The below FAQ is specific to our Commercial, Medicaid and Medicare lines of business. Any distinctions between lines of business are called out.

Definitions:

Telemedicine

Refers to actual medical consultations provided in real-time over an electronic mechanism as allowed below. This includes, but is not limited to, the Teladoc-style web doctor services. Telemedicine visits typically result in normal claims specifically coded as telemedicine visits.

Telehealth

Telehealth refers to health and wellness programs, nurse lines, and other services supporting patient health that are delivered by live video or live chat evaluation. Telehealth may be used to diagnose or consult on minor conditions (e.g., colds, sinus infections, sprains or rashes), on-going conditions (e.g., mental health, substance abuse or chronic conditions) and/or follow-up appointments. It can also be used to prescribe medications. In-network providers may offer this service and standard plan specific copays apply.

Tele-Video and Telephonic:

Services that are eligible for reimbursement must be delivered by real-time, interactive, two-way video and phone communication when determined medically necessary, evidence-based, and a covered benefit. 

Originating Site:

The originating site means the physical location of the patient and or provider (receiving or rendering telemedical health services), be that a healthcare facility, home, school or workplace, etc. 

Question & Answers:

What are PacificSource’s guidelines for eligible reimbursement for Telemedicine and Telehealth Services?

Billing expectations and billing practices are the same as any other service rendered by our provider partners. Prior to rendering any service, providers are expected to check eligibility and benefits.

How do I know if a service or medication requires a prior authorization?

If the service requires preauthorization when done in-person, then preauthorization is required when done as telemedicine and telehealth. To determine if a service and or medication requires preauthorization, consult our Prior Authorization Grid (authgrid.pacificsource.com).

Does PacificSource have a Policy and Procedure specific to Telemedicine?

Yes, upon request we can share this with providers.

MEDICAID SPECIFIC

How do I know if a service is covered under the Oregon Health Plan (OHP)?

This can be identified by using LineFinder. LineFinder is an online tool to assist providers in determining what is covered by OHP. OHP generally updates the information quarterly. (intouch.pacificsource.com/LineFinder)

How are Telemedicine and Telehealth Services identified on a claim?

Billing place of service (POS) 02, is required. We also allow GT modifier to be included when billing to identify type of service, however not required.

Are there limitations to Telemedicine and Telehealth that as a provider I should be aware of?

Yes. Services must meet all of the following criteria to be eligible for coverage.

• Limited to two-way real time video and phone communication. 

• Services must be medically necessary and eligible for coverage if the same service were provided in person.

• Services are subject to all terms and conditions of the plan. 

• Place of Service 02 is required when billing. 

• Facility fee charges from the originating site are ineligible for reimbursement.

• Some office visits and/or procedures will be subject to retrospective review.