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Reimbursement

Reimbursement policies are not consistent and comprehensive from State to State. There is a lack of an overall telemedicine reimbursement policy in the current United States health care system. Individual contracts for telemedicine services are commonly signed, which outline direct reimbursement to providers.

Claims for reimbursement in Utah should be submitted with the appropriate CPT code or HCPCS code for the professional services provided and the Telehealth modifier “GT” for interactive audio & video telecommunications system. The Utah Health Information Network provides standards for processing claims in Utah.
 

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Medicare

Medicare Benefit Policy Manual (Rev. 99, 12-24-08) - see Telehealth Services (section 270)

Medicare reimbursement for telehealth services was authorized with limitations related to geographic location, originating site and eligible telehealth services. The payment amount for the professional service provided via a telecommunications system by the physician or practitioner at the distant site is equal to the current fee schedule amount for the service provided. CMS reimbursement is limited to the type of services provided, geographic location of the patient site, type of institution delivering the services and type of health provider.

Medicare telehealth originating sites (patient locations) only include a physician’s or practitioner’s office, hospital, critical access hospital, rural health clinic, skilled nursing facilities, in-hospital dialysis centers, community mental health centers or Federally-qualified health center, that are located in a rural HPSA county outside of a metropolitan area. There is no limitation on the location of the physician or practitioner delivering the medical service.

A medical professional is not required to present the beneficiary to the physician or practitioner at the distant site unless medically necessary. The decision of medical necessity will be made by the physician or practitioner located at the distant site.
 

Utah Medicaid

Utah Medicaid Website

The Medicaid agency recognizes the following services when furnished using interactive video teleconferencing:

Telehealth mental health consultations
Telehealth special health care needs child
Telehealth home health - diabetic monitoring and education

The state uses CPT codes with GT modifiers to identify telehealth services.
 

Utah Medicaid Contact

Linda Morris APRN MSN
Health Program Manager
Coverage Reimbursement Policy
Phone (801)538-6731
Fax (801)536-0171
limorris@utah.gov

Third Party Payors

Historically, Utah Third Party Payors have reimbursed providers for some telemedicine services. When starting a new program, make certain the payor is aware that they are paying for a telemedicine program.