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WASHINGTON STATE TELEHEALTH REIMBURSEMENT
9/6/2011
INSURANCE CARRIER Regence BlueShield & RegenceCare (Asuris Northwest Health)
CONSULTANT CPT CODES COVERED 90804-90809 Individual Psychotherapy
90862 Pharmacology Management
99201-99215 Office or other Outpatient Visits
May have changed 1/1/10 99241-99275 Consultations
Initial inpatient telehealth consultation and
G0425-G0427, G0425-G0408
follow-up inpatient telehealth consultation
90801 Psychiatric diagnostic interview exam
90951, 952, 954, 955, 957, 958, 960 & 961 End stage renal disease related service
97802-97803 (G2070) Individual medical nutrition therapy
96116 Neurobehavioral status exam
G0425-G0427 Initial inpatient telehealth consultations
Follow-up inpatient telehealth
G0406-G0408
consultations
Speech Therapy
REFERRING PROVIDER CPT CODES COVERED
Store and Forward, E-Mail, Telephone,
Fax, Installation or maintenance of
telecommunication devices or systems,
SERVICES NOT COVERED
Home health monitoring, provider to
provider consultations when the member is
not present, radiology interpretations
RESTRICTIONS
PATIENT REQUIRED TO BE PRESENT Yes
WRITTEN REPORT REQUIRED
REAL-TIME INTERACTIVE VIDEO ONLY Yes
MD, PA, ARNP, Certified Nurse Midwife,
Clinical Nurse Specialist, Clinical
Psychologist, Clinical Social Worker,
ELIGIBLE CONSULTING PROVIDERS Registered dietitians or nutrition
professionals, Licensed professional
counselors, Licensed marriage and family
therapists
ELIGIBLE REFERRING PROVIDERS
ELIGIBLE CONSULTATION LOCATIONS HPSA or non-MSA County
Office of a physician or practitioner
Hospital
Critical Access Hospital
Rural Health Clinic (RHC)
Federally Qualified Health Center (FQHC)
hospital-based renal dialysis center
(including satellites)
Skilled nursing facility
community mental health center
SITE FEE per provider contract
This information is for general reference only. Please refer to carrier specific policy guidelines.
ed40b1cc-6ad7-4944-948a-920683eaf32d.xls
WASHINGTON STATE TELEHEALTH REIMBURSEMENT
9/6/2011
SITE FEE HCPCS CODE Q3014
SITE FEE REVENUE CODE 0780
MODIFIER GT
PROVIDER CONTACT Kay Etherington 253-382-7781
Kay.Etherington@regence.com
http://www.wa.regence.com/provider/library/polic http://www.asurisnorthwesthealth.com/provider/li
REFERENCE DOCUMENTS ies/reimbursementPolicy/administrative/telemedi brary/policies/reimbursement-
cine.html policy/administrative/telemedicine.html
ADDITIONAL NOTES
EFFECTIVE DATE
REVISED DATE
This information is for general reference only. Please refer to carrier specific policy guidelines.
ed40b1cc-6ad7-4944-948a-920683eaf32d.xls
WASHINGTON STATE TELEHEALTH REIMBURSEMENT
9/6/2011
INSURANCE CARRIER Washington State Labor & Industries (L&I)
CONSULTANT CPT CODES COVERED 99241-99244 (DC's, ND's)
99241-99245
99251-99255
99261-99263
99271-99275
99441 - 99443 (98966-98968 non phys) Telephone calls
99444 (98969 non phys) Online communications and consultation
REFERRING PROVIDER CPT CODES COVERED 90801 (PhD Clinical Psychologists)
99211-99214 (DC's, ND's)
99211-99215
99218-99239
99301-99313
99331-99333
99347-99357
Store and Forward, Fax, Installation or
maintenance of telecommunication
SERVICES NOT COVERED
equipmetn or systems, home health
monitoring telehealth transmission.
Referring provider who is not attending
Examination of patient must be under
RESTRICTIONS must consult with the attending prior to
control of the consultant.
making referral
PATIENT REQUIRED TO BE PRESENT YES
To the referring provider with a copy to the
WRITTEN REPORT REQUIRED
insurer See *
REAL-TIME INTERACTIVE VIDEO ONLY YES
MD, DO, ND, DPM, OD, DMD, DDS, DC-
ELIGIBLE CONSULTING PROVIDERS
approved provider
MD, DO, ND, DPM, OD, DMD, DDS, DC,
ELIGIBLE REFERRING PROVIDERS ARNP, PA, PhD Clinical Psychologist . DC
if approved consultant with L&I
ELIGIBLE CONSULTATION LOCATIONS
Online Communications:Non facility fee
SITE FEE $44.37, Facility Fee $42.55. Telehealth
Services: $34.19.
