Telehealth Reimbursement Guide for FQHCs & RHCs

Telehealth Reimbursement Guide for FQHCs & RHCs

Provided by the CTRC is intended for general information purposes and is by no means all-inclusive, implied, or intended to be a substitute for professional legal and billing advice.

About this Course

Please note: The content provided in this course does not constitute legal advice. Many factors can impact the successful submission of claims for reimbursement. The ability to bill for a service does not necessarily guarantee reimbursement. CTRC does not guarantee payment for any service. Use the information in this guide in consultation with your billing specialist and other telehealth billing advisers.

This course is intended to help organizations obtain accurate information about telehealth billing and reimbursement programs for most major payors in the state of California. For information about national telehealth billing and reimbursement policies, please refer to the Center for Connected Health Policy (CCHP).
Telehealth service and reimbursement information can become outdated quickly and is often subject to change without notice. CTRC publishes updates to the CA Telehealth Reimbursement Guide and this course as often as possible and makes the most current version available on our website. To sign up for CTRC email updates, please visit
Despite these comprehensive efforts, CTRC may not always be aware of all California payor policies or changes to these policies. It is advisable to directly check periodically with your public, private, and commercial payors to remain current on all telehealth services eligible for reimbursement as well as rates of reimbursement for those services.

The state of California uses the term telehealth, though some providers and payors may use the term telemedicine when referring to the provision of health care at a distance. While the term telemedicine has been commonly used in the past, telehealth is a more universal term that covers a broad array of applications in the field. Its use crosses most health service disciplines including dentistry, counseling, physical therapy, and home health, among other domains.
Ideally, there should not be any regulatory distinction between a service delivered via telehealth and service delivered in person. Both should be held to the same quality and practice standards. The “tele-” descriptor should ultimately fade from use as these technologies seamlessly integrate into health care delivery systems. Note that while a connection exists between health information technology (HIT), health information exchange (HIE), and telehealth, neither HIT nor HIE is considered telehealth.

Telehealth (or virtual care) can include a range of services. Here are some common terms related to telehealth:

Virtual Care This broad term encompasses the full range of digital modes by which health providers remotely interact with patients in the course of delivering care. Similar terms include connected health care. Providers and patients may use a blend of synchronous and asynchronous digital technologies to complement care delivered in person.

Face-to-Face Is when a patient physically goes into a health center to see a provider.

Originating Site means the site where the patient is physically located at the time a telehealth service or telehealth consultation is provided. Usually, a home or health care center.

Direct to Consumer (DTC) or Direct to Patient (DTP) Telehealth is when a patient is not required to physically go into a health care center to receive medical or mental health services. The patient can connect directly with a provider from their home using a mobile phone, tablet, computer, or any device that connects to the internet to receive care.

eConsult services are a type of store-and-forward service by which primary care provider consults with a specialist via electronic messages including lab and imaging results and other information documented in the patient chart. eConsults can expedite a specialist referral when a higher level of care is needed.

Asynchronous Telehealth or Store and Forward:  Is when someone from a medical or mental health office collects and records medical health history in the form of data, images, audio, or video that they send over to another provider for evaluation using a secure portal to be review at a later time by a clinical health provider for interpretation, diagnosis, consultation and/or treatment.

Virtual Check-In Brief services are administered in real time between a practitioner and a patient via digital communications technologies such as secure live video, telephone, or online patient portal.

Remote Patient Monitoring/Remote Physiological Monitoring (RPM) describes self-collected patient health and medical data gathered in one location and transmitted via electronic communication technologies to a provider in a different location for use in care and related support. RPMs include digital devices self-administered by patients to monitor a health condition from home. Examples include wireless blood pressure cuffs, glucometers, and continuous glucose meters (CGMs). CMS uses the terminology Remote Physiological Monitoring to describe these activities.

Audio-only Telecommunication is communication through the use of a telephone.

In-Person Visit is when a provider and patient are physically present in the same room.

Remote Therapeutic Monitoring/Remote Treatment Management (RTM) describes the self-collection and electronic transmission of patient health information captured with medical devices that track non-physiological data such as medication adherence, responses to medications, or levels of pain.

