We updated this notice to include information on Intensive Outpatient Program (IOP) telehealth coverage.
In response to the COVID-19 pandemic, Blue Cross and Blue Shield of Texas (BCBSTX) expanded access to telehealth services to give our members greater access to care. The experience confirmed the importance of telehealth in health care delivery. Members can access their medically necessary, covered benefits through providers who deliver services through telehealth. Many of our members also have access to various telehealth vendors, such as MDLIVE.
Coverage is based on the terms of the member’s benefit plan and applicable law. As of Jan. 1, 2021, for our state regulated fully insured HMO and PPO members and our self-funded employer group members, we cover telehealth codes consistent with the permanent code lists from:
By, permanent, we mean those codes that are not temporarily available for the duration of the public health emergency (PHE) or the year of the PHE.
CMS and AMA periodically update their lists. We will follow their updates.
Intensive Outpatient Program (IOP) - IOP services are not included on the CMS telemedicine code list because they are not a covered benefit for Medicare recipients. However, IOP services can be appropriately delivered by telemedicine. Therefore, we will cover IOP services delivered by telemedicine.
We will not cover the following codes:
- Codes that are not on the telemedicine code list provided by CMS or the AMA except for IOP services and those required by state statute
- CMS codes that are temporary for the PHE
- CMS Codes that are active for the year of the PHE only
- AMA codes listed as Private Payer
Our self-funded employer group customers make decisions for their employee benefit plans. Check eligibility and benefits for any variations in member benefit plans.
We recommend the following:
- Consider telehealth a mode of care delivery to be used when it can reasonably provide equivalent outcomes as face-to-face visits.
- Choose telehealth when it enhances the continuity of care and care integration if you have an established patient-provider relationship with members.
- Integrate telehealth records into electronic medical record systems to enhance continuity of care, maintain robust clinical documentation and improve patient outcomes.
Providers can use telehealth for members with the following types of benefit plans. Care must be consistent with the terms of the member’s benefit plan.
- State-regulated fully insured HMO and PPO plans
- Blue Cross Medicare Advantage (excluding Part D) and Medicare Supplement (see Medicare info below)
- Self-funded employer group plans
We will continue to follow applicable state and federal requirements.
The provider submitting the claim is responsible for accurately coding the service performed. Submit claims for medically necessary services delivered via telehealth with the appropriate modifiers (95, GT, GQ, G0) and Place of Service (POS) 02. If a claim is submitted using a telehealth code, no modifiers are necessary. Only codes that are not traditional telehealth codes require a modifier.
- 95 – synchronous telemedicine (two-way live audio visual)
- GT – interactive audio and video telecommunications
- GQ – asynchronous telecommunications system
- G0 – telehealth services for diagnosis, evaluation or treatment of symptoms of an acute stroke; G0 must be billed with one of the approved telemedicine modifier (GT, GQ or 95)
Member cost share
As of Jan. 1, 2021, copays, deductibles and coinsurance apply to telehealth visits for most members. The cost share varies according to the member’s benefit plans. Check eligibility and benefits for each member for details.
Our self-funded employer group customers make decisions for their employee benefit plans and may choose to waive telemedicine cost share. Check eligibility and benefits for any variations in member benefit plans.
What’s covered for Medicare Advantage and Medicare Supplement members
CMS identifies covered services for Medicare members. This means we will cover all the CMS telemedicine codes , including those available only during the PHE for Medicare Advantage and Medicare Supplement members.
For the duration of the PHE, we are waiving cost share for our Medicare Advantage members. This means these members will not owe any copays, deductibles or coinsurance for telehealth visits. The cost share waiver does not apply to Medicare Supplement members.
We will follow the applicable guidelines of the Texas Department of State and Health Services for Medicaid STAR, CHIP and STAR Kids members.
Referrals and prior authorizations
Some telehealth care will require referrals and prior authorizations in accordance with the member’s benefit plan. Check eligibility and benefits for each member for details.
Available telehealth visits with BCBSTX providers include:
- 2-way, live interactive telephone communication (audio only) and digital video consultations
- Asynchronous telecommunication via image and video not provided in real-time (a service is recorded as video or captured as an image; the provider evaluates it later)
- Other methods allowed by state and federal laws, which can allow members to connect with physicians while reducing the risk of exposure to contagious viruses or further illness
Delivery methods for Medicare members
- Providers should use an interactive audio and video telecommunications system that permits real-time interactive communication to conduct telehealth services. CMS permits audio only in limited circumstances. See the CMS website for designated audio-only codes.
Providers can find the latest guidance on acceptable Health Insurance Portability and Accountability Act (HIPAA) compliant remote technologies issued by the U.S. Department of Health and Human Services’ Office for Civil Rights in Action.
For state-regulated fully insured members, providers are not required to use a vendor for telehealth services. For self-funded members, providers may be required to use specific vendors as outlined in the member’s benefit plan.
Currently, covered telehealth claims for eligible members for in-network medically necessary health care services will be reimbursed at the same rate as in-person office visits for the same service. We will continue to evaluate reimbursement. Submit claims with appropriate codes and modifiers. For claims using a specific telehealth code, the applicable telehealth reimbursement will apply.
Member benefit and eligibility assistance
Check eligibility and benefits for each member at every visit prior to rendering services. Providers may:
- Check general coverage by submitting an electronic 270 transaction through Availity® or your preferred vendor.
- Connect with a Customer Advocate to check eligibility and telehealth benefits by calling our Provider Customer Service Center at 1-800-451-0287.
- For Medicare Advantage members, call Blue Cross Medicare Advantage Network Management at 1-972-766-7100.
Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association