UPMC Health Plan POLICY AND PROCEDURE MANUAL
POLICY NUMBER: PAY.065 REVISION DATE: NA ANNUAL APPROVAL DATE: 03/09 PAGE NUMBER: 1 of 6 SUBJECT: INDEX TITLE: ORIGINAL DATE: Telemedicine and E-visits Medical Management 03/02/2009
This policy applies to the following lines of business: (Check those that apply.) Commercial: HMO ( ) Fully Insured ( ) Medicare Select ( ) DPW-MA: Health Choices ( ) CMS-MA: HMO ( X) PPO ( X ) PID-CHIP: Free ( )
POS ( ) Self-funded/ASO ( ) Medicare Supplement ( ) Voluntary ( ) Specialty Needs Plan (X ) Sub ( )
PPO ( ) HSA ( )
OOA/DOC ( ) All ( X )
All ( ) PFFS (X ) All ( ) All ( )
Part D ( )
I.
POLICY
It is the policy of UPMC Health Plan to recognize Telemedicine and E-visits as appropriate and consistent with good medical practice when performed for the indications listed in this policy. Coverage for this service is based upon medical necessity as detailed in this policy and according to the member’s specific benefit plan. Practitioners who utilize any form of Telemedicine or e-visits should be in compliance with online secure transmission of private patient health information. The handling of electronic patient information is considered the same as in an in-office location, and patient privacy must be maintained. II. DEFINITIONS
E-visit: is the service provided to a patient from a physician or other qualified health professional by means of on-line communication via the Internet through a secure Web based system. Telehealth: is the use of advanced telecommunication technologies to exchange live health information (clinical and non-clinical) and provide these services through multiple variations of electronic transmission such as video-conferencing and transmission of still images of the patient. Telemedicine: is the use of modern telecommunication and information technologies to deliver health care services at a distance.
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POLICY NUMBER: PAY.065 REVISION DATE: NA ANNUAL APPROVAL DATE: 3/09 PAGE NUMBER: 2 of 6
III.
PURPOSE
The purpose of this policy is to define the appropriate indications for coverage of Telemedicine and e-visits. IV. SCOPE
This policy applies to various UPMC Health Plan departments as indicated by the Benefit and Reimbursement Committee. These include but are not limited to: Medical Management, Benefit Configuration and Claims departments. V. PROCEDURE
A. Medical Description/Background Telemedicine combines traditional medicine and modern technology to extend the capabilities of traditional medicine. It is an important component of the future of medicine and can be the answer to many problems that are faced today with health care. The Balanced Budget Act of 1997 and the Benefits Improvement and Protection Act of 2000 included amendments to the Social Security Act to allow reimbursement for these services through Medicare. Regulations for telemedicine reimbursement by private insurers are set by the states although not all states have enacted laws requiring these services be reimbursed. Telemedicine utilizes technology for many reasons including increased cost efficiency, improved patient access to specialists, improved quality of care, and better communication between providers. Telemedicine is practiced on the basis of two concepts: real-time and store-and-forward. Real-time telemedicine requires the presence of both parties at the same time and a communications link between them that allows real-time interaction to take place. Store-and-forward telemedicine involves acquiring medical data and then transmitting this data to a medical provider for later assessment. It does not require the presence of both parties at the same time. Dermatology, radiology and pathology are common specialties that are conducive to store-and-forward technologies. An originating site is the location of an eligible member at the time the service is being provided via a telecommunication system. The distant site is the location of the consulting practitioner. Telehealth services originally were used to describe non- clinical services such administration, medical education and research and it now encompasses preventive, promotive, and curative aspects.