A distant Site is a telehealth site where the provider/specialist sees the patient at a distance or consults with a patient’s provider. Other common names for this term include – hub site, specialty site, provider site, and referral site.

Consent is when a patient is agreeing to receive care treatment virtually. Consent is required before a healthcare service is provided via telehealth.

Communication Technology-Based Services (CTBS):

Medicare’s Definition of Telehealth
Medicare only includes virtual care services that have an in-person equivalent under the umbrella definition of telehealth.
All other reimbursable Medicare services delivered via telehealth technologies are considered to be communication technology-based services (CTBSs). Examples include:
• Virtual Check-In: Established patient-initiated secure messaging or transmission of images and/or pre-recorded video via asynchronous store-and-forward methods followed up with a brief phone call or video chat between patient and provider
• E-Visit: Asynchronous or synchronous medical evaluation conducted via a patient portal
• E-Consult: Interprofessional online consultation

Lesson 1 of 6

The Centers for Medicare and Medicaid Services (CMS) published current payment policies, payment rates, and other service provisions in the CY 2022 Medicare Physician Fee Schedule (PFS). Summary of key provisions effective on or after January 1, 2022:
● Revises telehealth services under the Consolidated Appropriations Act, 2021; allows audio-only communications technology to furnish mental health services in certain circumstances.
● Finalizes recent changes to Evaluation and Management (E/M) visit codes, such as policies for split or shared E/M visits, critical care services, and services furnished by teaching physicians.
● Modifies payment for therapy services furnished in whole or in part by a physical therapist assistant or occupational therapy assistant.
● Updates payment regulation for medical nutrition therapy services.
● Finalizes considerations for vaccine administration services.

In general, an FQHC/RHC is allowed to be an originating site for Medicare when the clinic is in an eligible geographic location and the patient is receiving services from a distant site provider while physically present within the four walls of the FQHC or RHC.
As of 2022, FQHCs and RHCs are permitted to bill for Chronic Care Management (CCM) and Transitional Care Management (TCM) services for the same patient during the same time period.

CMS established five basic criteria for telehealth reimbursement. Let’s review these along with the corresponding changes during the public health emergency:

Eligible originating sites

The location of the patient during a telehealth visit is also known as the “originating site”.
In order to meet this criteria for reimbursement, the patient must have been seen at an originating site as defined by CMS. Eligible originating sites include:

● Hospitals (inpatient or outpatient)
● Critical Access Hospitals
● Rural Health Clinics
● Federally Qualified Health Centers
● Skilled Nursing Facilities
● Community Mental Health Centers
● Mobile Stroke Units
● Rural Emergency Hospitals
● Hospital-based or critical access hospital-based renal dialysis centers (including satellites)
● Home of a patient for mental health services
Geographical requirements do not apply if certain conditions are met, including an initial in-person visit with the telehealth provider six months prior to provision of telehealth mental health services
● Home of a patient for:
◊ Monthly end stage renal disease (ESRD)-related clinical assessments
◊ Treatment of a substance use disorder


Patient does not need to be seen at an eligible originating site. Patients may be located in their place of residence or at an eligible originating site for the remainder of the public health emergency as deemed by the Secretary of the HHS.

Tip: HRSA developed the Medicare Telehealth Payment Eligibility Analyzer, a tool to help providers determine geographic eligibility for Medicare originating site telehealth services.
NOTE: Medicare does not apply originating site geographic conditions to hospital-based and critical access hospital-based renal dialysis centers, renal dialysis facilities, and beneficiary homes when practitioners furnish monthly home dialysis end-stage renal disease (ESRD)-related medical evaluations. Independent renal dialysis facilities are not eligible originating sites.
NOTE: As of January 1, 2019, the Bipartisan Budget Act of 2018 removed the originating site geographic conditions and added eligible originating sites to diagnose, evaluate, or treat symptoms of an acute stroke.
NOTE: The Consolidated Appropriations Act of 2021 included an update to the eligible originating site list to include rural emergency hospitals. The Act also requires an in-clinic visit six months prior in order for a patient to receive telehealth mental health services in the home.