SITE FEE HCPCS CODE Q3014 (Telehealth Services)
SITE FEE REVENUE CODE 99444 (98969 non phys)
MODIFIER GT
PROVIDER CONTACT Tom Davis 360-902-6687
dato235@lni.wa.gov
REFERENCE DOCUMENTS *
(pages 35,36)
This information is for general reference only. Please refer to carrier specific policy guidelines.
ed40b1cc-6ad7-4944-948a-920683eaf32d.xls
WASHINGTON STATE TELEHEALTH REIMBURSEMENT
9/6/2011
*
http://www.lni.wa.gov/ClaimsIns/Files/ProviderPa
y/FeeSchedules/2010FS/ProfSvcs/EvalMgmtSvc
s.pdf
Consultations, Follow-up visits after the
initial consultation, psychiatric intake and
ADDITIONAL NOTES evaluation, individual psychotherapy,
pharmacologic managemnt, end stage
renal disease services
EFFECTIVE DATE 8/1/2003
REVISED DATE 2009
This information is for general reference only. Please refer to carrier specific policy guidelines.
ed40b1cc-6ad7-4944-948a-920683eaf32d.xls
WASHINGTON STATE TELEHEALTH REIMBURSEMENT
9/6/2011
INSURANCE CARRIER Medical Assurance Administration (Medicaid)
CONSULTANT CPT CODES COVERED 90801 Psychiatric Interview Exam
90804-90809 Individual Psychotherapy
90862 Pharmacology Management
99201-99215 Office or other Outpatient Visits
99241-99245 99251-99255 Consultations
REFERRING PROVIDER CPT CODES COVERED
Store and Forward, E-Mail, Telephone,
Fax, Installation or maintenance of
SERVICES NOT COVERED
telecommunication devices or systems,
Home health monitoring,
RESTRICTIONS "Non-plan" participants only
PATIENT REQUIRED TO BE PRESENT YES
Documentation of referral and consultation
required for payment. Report required on
WRITTEN REPORT REQUIRED
patient chart. Documenting telehealth
medically necessary (shnv).
REAL-TIME INTERACTIVE VIDEO ONLY YES
MD, PA (billing under a supervising
physician), ARNP, Certified Nurse Midwife,
ELIGIBLE CONSULTING PROVIDERS Clinical Nurse Specialist, Clinical
Psychologist (limited), Clinical Social
Worker
ELIGIBLE REFERRING PROVIDERS
ELIGIBLE CONSULTATION LOCATIONS Office of a physician or practitioner
Hospital
Critical Access Hospital
Rural Health Clinic (RHC)
Federally Qualified Health Center (FQHC)
Skilled home nursing visit delivered with
assistance of telemedicine (2009)
SITE FEE $20.00
SITE FEE HCPCS CODE Q3014
SITE FEE REVENUE CODE 0789
MODIFIER GT
PROVIDER CONTACT Silverman, Ellen S. (360)725-1840
SILVEES@dshs.wa.gov
REFERENCE DOCUMENTS
This information is for general reference only. Please refer to carrier specific policy guidelines.
ed40b1cc-6ad7-4944-948a-920683eaf32d.xls
WASHINGTON STATE TELEHEALTH REIMBURSEMENT
9/6/2011
http://maa.dshs.wa.gov/download/Billin
g_Instructions/Physician-
Related_Svcs/Physician-
Related_Services_BI.pdf
http://maa.dshs.wa.gov/rbrvs/
ADDITIONAL NOTES Can request an exception to policy
EFFECTIVE DATE 1-Oct-10
REVISED DATE
This information is for general reference only. Please refer to carrier specific policy guidelines.
ed40b1cc-6ad7-4944-948a-920683eaf32d.xls
WASHINGTON STATE TELEHEALTH REIMBURSEMENT
9/6/2011
INSURANCE CARRIER Medicare
CONSULTANT CPT CODES COVERED 90801 Psychiatric Interview Exam
90804-90809 Individual Psychotherapy
90862 Pharmacology Management
99201-99215 Office or other Outpatient Visits
99241-99255 Consultations
End-Stage Renal Disease (ESRD) -
related services included in the monthly
90951, 952, 954, 955, 957, 958, 960 & 961 capitation payment. (At least on face-to-
face, "hands on" visit each month by
physician, NP, PA or CNS.)
