the following:

  • Health plans may not exclude coverage for certain types of services or categories of services simply because the services are rendered via telehealth, if the provider, in his/her professional judgment, determines the services can be effectively delivered via telehealth.
  • Plans are prohibited from placing limits on covered services simply because the services are provided via telehealth, if such limits would not apply if the services were provided in-person.
  • During the COVID-19 emergency, plans cannot require enrollees of DMHC regulated plans to use the plan’s third-party telehealth vendor.
  • Plans cannot require the provider to be approved/credentialed specifically for telehealth if the plan would have otherwise covered the services if provided in person. However, this does not authorize out-of-network telehealth services.  
  • Plans are prohibited from requiring providers to use particular platforms or modalities of telehealth as a condition of reimbursement.

For more information about providing telehealth services during the COVID-19 emergency, see CMA’s Telehealth Overview. This document will be updated regularly as new information becomes available.


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