The Originating site must be located in one of the following geographical areas

Outside of a Metropolitan Statistical Area (MSA)
Inside of a Rural Health Professional Shortage Area (HPSA) inside of a rural census tract.

To determine if a location is eligible, visit the HRSA eligibility analyzer FOUND HERE



For the remainder of the public health emergency patients may be located in an urban or rural area.

The location of the provider during a telehealth visit is also known as the “distant site”.

In order to meet this criteria for reimbursement, the encounter must have been performed by an eligible practitioner at the distant site. Eligible distance site practitioners are as follows:

● Physicians
● Nurse Practitioners (NPs)
● Physician Assistants (PAs)
● Nurse-midwives
● Clinical Nurse Specialists (CNSs)
● Certified Registered Nurse Anesthetists (CRNAs)
● Clinical Psychologists (CPs)*
● Clinical Social Workers (CSWs)*
● Registered Dieticians or Nutritional Professionals
● X-waivered providers supporting SUD/MAT/Opioid Treatment Programs (OTP)

● MAs, RNs can work under supervision of collaborative physician or above listed practitioners (Exceptional)*

*Note: CPs and CSWs cannot bill for psychiatric diagnostic interview examinations with medical services or medical evaluation and management services under Medicare. These practitioners may not bill or receive payment for Current Procedural Terminology (CPT) codes 90792, 90833, 90836, and 90838
What is an Originating Site?


With the passage of the CARES Act, for the duration of the PHE, FQHCs/RHCs can act as a distant site. 

CMS also added PT, OT and SLPs as eligible distant site providers.  

The patient must be present and the encounter must involve interactive audio and video telecommunications that provides real-time communication between the practitioner and the Medicare beneficiary.

Select services can be audio only for the duration of the PHE


The type of service provided must fall within the Medicare eligible services table.

You can find eligible services and corresponding CPT and HCPCS codes in the Telehealth Services Fact Sheet

CMS has added 80 additional codes to the existing list of eligible telehealth services


Billing & Reimbursement

Originating Site Fee
The originating site is eligible to receive a facility fee for providing services via telehealth. As of January 2022, the payment amount is 80% of the lesser of the actual charge, or $27.59. The site receives a flat reimbursement rate, outside of any other reimbursement arrangements such as inpatient prospective payment systems (IPPS)/diagnosis-related groups (MS-DRGs) under or Rural Health Center (RHC) per-visit payments.

Billing Instructions for Various Originating Site Facilities

  • Community Mental Health Centers (CMHCs)
    The originating site facility fee does not count toward the number of services used to determine payment for partial hospitalization services.
  • Critical Access Hospitals (CAHs)
    Traditional Medicare payment amount is 80 percent of the originating site facility fee.
  • FQHCs and RHCs
    The originating site facility fee for Medicare telehealth services is not an FQHC or RHC service. When an FQHC or RHC serves as the originating site, the originating site facility fee must be paid separately from the center or clinic all-inclusive rate (AIR).

Medicare Telehealth Billing Reference

  • In addition to FQHCs, RHCs, and CAHs, Chapter 12 of the Medicare Claims Processing Manual, Section 190 describes Medicare payment for telehealth services delivered in a variety of originating and distant sites

Distant Site Clinical Services Fees

NOTE: A distant site designates the location of the practitioner at the time the telehealth service is furnished. The cost of a visit may not be billed or included on the cost report.

  • Distant Site Clinical Services Fees provide reimbursement to the health professional delivering the clinical service at the same rate as the current fee schedule amount for the service provided without telemedicine.
  •  Distant site claims for reimbursement should be submitted with the appropriate CPT code or HCPCS code for the professional services provided. Distant site practitioners billing telehealth services under the CAH Optional Payment Method (Method II) will submit institutional claims using the GT modifier.
  • Distant sites use Place of Service (POS) 02 (Telehealth) for all encounters.
  • Although FQHCs and RHCs are included on the eligible list of facility types that may serve as distant site providers, FQHCs and RHCs are not paid the typical prospective payment system (PPS) or all-inclusive rate (AIR). While these entities may provide services via telehealth under Medicare, they will not be paid a set rate calculated by CMS for each eligible service delivered via telehealth, all of which are billed using HCPCS code G2023. The amount is based on a formula created by CMS.

