​​COVID-19 (Coronavirus): Telemedicine services for AmeriHealth Pennsylvania members

June 24, 2020

This article was revised on June 24, 2020, to update the effective date range. To learn about the AmeriHealth New Jersey position, please read this article.

AmeriHealth is committed to providing our members with access to the care they need. As COVID-19 has escalated into a pandemic, we are working to make sure that our members can receive appropriate testing and treatment for the virus causing COVID-19 if needed.

We encourage all AmeriHealth members to visit our dedicated COVID-19 webpage for AmeriHealth Pennsylvania regularly for the latest news and updates. We will continue to evaluate member needs as the situation changes.

​​​Expansion of telemedicine coverage

To encourage social distancing and increase access to care, AmeriHealth is expanding its telemedicine services through the following channels. Telemedicine services are effective March 6, 2020, through December 31, 2020.

Primary care providers (PCP)

  • We will waive cost-sharing for a majority of telemedicine PCP visits (announced previously on March 6, 2020)*
  • HMO/HMO-POS telemedicine visits are considered to be included in capitation.
  • PCPs will need to submit an encounter claim (837P) in order to be compensated for copayments.

Specialists and ancillary service providers

  • We are expanding telemedicine service availability to specialists and certain ancillary services, as shown in the Billing and coding for telemedicine services section of this article.
  • We will expand Behavioral Health telemedicine services to ensure that ASD (Autism Spectrum Disorder) affected members are still receiving ABA support while they are at home from school/clinic/community-based programming.  
  • Behavioral Health telemedicine services have also been expanded to include the Partial Hospitalization Program (PHP) and Intensive Outpatient Program (IOP).

Cost-sharing

  • Regular cost-sharing will apply to all specialist and ancillary telemedicine services not related to COVID-19 testing.
  • For high-deductible health plan (HDHP) members, cost-sharing will be waived for COVID-19 testing and primary care telemedicine visits and will be covered before deductible.

Reimbursement

  • Reimbursement will be at the same level as the current applicable contracted office fee schedule for a standard in-office visit including up to level 5 evaluation and management.

*Self-funded groups

  • Self-funded customers can opt-out of waiving PCP cost-sharing for non-COVID related telemedicine visits.
  • However, for self-funded health plans, coverage of telemedicine services is provided for COVID-19 testing without member cost-sharing consistent with the federal Families First law.

Billing and coding for telemedicine services

From March 6, 2020, through December 31, 2020, in addition to existing telemedicine services coverage, telemedicine services are eligible for reimbursement consideration by AmeriHealth when all the following criteria are met:

  • The service is medically necessary and able to be delivered using one of the following modes of communication:
    • Interactive, synchronous (real-time) two-way audio and video communications
    • A telephone (i.e., audio telecommunication only/telephone call) or online digital communication

Please note: The services outlined in the table below are only covered if delivered through an audiovisual (interactive, synchronous [real-time]) telecommunication.

  • Covered services provided through the AmeriHealth network of eligible providers include, but are not limited to:
    • primary medical care
    • specialty medical care (including behavioral health and applied behavioral analysis)
    • medical nutrition therapy
    • physical therapy
    • occupational therapy
    • speech therapy
    • home care
      • skilled nursing (intermittent; not including private duty nursing)
      • physical therapy
      • occupational therapy
      • speech therapy
      • medical nutrition therapy
      • social services
    • urgent care
  • The telemedicine services are reported with one of the procedure codes listed in the Coding section of the News Article referenced below.
The following services are covered through an audiovisual (interactive, synchronous [real-time]) telecommunication mode only:

Behavioral health – applied behavioral analysis

Outpatient physical therapy/occupational therapy

Urgent care

Home care – skilled nursing (intermittent; not including private duty nursing)

Home care – physical therapy

Home care – occupational therapy

Orthotics/prosthetic training

Preventive well visits

Reimbursement

For products with capitation arrangements, services delivered through telemedicine are considered included in capitation with the exception of those services identified in applicable policies identifying fee for service reimbursement. Refer to the appropriate claim payment policies for list of exceptions to capitation arrangements.

Required documentation

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to records from:

  • professional provider's office
  • hospital
  • nursing home
  • home health agencies
  • therapies
  • test reports

AmeriHealth may conduct reviews and audits of services to our members, regardless of the participation status of the professional provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

Billing requirements

  • Professional services: Eligible professional providers performing telemedicine services must report the appropriate modifier (Modifier GT or 95) and place-of-service (POS) code 02 (Telehealth) to ensure payment of eligible telemedicine services. 

Telemedicine services performed through a telephone communication only must report the appropriate POS code 02      ​(Telehealth) to ensure payment. Use of Modifier GT or 95 will not be required.

  • Facility services: Telemedicine evaluation and management (E&M) reported by facilities billing on a UB-04 claim form, or the equivalent form 837I, should report revenue code 0780 along with an appropriate E&M procedure code appended by Modifier GT or 95, as needed.
  • Ancillary services: Telemedicine ancillary services (e.g., PT/OT/ST) reported by facilities billing on a UB-04 claim form, or the equivalent form 837I, should report the appropriate revenue code along with the corresponding procedure code representing the service provided appended by Modifier GT or 95, as needed.

Inclusion of a code in this article does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and AmeriHealth policies apply.

Coding

For detailed coding information for the services listed above, please read the News Article, TelemedicineServices for AmeriHealth Pennsylvania Members (Updated May 19, 2020), which can be found in the News & Announcements section of the Medical Policy Portal.

Learn more

For more information about the AmeriHealth position on COVID-19, please review the following resources: