California Medicaid Telehealth Reimbursement

 Medicaid Reimbursement / Posted 6 months ago by Telehealthist

Medi-Cal allows providers to decide what modality, live video or store-and-forward, will be used to deliver eligible services to a Medi-Cal enrollee as long as the service is covered by Medi-Cal and meets all other Medi-Cal guidelines, and policies, can be properly provided via telehealth, and meets the procedural and definition components of the appropriate CPT or HCPCS code.

“Telehealth” means the mode of delivering health care services and public health via information and communication technologies to facilitate the diagnosis, consultation, treatment, education, care management and self-management of a patient’s health care.

Live Video
Medi-Cal allows the distant site provider to decide whether the services should take place by live-video, store-and-forward, or in person if certain conditions are met.

Eligible Services/Specialties
All benefits or services are covered for live video under fee-for-service Medi-Cal, including any Treatment Authorization Request (TAR) requirements.

Eligible Providers
Click to see provider eligibility requirements.

Eligible Sites
For purposes of reimbursement for covered treatment or services provided through telehealth, the type of setting where services are provided for the patient or by the health care provider is not limited (Welfare and Institutions Code [WIC] Section 14132.72(e)). This may include, but is not limited to, a hospital, medical office, community clinic, or the patient’s home.

Geographic Limits
No reference found.

Facility/Transmission Fee
Medi-Cal will reimburse the originating site a facility fees, and originating and distant site for live video transmission costs.

Medi-Cal allows the distant site provider to decide whether the services should take place by live-video, store-and-forward, or in person.

Eligible Services/Specialties
All benefits or services are covered under Medi-Cal through live video or store-and-forward. The decision that services can be appropriately provided by the selected telehealth modality is based on the distant site provider’s belief it is clinically appropriate due to evidence-based medicine and best practices.

Geographic Limits
No reference found.

Transmission Fee
The originating site is eligible for a facility fee. A transmission fee is only reimbursed for live video, and therefore store-and-forward is not eligible.

Remote Patient Monitoring
No reference found.

No reference found.

Provider Limitations
No reference found.

Other Restrictions
No reference found.

Telephonic services must be reimbursed when provided by specific entities during or immediately following an emergency, subject to the Department obtaining federal approval and matching funds.

Providers must inform the patient about the use of telehealth and obtain verbal or written consent from patients before utilizing telehealth. If a healthcare provider at the originating or distant site maintains a general consent agreement that addresses the use of telehealth that is sufficient for documentation of patient consent and must be kept in the patient’s medical file.

Out of State Providers
Provider must be licensed in CA, enrolled as a Medi-Cal rendering provider or non-physician medical practitioner (NMP) and affiliated with an enrolled Medi-Cal provider group. The enrolled Medi-Cal provider group for which the health care provider renders services via telehealth must meet all Medi-Cal program enrollment requirements and must be located in California or a border community.

Specific documentation requirements apply to substantiate the corresponding technical and professional components of billed CPT or HCPCS codes.