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

June 29, 2020

This article was revised on June 29, 2020, to update the effective date range. To learn about the AmeriHealth Pennsylvania position on telemedicine services, please read this article.

AmeriHealth New Jersey 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 New Jersey members to visit our dedicated COVID-19 webpage for AmeriHealth New Jersey 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 New Jersey is expanding its telemedicine and telehealth services. The below changes are effective March 6, 2020, through the public health emergency or December 31, 2020, whichever is later, and supersede Policy #00.10.42c Telemedicine and Telehealth (AmeriHealth New Jersey) during this time period:

  • The expanded telemedicine coverage for fully insured plans includes:
    • providing coverage by any licensed provider for any service that may be appropriately delivered through telemedicine;
    • waiving cost-sharing on any telemedicine services, including non-COVID-19 related services. 
  • Providers will receive the same reimbursement for telemedicine services as they do for in-person services for as long as this change is in effect.
    • Capitated providers will be kept whole consistent with prior decisions regarding cost-sharing.
    • Primary care providers will be reimbursed for cost-share based upon the initial claim submitted for telemedicine services.

        Refer to the member cost-share claims processing article for more information.

  • Prior authorizations are not required for services delivered via telemedicine while the COVID-19 emergency order is in place.
  • 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.

Under New Jersey law, telemedicine and telehealth are separate and defined terms. All mentions of telemedicine include both telemedicine and telehealth.

The new expansion of telemedicine complies with recently enacted New Jersey legislation.  

Billing and coding for telemedicine services

From March 6, 2020, through the public health emergency or December 31, 2020, whichever is later, and superseding Policy #00.10.42c Telemedicine and Telehealth (AmeriHealth New Jersey), in accordance with the member’s benefits, telemedicine and telehealth services are eligible for reimbursement consideration by AmeriHealth New Jersey when all the following criteria are met:

  • The services are medically necessary and able to be delivered using one of the following modes of communications:
    • two-way audio and video communications
      • Interactive, synchronous (real-time)
      • Interactive, synchronous (real-time) in conjunction with store and forward delayed communications
    • a telephone (i.e., audio telecommunication only/telephone call) or online digital communication
  • Covered services include, but are not limited to:
    • primary medical care
    • specialty medical care
    • behavioral health
    • medical nutrition therapy
    • physical therapy
    • occupational therapy
    • speech therapy
    • home care
      • skilled nursing (intermittent)
      • physical therapy
      • occupational therapy
      • speech therapy
      • medical nutrition therapy
      • social services
    • urgent care

New Jersey state mandates do not automatically apply to self-funded groups; therefore, individual group benefits must be verified through the Eligibility and Benefits transaction on the NaviNet® web portal (NaviNet Open).

Reimbursement

For products with capitation arrangements, services delivered through telemedicine and telehealth 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 New Jersey 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 AmeriHealth New Jersey 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 and telehealth services must report both the appropriate modifiers (Modifier GT, GQ, or 95) and place-of-service (POS) code 02 (Telehealth) to ensure payment of eligible telemedicine services.

    Telemedicine and telehealth services performed through a telephone or online digital communication must report the appropriate POS code 02 (Telehealth) to ensure payment. Use of Modifier GT, GQ, 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, GQ, 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, GQ, or 95, as needed.

Eligibility, benefits, limitations, exclusions, provider contracts, and AmeriHealth New Jersey policies apply.

Coding

Providers should report only those services that are medically necessary and are able to be delivered through one of the modes of communication detailed above.

AmeriHealth New Jersey continues to not recognize the following CPT® procedure codes as telemedicine. These are interprofessional services/procedure codes that do not represent direct communication with the member. The following services remain not eligible for reimbursement:

  • 99446
  • 99447
  • 99448
  • 99449
  • 99451
  • 99452

The following services continue to be considered a benefit exclusion for medical and behavioral health services:

  • Q3014
  • S5185

For more information, please read the News Article, Telemedicine and Telehealth Services for AmeriHealth New Jersey 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:

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