Telehealth Place of Service (POS) Codes
CMS publishes a list of Place of Service (POS) codes to use on the CMS-1500 Health Insurance Claim Form to indicate where the provider and patient are located during a health encounter. The treatment location affects reimbursement, CPT code categories, and modifiers to use with CPT codes.
Synchronous Services POS Codes.

The Q3014 is to be used when services are provided within an outpatient medical facility. It is not reimbursable for encounters outside of a clinical setting.

  • The POS 02 code is required to bill for Medicare synchronous telehealth services on billing form CMS 100.
  • In 2022, CMS introduced the code POS 10 for telehealth patients receive when located in their homes.

POS 02: Telehealth Provided Other than in a Patient’s Home. This code designates that the place of service where the patient receives health services and health-related services provided via telecommunication technology is not the patient’s home. Policy went into effect 1/1/17. An updated description went into effect 1/1/2022, and is applicable for Medicare as of 4/1/22.

POS 10: Telehealth Provided in a Patient’s Home. This code designates the patient’s home as the place of service where health services and health-related services are provided or received through telecommunication technology as opposed to locations other than the patient’s home such as a hospital, clinic, or other care facility. Effective 1/1/2022, and applicable for Medicare 4/1/2022.

  • HCPCS Originating Site Facility Fee Code: Q3014
  • Type of Service: 9-Other Items and Services
  • Place of Service: 02-Telehealth
  • Bill the Medicare Administrative Contractor (MAC) for the separately billable originating site facility under Medicare Part B

For a full List of Medicare Telehealth Services, view the CTRC California Telehealth Reimbursement Guide.

Medicare: FQHC/RHC Billing as a Distant Site

CMS originally released MLN SE20016 on April 17, 2020 detailing payment for FQHCs/RHCs during the public health emergency. On April 30, 2020, and again on July 6, 2020 CMS updated the previously mentioned MLN. See the latest Jun 2021 MLN901705. 

Distant site telehealth services can be furnished by any health care practitioner working for the clinic within their scope of practice. The practitioners can furnish the telehealth services from any distant site location, including their homes, during the time they are working for the RHC or FQHC.

  • RHCs and FQHCs can bill Medicare for telehealth services as distant site providers, at a reimbursement rate of $97.24 for claims submitted between January 1, 2022-December 31, 2022.
  • The patient’s home is an eligible originating site, as of March 6, 2020.

Specific Payment Codes for FQHC PPS 

Per the CMS MLN: For RHC telehealth distant site services starting July 1, 2020 through the end of the public health emergency:

  • Telehealth services, for established patients only, will be billed with G2025
    • Appending modifier 95 is optional

Per the CMS MLN: For FQHC qualifying telehealth visits furnished from January 27, 2020 through June 30, 2020

  • Bill using the FQHC PPS specific payment code (GO466, G0467, G0468, G0469, or G0470) and;
  • The HCPCS/CPT code that describes the services furnished via telehealth with modifier 95 and;
  • G2025 with modifier 95
  • POS is equivalent to where the service would have been rendered in person

Per the CMS MLN: For FQHC qualifying telehealth visits furnished beginning July 1, 2020 through the end of the public health emergency:

  • Bill using G2025 for established patients only
    • Modifier 95 is optional

Per the MAC (Noridian): For FQHC qualifying telehealth visits BILLED July 1, 2020 through the end of the public health emergency:

  • Bill using G2025
    • Modifier 95 is optional



Only distant site telehealth services furnished during the COVID-19 PHE are authorized for payment to RHCs and FQHCs.


