Telehealth Services

Overview

There are three main types of virtual services: telehealth visits, e-visits, and virtual check ins.

Telehealth Visits

Telehealth is the delivery of health care services or consultations through the use of a real time, two-way interactive audio and visual communications system that permits communication between the distant site and the member’s location. Telehealth provides or supports health care delivery and facilitates the assessment, diagnosis, consultation, treatment education, and care management of a member’s health care while they are at an originating site and the licensed health care provider is at a distant site. Providers providing health care services by telehealth are held to the same standards as providers of in-person health care services. Distant site providers who can furnish and get payment for covered telehealth services (subject to State law) can include physicians, nurse practitioners, physician assistants, nurse midwives, certified nurse anesthetists, clinical psychologists, clinical social workers, registered dietitians, home care providers, and nutrition professionals.

Telehealth includes the following:

• Secure video conferencing
• Store-and-forward technology
• Audio-only communication between the health care provider and the member (until July 1, 2027)

Store-and-forward technology

Store-and-forward technology is the asynchronous electronic transfer or transmission of a member’s medical information or data from an originating site to a distant site for purposes of diagnostic and therapeutic assistance. Medical information may include, but is not limited to, video clips, still images, X-rays, MRIs, EKGs, laboratory results, audio clips, and text. The provider at the distant site reviews the case without the member present. Store-and-forward substitutes for an interactive encounter with the member present; the member is not present in real time.

Audio only

Audio only is the delivery of health care services or consultations through telephone communication while the member is at one site and the qualified health care provider is at a distant site.

Distant site: Site at which the health care provider is located while providing health care services or consultations by means of telehealth, which can include the provider’s home.

Originating site: The site at which the member is located at the time health care services are provided to them by means of telehealth, which can include the member’s home. For purposes of store-and-forward technology, the originating site also means the location at which the health care provider transfers or transmits information to the distant site.

E-Visits

An e-visit is a non-face-to-face digital communication between an established patient and a provider through an online portal that requires a clinical decision that would otherwise typically have been provided in an office or outpatient clinic setting. The service is provided in lieu of in-person clinic visits, video-conference visits, and telephonic visits between a member and their established provider for basic health care services.

PrimeWest Health follows Minnesota Department of Human Services (DHS) and Centers for Medicare & Medicaid Services (CMS) guidelines during a Public Health Emergency.

Virtual Check-Ins

A brief (5 – 10 minute) check-in with a provider via telephone or other communications device to decide whether an office visit or other service is needed; a remote evaluation of recorded video and/or images submitted by an established patient.

Telehealth Services

Telehealth visits (which may include e-visits) are intended to discuss, diagnose, and treat conditions in which the provider is comfortable not seeing the member face-to-face, and which do not require immediate use of laboratory tests or radiology. The conditions include but are not limited to the following: 

• Skin conditions: rash, diaper rash, eczema, impetigo, contact dermatitis, rosacea, cold sores, shingles, jock itch, ringworm, shingles, sunburn, acne, athlete’s foot, skin infections, head lice, insect bites, tick bites, ingrown toenail, unknown skin conditions
• Ear, nose, and throat conditions: colds, ear pain, swimmer’s ear, pink eye, eyelid infections (stye), sinus infection, canker sores, allergies, hay fever, influenza
• Minor injuries and burns: abrasions, minor lacerations, minor burns, sprains, strains, contusions
• Chest conditions: cough
• Abdominal and pelvic problems: heartburn or acid reflux, diarrhea, constipation, irritable bowel syndrome, stomach pain, bloating, urinary tract infection, vaginal discharge
• Pain: low back pain, headaches
• COVID-19/coronavirus concerns
• Medication refills (for current patients)
• EpiPen, erectile dysfunction, mild or exercise-Induced asthma, birth control pills
• Medications to prevent an illness or infection: influenza (flu) prevention, pertussis (whooping cough) exposure, cold sore prevention
• Sexual health: sexually-transmitted infections
• Tobacco cessation: medication and nicotine replacement options
• Travel medication: malaria prevention, motion sickness prevention
• Women’s health: emergency contraception (morning-after pill), initiation of birth control pills, vaginal yeast infection

The range of services from this list available through e-visits is determined by the provider and may vary from provider to provider.

States have broad flexibility to cover telehealth through Medicaid, including the methods of communication (e.g., telephonic, e-visits, and video technology commonly available on smart phones and other devices) to use. No Federal approval is needed for State Medicaid programs to reimburse providers for telehealth services in the same manner or at the same rate that states pay for face-to-face services.

Expanded Medicare telehealth coverage was announced March 17, 2020, effective retroactively to March 6, 2020. In accordance with the 1135 waiver, members can remain at home and receive a telehealth visit from their provider. Providers may also provide services from their homes, but must use place of service code 02 for distant site when billing for claims reimbursement.

CMS recently released a video with answers to common questions about the Medicare telehealth services benefit. CMS is expanding this benefit on a temporary and emergency basis under the 1135 waiver authority and Coronavirus Preparedness and Response Supplemental Appropriations Act.

The United States Department of Health & Human Services (HHS) Office for Civil Rights (OCR) is responsible for enforcing certain regulations issued under the Health Insurance Portability and Accountability Act (HIPAA), as amended by the Health Information Technology for Economic and Clinical Health Act (HITECH). During the COVID-19 national emergency, providers may communicate with members through alternative, non-HIPAA-compliant communication technologies. The OCR will exercise its enforcement discretion and will not impose penalties for noncompliance with HIPAA during the COVID-19 nationwide public health emergency.

For a list of acceptable telehealth communication technologies, refer to the HHS Notification of Enforcement Discretion for Telehealth Remote Communications during the COVID-19 Nationwide Public Health Emergency web page.