97802-97803 (G2070 - G2071) Individual medical nutrition therapy
96116 Neurobehavioral status examination
Follow-up inpatient telehealth
(G0406, G0407, G0408)
consultations
individual health and behavior assessment
96150 - 96152
and intervention (HBAI) services
Proposed 1/1/2011 99307-99310 Subsequent nursing facility care servcies
Subsequent hospital care services
99231-99233 provided after initial treatment and
admission
Health and behavior assessment and
96153-96154
intervention - Family with patient
97804 Group medical nutrition services
Individual and group services related to
G0420, G0421 kidney disease education
Individual and group diabetes self
management training, not incouding at
G0108, - G0109 least 1 hour of in-person injection training
REFERRING PROVIDER CPT CODES COVERED
Store and Forward, E-Mail, Telephone,
Fax, Installation or maintenance of
SERVICES NOT COVERED
telecommunication devices or systems,
Home health monitoring,
Patient must be enrolled in Medicare Part-
RESTRICTIONS
B
PATIENT REQUIRED TO BE PRESENT Yes
WRITTEN REPORT REQUIRED
REAL-TIME INTERACTIVE VIDEO ONLY Yes
MD, PA, ARNP, Certified Nurse Midwife,
Clinical Nurse Specialist, Clinical
Psychologist, Clinical Social Worker (no
ELIGIBLE CONSULTING PROVIDERS
psychotherapy med eval & mgt),
Registered dieticians or nutrition
professionals
ELIGIBLE REFERRING PROVIDERS
ELIGIBLE CONSULTATION LOCATIONS HPSA or non-MSA county
This information is for general reference only. Please refer to carrier specific policy guidelines.
ed40b1cc-6ad7-4944-948a-920683eaf32d.xls
WASHINGTON STATE TELEHEALTH REIMBURSEMENT
9/6/2011
Office of a physician or practitioner
Hospital
Critical Access Hospital
Rural Health Clinic (RHC)
Federally Qualified Health Center (FQHC)
Hospital-based or CAH-based Renal
Dialysis Centers (including satellites)
Skilled Nursing Facilities (SNF)
Community Mental Health Centers
(CMHC)
Federal telemedicine demonstration projects as
of Dec 31, 2000, may serve as the originating
site regardless of geographic location
(approved by or receiving funding from
Secretary of HHS)
SITE FEE $24.10
SITE FEE HCPCS CODE Q3014
SITE FEE REVENUE CODE
MODIFIER GT
PROVIDER CONTACT
REFERENCE DOCUMENTS https://www.cms.gov/Telehealth/
http://www.telemedicine.com/pdfs/Teleheal
Medicare Program Memorandum 5-03.pdf thSrvcsfctsht.pdf
changes to cardiac remote monitoring
Distant site: 80% of MPFS amount for codes that require technical and
ADDITIONAL NOTES
telehealth services professional components of the fee to
align with an overall cap.
EFFECTIVE DATE
REVISED DATE
This information is for general reference only. Please refer to carrier specific policy guidelines.
ed40b1cc-6ad7-4944-948a-920683eaf32d.xls
INSURANCE CARRIER Premera Blue Cross
CONSULTANT CPT CODES COVERED 90801 Psychiatric Interview Exam
90804-90809 Individual Psychotherapy
90862 Pharmacology Management
99201-99215 Office or other Outpatient Visits
99241-99275 Consultations
REFERRING PROVIDER CPT CODES
COVERED
Store and Forward, E-Mail,
SERVICES NOT COVERED
Telephone, Fax
RESTRICTIONS
PATIENT REQUIRED TO BE PRESENT Yes
WRITTEN REPORT REQUIRED
REAL-TIME INTERACTIVE VIDEO ONLY Yes
ELIGIBLE CONSULTING PROVIDERS ?