Medicare Advantage Wrap Payments:

Since telehealth distant site services are not paid under the RHC AIR or the FQHC PPS, the Medicare Advantage (MA) wrap-around payment does not apply to these services. Wrap-around payment for distant site telehealth services will be adjusted by the MA plans.

Audio Only Billing for FQHCs & RHCs

Effective March 1, 2020 FQHCs and RHCs can furnish and bill for audio-only (telephone) E/M services.

Bill these services using HCPCS code G2025.

To bill for these services, at least 5 minutes of telephone E/M service by a physician or other qualified health care professional who may report E/M services must be provided to an established patient, parent, or guardian. These services cannot be billed if they originate from a related E/M service provided within the previous 7 days or lead to an E/M service or procedure within the next 24 hours or soonest available appointment.

COVID-19 Testing and Treatment: Waiving of Cost Sharing

NOTE: COVID-19 Guidelines are updated frequently!

Retroactive to March 18, 2020, CMS will pay all of the reasonable costs for specified categories of E/M services, if they result in an order for, or administration of, a COVID-19 test and relate to the furnishing, or administration of, such test or to the evaluation of an individual for purposes of determining the need for such test. This would include applicable telehealth services.

For visits and services related to COVID-19 testing, clinics must waive the collection of co-insurance from beneficiaries. Clinics have the option to waive cost sharing for all telehealth services.

For all visits and services in which the coinsurance is waived, FQHCs and RHCs must append modifier CS on the service line.

Claims with the CS modifier will initially be paid with the coinsurance applied, HOWEVER, the MAC will automatically reprocess these claims.

Coinsurance should not be collected from beneficiaries if the coinsurance is waived.

Let’s say you’re providing services that are not equivalent to a face-to-face visit and will not be able to bill for telehealth as a distant site… What other choices do you have available? Let’s explore the following options!

CTRC - Contact Us
Virtual Check-Ins

Virtual Check-Ins are billed with code G0071.

These interactions are patient initiated telephone or live video interactions. They involve a physician or non-physician practitioner having a brief, at least 5 minute, check-in with a patient to assess whether the patient needs to come in for an office visit. The practitioner may respond to the patient’s concern by telephone, audio/video, secure text messaging, email, or use of a patient portal.

The virtual check-in must be for a condition not related to an E/M service provided within the previous 7 days and does not lead to an E/M service or procedure within the next 24 hours or soonest available appointment.

There are no frequency limitations at this time.

Billable providers are physicians, nurse practitioners, physician assistants, certified nurse midwives, clinical psychologists, and clinical social workers. If the discussion could be conducted by a nurse, health educator, or other clinical personnel, it would not be billable as a virtual communication service.

A medical professional taking a young patient's vitals to demonstrate how telehealth can improve health care workforce retention.

E-visits are billed with code G0071.

E-visits are patient-initiated digital communications via an online patient portal that requires a clinical decision that otherwise typically would have been provided in the office.

Billable provider spends at least five or more minutes over the course of seven days providing online E/M services. Seven days must lapse before you bill G0071 again for the same condition.

Includes multiple digital visits over the course of seven days if for related signs/symptoms/conditions.

Remote Evaluation Services – Store & Forward

Remote Evaluation Services are billed with code G0071.

Remote evaluation services are patient initiated and consist of a practitioner evaluating a patient’s transmitted information via pre-recorded video or image. The practitioner may respond to the patient’s concern by telephone, audio/video, secure text messaging, email, or use of a patient portal.

 The services can only be billed if the condition is not related to a service provided within the previous 7 days and does not lead to a service provided within the next 24 hours or soonest available appointment.

There are no frequency limitations at this time.

Billable by physicians, nurse practitioners, physician assistants, certified nurse midwives, clinical psychologists, and clinical social workers. If the discussion could be conducted by a nurse, health educator, or other clinical personnel, it would not be billable as a virtual communication service. 

For more information on Remote Evaluation Services, click HERE.

Billing the G0071

Use a UB 04 claim form

      • RHC Type Of Bill 711
      • FQHC Type Of Bill 771

Assign revenue code 0521

No modifier is required

For the emergency period effective Jan 1, 2022, CMS will pay $23.88. See here.