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POLICY NUMBER: PAY.065 REVISION DATE: NA ANNUAL APPROVAL DATE: 3/09 PAGE NUMBER: 3 of 6
The use of real-time telemedicine through a telecommunication system may substitute for face-to-face”, “hands on” encounters for any of the following services: Office or other outpatient visits Consultations Pharmacologic management The above services can be provided by the following participating health professionals: Physician Nurse practitioner Physician Assistant The use of store-and-forward telemedicine involves the transmission of data to a medical provider for later assessment and includes the following services: Interpretation of lab results Interpretation of diagnostic imaging Interpretation of pathology results and review of specimens Patient monitoring using remote patient monitors that allow transmission of data to a health professional through a telephone (e.g. cardiac monitoring) The following facilities are eligible to be an originating site for telemedicine services: The office of a physician or practitioner A hospital A clinic Skilled nursing facility Community mental health center Hospital-based renal dialysis center E-visits are convenient, secure online consultations available to established patients with their physician using a pre-approved template with decision logic or a vendor approved format for use for non-urgent health issues. The service is provided over a safe, secure electronic communication system that is HIPAA compliant and uses a structured interview format to communicate member symptoms to the physician. The physician responds within a defined period of time (such as 24 business hours) and if necessary may request an in-office visit. Written documentation related to the service must be included in the patient’s record. B. Indications For real-time telemedicine includes all of the following: The patient must be present at the originating site at the time of the consultation for real-time services All services provided must be medically necessary and appropriate
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POLICY NUMBER: PAY.065 REVISION DATE: NA ANNUAL APPROVAL DATE: 3/09 PAGE NUMBER: 4 of 6
The medical examination of the patient must be under the control of the consulting provider For store-and-forward telemedicine the following are applicable: Interpretation of covered lab, pathology, dermatology or radiology services The practitioner at the interpretation site must be specialized in the field that the service is required. Follow-up inpatient consultations delivered electronically such as monitoring a patient’s progress, recommending care-managed changes, etc For e-visits- services are available only to established patients who have previously received care from the physician’s practice and include all of the following: These indications are applicable for coverage of the list of diagnoses in the attached appendix. Non urgent needs such as allergies or cough and cold symptoms Managing your chronic condition such as diabetes or high blood pressure Recurring acute conditions like sinusitis or ear infections C. Limitations For telemedicine/ e-visit services this includes all of the following: The service must be within a practitioner’s scope of specialty practice and State law. The practitioner at the distant site must be licensed to provide the service under State law. Telephones, facsimile machines and electronic mail systems or devices do not meet the requirements of interactive telecommunications systems. (such as the interpretation of an EKG that has been transmitted via telephone) Home telehealth services provided via a telecommunications system unless covered under a specific UPMC Health Plan policy. Note: exceptions to the above limitations will be addressed in condition specific UPMC Health Plan Policies Additionally for e-visits - limitations include all of the following: Emergent/urgent or life threatening conditions Conditions that require a high visual component Appointment scheduling Renewing or refilling existing prescriptions Reporting test results Updating patient information Providing educational materials Reminders of scheduled office visits
Proprietary and Confidential Information of UPMC Health Plan
POLICY NUMBER: PAY.065 REVISION DATE: NA ANNUAL APPROVAL DATE: 3/09 PAGE NUMBER: 5 of 6
Clarification of simple instructions Limited to one e-visit per 7 day period (global time frame includes all replies related to the patient’s initial question/query) D. Variations N/A E. References 1. Telemedicine and Telehealth News, New Federal legislation Impacts Telemedicine, 07/15/2008 2. Centers for Medicare and Medicaid Services, Medicare Payment of Telemedicine and Telehealth Services, 01/22/2007 3. U.S. Department of Health and Human Services, Health Resources and Services Administration, Telemedicine Report, 10/2003 4. BlueCross BlueShield of North Carolina, Corporate Medical Policy MED1395, Telemedicine, 09/2007 5. Cigna HealthCare Coverage Position #0196, Telemedicine, 12/15/2007 6. Highmark Medicare Advantage Medical Policy Bulletin #Z-66, Telemedicine/Telehealth Services, Issued 04/21/2008 7. Blue Cross and Blue Shield of Florida, Coverage Guideline for E- Medicine, Revised 01/01/2008 8. RelayHealth - Secure Connectivity for Healthcare Health, www.relayhealth.com/ 9. American Academy of Physicians, Guidelines for e-visits, www.aafp.org
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POLICY NUMBER: PAY.065 REVISION DATE: NA ANNUAL APPROVAL DATE: 3/09 PAGE NUMBER: 6 of 6
Disclaimer: UPMC Health Plan medical payment and prior authorization policies do not constitute medical advice and are not intended to govern or otherwise influence the practice of medicine. The policies constitute only the reimbursement and coverage guidelines of UPMC Health Plan and its affiliated managed care entities. Coverage for services varies for individual members in accordance with the terms and conditions of applicable Certificates of Coverage, Summary Plan Descriptions, or contracts with governing regulatory agencies. UPMC Health Plan reserves the right to review and update the medical payment and prior authorization guidelines in its sole discretion. Notice of such changes, if necessary, shall be provided in accordance with the terms and conditions of provider agreements and any applicable laws or regulations. These policies are the proprietary information of UPMC Health Plan. Any sale, copying, or dissemination of said policies is prohibited.
APPENDIX (E-Visits only) The E-visit benefit is applicable to this list of clinical conditions only:
Back Pain Cough Diarrhea Red Eye Sinus/Cold Symptoms Urinary Symptoms Vaginal Irritation/Discharge
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