ELIGIBLE REFERRING PROVIDERS n/a
ELIGIBLE CONSULTATION LOCATIONS Office of a physician or practitioner
Hospital
Critical Access Hospital
Rural Health Clinic (RHC)
Federally Qualified Health Center
(FQHC)
SITE FEE $21.86
SITE FEE HCPCS CODE Q3014
SITE FEE REVENUE CODE
MODIFIER GT
Katherine Stojkovic
PROVIDER CONTACT katherine.stojkovic@premera.com
(425) 918--5882
tom.Faltz@Premera.com
https://www.premera.com/stellent/grou
REFERENCE DOCUMENTS ps/public/documents/paymentpolicy/c
mi_051750.pdf
Oregon exception for location:
Outpatient services: telehealth office add community mental health
visits including consultation, center, skilled nursing facility,
ADDITIONAL NOTES
diagnosis and treatment by a renal dialysis center or a site
specialist where public health services are
provided.
EFFECTIVE DATE 1-Jan-05
REVISED DATE
WASHINGTON STATE TELEHEALTH REIMBURSEMENT
9/6/2011
INSURANCE CARRIER Uniform Medical Plan (UMP)
Outsourced to Regence beginning 1/1/11
Info below is from 2007
& reimbursement will follow their plan
CONSULTANT CPT CODES COVERED 90801 Psychiatric Interview Exam
90804-90809 Individual Psychotherapy
90862 Pharmacology Management
99201-99215 Office or other Outpatient Visits
99241-99275 Consultations
Diabetes outpatient self management
HCPCS codes G0108-G0109 training sessions by Medicare-approved
diabetes education program
REFERRING PROVIDER CPT CODES COVERED
Store and Forward, E-Mail, Telephone,
Fax, Installation or maintenance of
Store and Forward, E-Mail, Telephone,
telecommunication devices or systems,
Fax, Installation or maintenance of
SERVICES NOT COVERED Home health monitoring, HCPCS code
telecommunication devices or systems,
T1014 (telehealth transmission/minute),
Home health monitoring,
CPT code 0074T (on-line medical
evaluation)
RESTRICTIONS
PATIENT REQUIRED TO BE PRESENT Yes
WRITTEN REPORT REQUIRED
REAL-TIME INTERACTIVE VIDEO ONLY Yes
UMD provider and MD, Clinical
ELIGIBLE CONSULTING PROVIDERS
Psychologist
ELIGIBLE REFERRING PROVIDERS UMB-approved provider type
ELIGIBLE CONSULTATION LOCATIONS Office of a physician or practitioner
Hospital
Critical Access Hospital
Rural Health Clinic (RHC)
Federally Qualified Health Center (FQHC)
SITE FEE $21.20
SITE FEE HCPCS CODE Q3014
SITE FEE REVENUE CODE
MODIFIER GT
PROVIDER CONTACT Kathy Fancher (206)521-2007 Bettina Maki wcb w/contact
http://www.wa.regence.com/provider/li
REFERENCE DOCUMENTS brary/policies/reimbursementPolicy/ad
ministrative/telemedicine.html
ADDITIONAL NOTES Can request an exception to policy
This information is for general reference only. Please refer to carrier specific policy guidelines.
ed40b1cc-6ad7-4944-948a-920683eaf32d.xls
WASHINGTON STATE TELEHEALTH REIMBURSEMENT
9/6/2011
EFFECTIVE DATE 1-Jul-04
REVISED DATE
This information is for general reference only. Please refer to carrier specific policy guidelines.