Consent for Medicare Services

A verbal patient consent is required for all Virtual Visits (Virtual Check-Ins, e-visits, and Remote Evaluation).

Consent can be obtained at the time that the service is furnished or prior to the service being furnished during the emergency period.

Consent may be obtained by ancillary staff under the general supervision of the RHC or FQHC provider.


A Note About Video Platforms

The federal Office of Civil Rights (OCR) has temporarily relaxed its enforcement standards during this national emergency to allow covered health care providers to use video technologies that do not fully comply with HIPAA rules. These include non-public facing “popular” video products such FaceTime or Skype.
Health care providers choosing to use these products a required to inform patients that there may be privacy risks and obtain consent.
Health care providers seeking more privacy for patients should consider products that use encryption and tools such as passcodes to restrict the session, and vendors that will sign HIPAA Business Associates Agreements (BAAs) in connection with their video solutions.


CMS COVID-19 Resources
CMS Current Emergencies Page

Go here for information and updates about natural disasters, man-made incidents, and public health emergencies that are happening now.

CMS Newsroom

Look here for media releases to be updated on the latest from CMS

CMS MLN Connects Newsletters

Scroll bottom of the page and sign up for emails so you can be notified as soon as any CMS changes are made

FFS Medi-Cal Billing Requirements for Virtual/Telephonic Communications

On February 3rd, 2022, DHCS updated their Medi-Cal Billing requirements for Virtual/Telephonic Communications.

FQHCs/RHCs are able to bill their PPS rate, as applicable, for live video telehealth and telephone services.

Patients do NOT have to be HHMS to be seen in their home during the public health emergency.

Medi-Cal also released a COVID-19 PHE Operational Unwinding Plan on August 22, 2022. This includes information on Medi-Cals global unwinding approach in regards to Telehealth and Medi-Cal, Medi-Cal benefit, reimbursement rate changes, HCBS, tracking Medi-Cal trends during PHE period and beyond.

Below is a chart that outlines the associated HCPCS or CPT codes for billing either the Medi-Cal FFS rate or PPS rate.


Please Note:

DHCS is aware that FQHCs, RHCs, and Tribal 638 Clinics do not include CPT codes as part of traditional claim submission. That said, for purposes of the temporary flexibilities under this policy and to allow DHCS to track that services were provided via virtual/telephonic communication modalities, DHCS is requesting this modified billing structure relative to the Section III guidance, i.e., including the CPT codes on the “information line” of the claim form. The selected CPT codes will also allow DHCS to also track the level of complexity (low, medium, high, etc.) of the visit and whether it is a new or established patient.


Medi-Cal FFS:

For the PPS rate, FQHCs/RHCs would need to list HCPCS code T1015 in the “payable” claim line in conjunction with one of the appropriate corresponding CPT codes (i.e., 99201-99203 for “new” patients, and 99212-99214 for “established patients) on the “informational” line relative to the complexity of the virtual/telephonic communication. Please note that the corresponding CPT codes are not separately reimbursed, but instead will be used to identify the virtual/telephonic communication visit as well as by DHCS for tracking and reporting purposes related to COVID-19.

For the Medi-Cal FFS rate when billing with the HCPCS code G0071, clinics should only list the HCPCS code on the “payable” claim line and should not include a corresponding CPT code.

Medi-Cal Managed Care:

FQHCs/RHCs will receive their PPS rate, as applicable, for rendering a Medi-Cal covered benefits or services – whether provided through telehealth or virtual/telephonic communication – if they meet the criteria/guidance.

DHCS will ensure the FQHCs/RHCs are made whole with an appropriate wrap payment, consistent with existing DHCS policy.

Medi-Cal Fee-For-Service
Informed Consent Requirements Prior to COVID-19

Health care providers must inform the patient about the use of telehealth and obtain verbal or written consent from the patient for the use of telehealth as an acceptable mode of delivering health care services.
If a health care provider, whether at the originating site or distant site, maintains a general consent agreement that specifically mentions use of telehealth as an acceptable modality for delivery of services, then this is sufficient for documentation of patient consent and should be kept in the patient’s medical file.