Equipment

Specific telecommunications equipment is not required as a condition of coverage provided the health care provider uses equipment that complies with current industry interoperable standards and with the standards required under HIPAA Public Law 104-191. A health care provider may not require a member to pay for a specific communication technology or application.

Eligible Providers

Providers must self-attest that they meet all of the conditions of the PrimeWest Health telehealth policy.

PrimeWest Health covers medically necessary services and consultations delivered by a health care provider through telehealth. A health care provider means a health care professional who is licensed or registered by the State to perform health care services within the provider’s scope of practice according to State law.

Eligible Members

All PrimeWest Health members are eligible for medically necessary services delivered through telehealth.

Covered Services

PrimeWest Health covers telehealth services in the same manner as any other benefits covered through PrimeWest Health programs. Coverage is not limited on the basis of geography or location. Out-of-state coverage policy applies to services provided via telehealth.

List of telehealth services

The Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes that describe a telehealth service are generally the same codes that describe an encounter when the health care provider and patient are at the same site. Examples of covered telehealth services include, but are not limited to, the following:

• Consultations
• Telehealth consults (emergency department or initial inpatient care)
• Subsequent hospital care services
• Subsequent nursing facility care services
• End-stage renal disease services
• Individual and group medical nutrition therapy
• Individual and group diabetes self-management training with a minimum of one hour of in-person instruction to be furnished in the initial year training period to ensure effective injection training
• Smoking cessation
• Alcohol and substance abuse (other than tobacco) structured assessment and intervention services

Audio only (until July 1, 2027)

Audio-only communication will be covered if:

• There is a scheduled appointment and the standard of care for that particular service can be met through the use of audio-only communication.
• Substance use disorder (SUD) treatment services and mental health services delivered without a scheduled appointment when initiated by the member while in an emergency or crisis situation and a scheduled appointment was not possible due to the need of an immediate response.

Telehealth for Indian Health Services, Tribal 638 facilities, Federally Qualified Health Centers and Rural Health Clinics

Indian Health Services (IHS), Tribal 638 facilities, Federally Qualified Health Centers (FQHCs), and rural health clinics that provide services through telehealth via audio-only do not receive the encounter rate (Federal all-inclusive rate for IHS or Tribal 638 facilities). Only a face-to-face or video call with audio is allowed to receive the encounter rate (Federal all-inclusive rate for IHS or Tribal 638 facilities) under the State Plan Amendment.

Two-way interactive video consultation in an emergency department (ED)

Two-way interactive video consultation may be billed when no physician is in the ED and the nursing staff is caring for the member at the originating site. The ED physician at the distant site bills the ED CPT codes with place of service 02. Nursing services at the originating site should be included in the ED facility code. If the ED physician requests the opinion or advice of a specialty physician at a "hub" site, the ED physician bills the ED CPT codes and the consulting physician bills the consultation E/M code with place of service 02.

Noncovered Services

Telehealth does not include the following:

• Communication between health care provider and a member that consists solely of an email or facsimile
• Electronic connections that are not conducted over a secure encrypted website as specified by HIPAA Privacy and Security rules
• Prescription renewal
• Scheduling a test or appointment
• Clarification of issues from a previous visit
• Reporting test results
• Nonclinical communication

Authorization Requirements

Prior authorization is required for health care services delivered through telehealth if prior authorization is required before the delivery of the same service through in-person contact.

Billing

Providers must have documentation of services provided and must have followed all clinical standards to bill for telehealth or telephonic telehealth.

As a condition of payment, a licensed health care provider must document each occurrence of a health service delivered through telehealth to a Medical Assistance (Medicaid) member. Health care service records for services delivered through telehealth must meet the requirements set forth in Minnesota Rules, 9505.2175, subparts 1 and 2, and must document the following:

• The type of service delivered through telehealth;
• The time the service began and the time the service ended, including an a.m. and p.m. designation;
• The health care provider's basis for determining that telehealth is an appropriate and effective means for delivering the service to the enrollee;
• The mode of transmission used to deliver the service through telehealth and records evidencing that a particular mode of transmission was utilized;
• The location of the originating site and the distant site;
• If the claim for payment is based on a physician's consultation with another physician through telehealth, the written opinion from the consulting physician providing the telehealth consultation; and
• Compliance with the criteria attested to by the health care provider in accordance with paragraph (b).

Providers should bill with place of service 02 for traditional telehealth and audio-only services.

Providers submitting professional claims for services rendered via telehealth must use claim format 837P (professional) and include the CPT or HCPCS code that describes the services rendered and the place of service 02 (when the member is not located in their home when receiving health services or health-related service through telecommunication technology) or place of service 10 (when the member is located in their home [a location other than a hospital or other facility where they get care] when receiving health services or health-related services through telecommunication technology). By reporting a service with place of service 02 or 10, providers are certifying that they are rendering services to a member located in an eligible originating site via an interactive audio and visual telecommunications system.

Modifier 93 must be included when billing for services provided via audio only (synchronous telehealth services rendered via telephone or other real-time interactive audio-only telecommunications system).

All the other telehealth modifiers (GT, GQ, G0, 95) can be used for informational purposes, but are not required. Telehealth place of service codes indicate that the service was rendered through telehealth. If any telehealth modifiers are used without place of service 02 or 10, the claim will deny.
 

Telephonic (audio only) telehealth providers

Outpatient facilities (APC or ASC claims) continue to use telehealth modifiers on their claims.

Providers who service SUD H2035 on type of bill 89X should continue to use telehealth modifiers on their claims.

Service Delivery

The member must have an established relationship with the e-visit provider; an e-visit may not be used as a first visit with a provider.

Updated_09/08/2025