ed40b1cc-6ad7-4944-948a-920683eaf32d.xls
1.2
1
0.8
0.6
0.4
0.2
0
G0308-G0309, G0311-G0312, G0314-G0315, …
Yes
Yes
$21.20
GT
Hospital
Q3014
90801
90862
Rural Health Clinic (RHC)
kfan107@hca.wa.gov
1-Jan-05
1-Jan-05
9/29/2010 See Regence
90804-90809
99201-99215
99241-99255
Critical Access Hospital
United Health
HCPCS codes G0108-G0109
92541-92548, 92551-92588, 92597
UMB-approved provider type
switching to Regence 1/1/11
Can request an exception to policy
UMD provider and MD, Clinical Psychologist
Community Mental Health Center/RSN
Kathy Fancher (206)521-2007
Office of a physician or practitioner
Federally Qualified Health Center (FQHC)
90801 99241-99255
99201-99215
90862
90804-90809 Store andthose whon/aHospital
Yes Yes Officebill aHealthQualified $21.86 katherine.stojkovic 2 2010
can of Access
Critical
Rural
Federally Clinic GT request an Aetna
Can 1-Jan-05
Q3014Katherine Nov
Forward, E-Mail, above Hospital
or
codesphysician Health Center
(RHC) @premera.com
exception to
Stojkovic (425 918policy Aetna
Telephone, Fax practitioner (FQHC) 5882
UHC
90804-90809G0108-G0109 2011:99307 - 99310
90801 99241-99255G0425-G0427,G04, 99233 Patient must be PA, ARNP,RuralaHealthQualifiedor
99201-9921596150 - 96152 - 96154
90862
97802-97804 in 96153 -
96116
New 97804,
99231 Store and MD,HPSA or non-MSAAccess Community Call Center 1/1/2011
Yes Yes Office of Hospital-based Q3014 GT
Critical Skilled Nursing
Hospital
Federally Clinic $24.10 Nov 2 2010 Health
First Choice Community Health Plan
G0406 G0108,
G0421,
G0270-G0271, - G0408 Forward, E-Mail,
enrolled Certified Nurse Hospital Center (SNF) (800)933-0614
in physician or Facilities
CAH-based Renal
(RHC)
County Health Mental Health Network
G0308-G0309,G0109, Medicare Part-B
Telephone, Fax, practitionerDialysis Centers
Midwife, Clinical Centers (CMHC)
(FQHC)
G0311-G0312, Nurse Specialist,
Installation or (including
G0314-G0315, maintenance of Clinical satellites)
G0317-G0318 telecommunicatio Psychologist,
n devices or Clinical Social
systems, Home Worker
health monitoring,
90801 99241-99245
99201-99215
90862
90804-90809 Store and MD (includingof aHealthQualified $22.94Ellen T 1/4/2005 -an
"Non-Plan" Yes Contracted Access
Documentation ofCritical
Yes MAA Office Federally Clinic
Hospital
Rural 0789 Can request 2009
SILVEES@dshs.wa.
10/1/2010
Pacific
Q3014 G Silverman 11/9/2010Medical
99251-99255 Forward, E-Mail, and
Participants psychiatrists),Hospital Center
referral Providers Health
Only physician or (RHC) exception
gov
360 725-1853 to
consultation
Telephone, Fax, ARNP practitioner (FQHC) policy. Medically
required for
Installation or necessary skilled
payment.
maintenance of Report home nursing visit
required
telecommunicatio on
WASHINGTON STATE TELEHEALTH REIMBURSEMENT - (Revised 11/2010)
Uniform Medical Plan
INSURANCE CARRIER Asuris L&I Medicaid Medicare Premera
(UMP)
switching to Regence
1/1/11
CONSULTANT CPT CODES
90801 99241-99244 (DC's, ND's) 90801 90801 90801 90801
COVERED
90804-90809 99241-99245 90804-90809 90804-90809 90804-90809 90804-90809
90862 99251-99255 90862 90862 90862 90862
99201-99215 99261-99263 99201-99215 99201-99215 99201-99215 99201-99215
99241-99255 99241-99255 99241-99245 99251-99255 99241-99255 99241-99255 99241-99255
90951, 952, 954, 955, 957, 958,
97802-97804 HCPCS codes G0108-G0109
960, 961
G0108-G0109 G0270-G0271,
G0308-G0309, G0311-
G0308-G0309, G0311-
96116 G0312, G0314-G0315,
G0312, G0314-G0315, G0317-
G0317-G0318
G0318
97802-97803 96116
92541-92548, 92551-92588,
96150 - 96152
92597
G0425-G0427, G0406 -
G0406-G0408
G0408
New in 2011 : G04, G0421,
G0425-G0428, G2070
G0108, G0109,
REFERRING PROVIDER CPT 90801 (PhD Clinical
97804,
CODES COVERED Psychologists)
99211-99214 (DC's, ND's) 96153 - 96154
99211-99215 99231 - 99233
99218-99239 99307 - 99310
99301-99313
99331-99333
99347-99357
Store and Forward, E-Mail, Store and Forward, Fax, Store and Forward, E-Mail, Store and Forward, E-Mail, Store and Forward, E-Mail,
Telephone, Fax, Installation or Installation or maintenance of Telephone, Fax, Installation or Telephone, Fax, Installation Telephone, Fax, Installation
maintenance of telecommunication equipment maintenance of or maintenance of Store and Forward, E-Mail, or maintenance of
SERVICES NOT COVERED
telecommunication devices or or systems, home health telecommunication devices or telecommunication devices or Telephone, Fax telecommunication devices or
systems, Home health monitoring, monitoring, telehealth systems, Home health systems, Home health systems, Home health
radiology interpretations transmission. monitoring, monitoring, monitoring,
Examination of patient must
be under control of the
Patient must be enrolled in
RESTRICTIONS consultant. Non-attending "Non-Plan" Participants Only
Medicare Part-B
must consult with attending
prior to referrals.