The consent shall be documented in the patient’s medical file upon DHCS request. Consent shall including the following:

  • A description of the risks, benefits and consequences of telemedicine
  • The patient retains the right to withdraw at any time
  • All existing confidentiality protections apply
  • The patient has access to all transmitted medical information
  • No dissemination of any patient images or information to other entities without further written consent

Telehealth informed consent requirement is suspended during the public health emergency for all health plans in California. This waiver does not affect the informed consent requirements for Medicare patients.

CA Executive Order N-43-20 (4.3.2020)


All health care practitioners providing covered benefits or services must maintain appropriate documentation to substantiate the corresponding technical and professional components of billed CPT or HCPCS codes.

Documentation for benefits or services delivered via telehealth should be the same as for a comparable in-person service.

Additional Resources

Providers may contant and email questions about Medi-Cal telehealth policy here.

California Department of Health Care Services Medi-Cal Program Telehealth Webpage

California Department of Health Care Services COVID-19 Resource Page

California Department of Managed Health Care COVID-19 Resource Page

CTRC has updated its Telehealth Reimbursement Guide effective Spring 2022. The guide includes telehealth reimbursement policies for Medicare, Medi-Cal Fee-For-Service, and some Managed Care plans. We have also expanded and updated the reimbursement information and scenarios specific to FQHCs and RHCs.

All health plans should be reimbursing for telehealth and telephone during the public health emergency.

The reimbursement rates should be equal to the rate for in person services.

Modifiers could be different – Some health plans use 95 and some still use GT.

POS could be 02 or 10.

Listen to your health plans, even if they want you to bill in a way that you are not used to. 

Department of Managed Health Care (DMHC) Updates

DMHC APL 20-009 from March 18, 2020 states: 

Pursuant to the authority granted in the California Emergency Services Act (Gov. Code sections 8566, et seq.), all health plans shall, effective immediately, comply with the following:

  • Health plans shall reimburse providers at the same rate, whether a service is provided in-person or through telehealth, if the service is the same regardless of the modality of delivery, as determined by the provider’s description of the service on the claim.  For example, if a health plan reimburses a mental health provider $100 for  50-minute therapy session conducted in-person, the health plan shall reimburse the provider $100 for a 50-minute therapy session done via telehealth.
  • For services provided via telehealth, a health plan may not subject enrollees to cost-sharing greater than the same cost-sharing if the service were provided in person.
  • Health plans provide the same amount of reimbursement for a service rendered via telephone as they would if the service is rendered via video, provided the modality by which the service is rendered (telephone versus video) is medically appropriate for the enrollee.

DMHC APL 20-013 from April 7, 2020 states:

A health plan may not exclude coverage for certain types of services or categories of services simply because the services are rendered via telehealth, if the enrollee’s provider, in his/her professional judgment, determines the services can be effectively delivered via telehealth. For example, a health plan may not categorically exclude coverage for Applied Behavioral Analysis services delivered via telehealth (video or telephone) during the State of Emergency.

Likewise, during the COVID-19 State of Emergency a health plan may not place limits on covered services simply because the services are provided via telehealth if such limits would not apply if the services were provided in-person. For example, if a health plan allows an enrollee to receive a particular covered service up to three times per week if the enrollee receives the service in-person, the health plan may not limit the service to only once per week if the service is delivered via telehealth.

The Department has heard from providers and enrollees that health plans are requiring their enrollees to access services through the plans’ contracted telehealth vendor (e.g., Teledoc) rather than covering telehealth services delivered by providers who have typically delivered services to the enrollees in person. 

During the COVID-19 State of Emergency, a health plan may not require enrollees to use the plan’s telehealth vendor, or a different provider from the one the enrollee typically sees, if the enrollee’s provider is willing to deliver services to the enrollee via telehealth and the enrollee consents to receiving services via telehealth.

Telehealth Reimbursement Guide

Telehealth E/M Coding Guide