Utah Reimbursement Strategies
Who pays for telemedicine in Utah and billing considerations?
Reimbursement policies are not consistent and comprehensive from State to State. There is a lack of an overall telemedicine reimbursement policy in the current United States health care system. Individual contracts for telemedicine services are commonly signed, which outline direct reimbursement to providers. The National Conference of State Legislatures tracks telemedicine reimbursement in the States.
Claims for reimbursement in Utah should be submitted with the appropriate CPT code or HCPCS code for the professional services provided and the Telehealth modifier “GT” for interactive audio & video telecommunications system. The Utah Health Information Network provides standards for processing claims in Utah (pdf).
- Third Party Payers in Utah
UTN invites payers to send information Payers on their telehealth reimbursement policies to be posted on this webpage. Please send information to firstname.lastname@example.org It is best to communicate with the insurer to verify telehealth coverage and to request pre-authorization
- UT Medicaid
The Division of Medicaid and Health Financing published their Telemedicine Policy effective January 1, 2015. This policy states that Medicaid providers may be reimbursed for physician and nurse practitioner services delivered via telemedicine to Medicaid members. No additional reimbursement will be given to the provider at the originating site for the use of telemedicine. Additional information for this policy can be found in the Utah Medicaid Provider Manual, at Utah Medicaid Provider Manual (pdf) in section 8-4.2 Telemedicine, page 47.
- CMS Medicare Telehealth
CMS Medicare reimbursement is limited to the type of services provided, geographic location of the patient, type of institution where the services are being delivered (originating site), technology used and the type of health provider. There is no limitation on the location of the physician or practitioner delivering the medical service. For additional information please refer to the CMS Medicare Telehealth Services Rural Health Fact Sheet (2016) (pdf)
The Center for Connected Health Policy published a summary of the 2017 additions to the CMS - CY 2017 Final Fee Schedule, "On November 2, 2016, the Center for Medicare and Medicaid Services (CMS) published their finalized CY 2017 Physicians Fee Schedule (PFS). The final rule includes the addition of several codes for reimbursement regarding end-stage renal disease related services for dialysis; advance care planning; and critical care consultations furnished via telehealth using new Medicare G-codes. CMS has also a new policy related to the use of a place of service (POS) code specifically designated to report services furnished via telehealth, and added new chronic care management (CCM) codes."
The payment amount for the professional service provided via a telecommunications system by the physician or practitioner at the distant site is equal to the current fee schedule amount for the service provided. Find out if an authorized originating site (patient location) is eligible for Medicare telehealth payment by using the Medicare Telehealth Payment Eligibility Analyzer.
- UHIN Standard (pdf)
The purpose of UHIN Standard #26 4010 Telehealth is to provide a uniform standard of billing for health care claims/encounter delivered via telehealth. Two types of telehealth technology have been identified to deliver health care:
Teleconsultation – is real time interactive audio and video conferencing delivered via a telecommunications system. This is a method to provide service to a patient at one location with the consulting provider at a separate location. A presenting provider may or may not be involved in the service.
Store and forward telehealth – is the electronic transmission of data and digitized images. The exchange of data and digitized images (i.e. teleradiology), and is done between the referring provider and consulting provider.
The resources presented on this website, and on the webpages accessible through the links on this page, are provided for informational purposes only. This information is not intended to be comprehensive and the manner in which it applies to your organization will be unique. You should seek expert advice to ensure that you are taking into account all relevant considerations. The UETN does not provide legal advice. If the resources that you find here do not answer your questions to your satisfaction, you should consult a lawyer or other qualified expert.