PATIENT REQUIRED TO BE
Yes Yes Yes Yes Yes Yes
PRESENT
Documentation of referral and
consultation required for
WRITTEN REPORT To the referring provider with
payment. Report required on
REQUIRED a copy to the insurer
patient chart. Medical
necessity
REAL-TIME INTERACTIVE
Yes Yes Yes Yes Yes Yes
VIDEO ONLY
MD,PA,Clinical
Psychologist,ARNP,Certified
Nurse Midwife, Clinical Nurse MD, PA, ARNP, Certified
Specialist,Clinical Social Worker, Nurse Midwife, Clinical Nurse
ELIGIBLE CONSULTING MD,DO,ND,DPM,OD,DMD,D MD (including psychiatrists), UMD provider and MD,
Speech Therapist, Registered Specialist, Clinical those who can bill codes above
PROVIDERS DS,DC-Approved Provider ARNP Clinical Psychologist
Dieticians or nutrition Psychologist, Clinical Social
professionals, Licensed Worker
professional counselors, Licensed
marriage and family therapists
MD,DO,ND,DPM,OD,DMD,D
ELIGIBLE REFERRING
DS,DC,ARNP,PA,PhD MAA Contracted Providers n/a UMB-approved provider type
PROVIDERS
Clinical Psychologist
ELIGIBLE CONSULTATION Office of a physician or Office of a physician or Office of a physician or
HPSA or non-MSA County HPSA or non-MSA County
LOCATIONS practitioner practitioner practitioner
Office of a physician or Office of a physician or
Hospital Hospital Hospital
practitioner practitioner
Hospital Critical Access Hospital Hospital Critical Access Hospital Critical Access Hospital
Critical Access Hospital Rural Health Clinic (RHC) Critical Access Hospital Rural Health Clinic (RHC) Rural Health Clinic (RHC)
Federally Qualified Health Federally Qualified Health Federally Qualified Health
Rural Health Clinic (RHC) Rural Health Clinic (RHC)
Center (FQHC) Center (FQHC) Center (FQHC)
Federally Qualified Health Center Federally Qualified Health Community Mental Health
(FQHC) Center (FQHC) Center/RSN
Hospital-based or CAH-based
hospital-based renal dialysis
Renal Dialysis Centers
center (including satellites)
(including satellites)
Skilled Nursing Facilities
SNF
(SNF)
Community Mental Health
community mental health cetner
Centers (CMHC)
34.19 telehealth services;
SITE FEE per provider contract $44.37/$42.55 oline $22.94 $24.10 $21.86 $21.20
communications
SITE FEE HCPCS CODE Q3014 Q3014 Q3014 Q3014 Q3014 Q3014
SITE FEE REVENUE CODE 0780 0789
MODIFIER GT GT GT GT GT GT
Katherine Stojkovic (425 918
PROVIDER CONTACT Kay Etherington (253)382-7781 Tom Davis (360)902-6687 Ellen Silverman 360 725-1853 Call Center (800)933-0614 Kathy Fancher (206)521-2007
5882
katherine.stojkovic@premera.c
Kay.Etherington@regence.com dato235@lni.wa.gov SILVEES@dshs.wa.gov kfan107@hca.wa.gov
om
Can request an exception to
Can request an exception to Can request an exception to
ADDITIONAL NOTES policy. Medically necessary
policy policy
skilled home nursing visit
EFFECTIVE DATE 1-Aug-03 1/4/2005 - 2009 1-Jan-05 1-Jan-05
REVISED DATE Oct-10 10/1/2010 1/1/2011 1-Jan-05
Confirmed updates 1-Nov-10 11/9/2010 Nov 2 2010 Nov 2 2010 9/29/2010 See Regence
Other Carriers
Foundation Health Service- Community Health Plan of Molina Healthcare 1 562-435-
Pacific Medical First Choice Health Network Aetna United Health
Tricare Washington 3666
INSURANCE CARRIER Regence Blue Shield
CONSULTANT CPT CODES COVERED
REFERRING PROVIDER CPT CODES
COVERED
SERVICES NOT COVERED
RESTRICTIONS
PATIENT REQUIRED TO BE PRESENT
WRITTEN REPORT REQUIRED
REAL-TIME INTERACTIVE VIDEO ONLY
ELIGIBLE CONSULTING PROVIDERS
ELIGIBLE REFERRING PROVIDERS
ELIGIBLE CONSULTATION LOCATIONS
SITE FEE
SITE FEE HCPCS CODE
SITE FEE REVENUE CODE
MODIFIER
PROVIDER CONTACT Katrin Fletcher 1800 977-8860
kfletcher@regence.com
REFERENCE DOCUMENTS
ADDITIONAL NOTES
EFFECTIVE DATE
REVISED DATE
Regence Blue Shield
http://www.wa.regence.com/provider/li
brary/policies/reimbursementPolicy/ad
ministrative/telemedicine.html
INSURANCE CARRIER Aetna
CONSULTANT CPT CODES COVERED
33282, 33284, 93012, 93014, 93228,
93229, 93268, 93270 - 93272, 93285,
93291, 93298, 93299
93224-93227, 93230-93237
REFERRING PROVIDER CPT CODES
COVERED
SERVICES NOT COVERED
RESTRICTIONS
PATIENT REQUIRED TO BE PRESENT
WRITTEN REPORT REQUIRED
REAL-TIME INTERACTIVE VIDEO ONLY
ELIGIBLE CONSULTING PROVIDERS
ELIGIBLE REFERRING PROVIDERS
ELIGIBLE CONSULTATION LOCATIONS
SITE FEE
SITE FEE HCPCS CODE C1764, E0616, S0625, S3000
SITE FEE REVENUE CODE
MODIFIER
PROVIDER CONTACT Tara Gable gabletl@aetna.com
http://www.aetna.com/cpb/medical/dat
a/500_599/0563.html
REFERENCE DOCUMENTS
http://www.aetna.com/cpb/medical/dat
a/1_99/0073.html
External intermittent cardiac event
monitors and external intermittent
ADDITIONAL NOTES cardiac event monitors with real-time
data transmission and analysis. Digital
retinopathy telescreening.
EFFECTIVE DATE
REVISED DATE
Aetna
cardiac monitors if selection criteria met
cardiac monitors other codes
INSURANCE CARRIER United Health Care
CONSULTANT CPT CODES COVERED
REFERRING PROVIDER CPT CODES
COVERED
SERVICES NOT COVERED
RESTRICTIONS
PATIENT REQUIRED TO BE PRESENT
WRITTEN REPORT REQUIRED
REAL-TIME INTERACTIVE VIDEO ONLY
ELIGIBLE CONSULTING PROVIDERS
ELIGIBLE REFERRING PROVIDERS
ELIGIBLE CONSULTATION LOCATIONS
SITE FEE
SITE FEE HCPCS CODE
SITE FEE REVENUE CODE
MODIFIER
Emily Patterson
PROVIDER CONTACT
emily_patterson@uhc.com
REFERENCE DOCUMENTS
ADDITIONAL NOTES
EFFECTIVE DATE
REVISED DATE
United Health Care
INSURANCE CARRIER United Health Care
CONSULTANT CPT CODES COVERED
REFERRING PROVIDER CPT CODES
COVERED
SERVICES NOT COVERED
RESTRICTIONS
PATIENT REQUIRED TO BE PRESENT
WRITTEN REPORT REQUIRED
REAL-TIME INTERACTIVE VIDEO ONLY
ELIGIBLE CONSULTING PROVIDERS
ELIGIBLE REFERRING PROVIDERS
ELIGIBLE CONSULTATION LOCATIONS
SITE FEE
SITE FEE HCPCS CODE
SITE FEE REVENUE CODE
MODIFIER
PROVIDER CONTACT 1800 440-1561
REFERENCE DOCUMENTS
ADDITIONAL NOTES
EFFECTIVE DATE
REVISED DATE
United Health Care
Out patient Services: Telehealth office
visits includding consultation,
diagnosis and treatment by a specialist
