C.M.R. 10, 144, ch. 101, ch. I, § 144-101-I-4, subsec. 144-101-I-4.04

Current through 2024-46, November 13, 2024

Subsection 144-101-I-4.04 - COVERED SERVICES

4.04-1Telehealth Services

Any medically necessary MaineCare Covered Service may be delivered via Telehealth Services, provided the following requirements are met:

1. The Member is otherwise eligible for the Covered Service, as described in the appropriate Section of the MBM; and

2. The Covered Service delivered by Telehealth Services is of comparable quality to what it would be were it delivered in person.

Prior authorization is required for Telehealth Services only if prior authorization is required for the underlying Covered Service. In these cases, the prior authorization is the usual prior authorization for the underlying Covered Service, rather than a prior authorization for the mode of delivery. Unless otherwise required by law, a face-to-face encounter is not required prior to delivering Telehealth Services.

4.04-2Store-and-Forward Telehealth Services

Store-and-Forward (asynchronous) Telehealth is only permitted for established patients and involves the transmission of recorded clinical information (including, but not limited to radiographs, photographs, video, digital impressions, and photomicrographs of patients) through a secure electronic communications system to a Health Care Provider. All health information must be transmitted via secured email. In order for the Health Care Provider to be reimbursed for a covered service delivered via Store-and-Forward Telehealth, a Member must not be present.

A.Virtual Transfer of Health Information

The Health Care Provider uses health information that has been virtually transferred to evaluate a Member's condition or render a covered MaineCare service separate from Telehealth Services. The Health Care Provider uses a computer or a mobile device, such as a smartphone, to gather and send the information. Information is transmitted by electronic mail, uploaded to a secure website, or a private network. Only the Health Care Provider who receives and reviews the recorded clinical information is eligible for reimbursement.

B.Remote Consultation Between a Treating Provider and Specialist

A Specialist provides interprofessional telecommunications assessment and management services to a Treating Provider. The interaction includes discussion (via telephone or internet) of a written report by the Specialist to assess the Member's Electronic Health Record and/or diagnoses/treatment.

Duration of this service must be a minimum of five minutes and no greater than thirty minutes. The Treating Provider must document that they have informed the Member as to results and conclusions following the Remote Consultation.

The Treating Provider must document in the Member's medical record the Member's written, electronic, or verbal consent for each Remote Consultation. Billing for interprofessional services is limited to those practitioners who can independently bill MaineCare for evaluation and management services.

Remote Consultation may be utilized as often as medically necessary, per the terms of these rules.

4.04-3Telemonitoring Services

A. Telemonitoring Services are intended to collect a Member's health related data, such as pulse and blood pressure readings, that assist Health Care Providers in monitoring and assessing the Member's medical conditions. The following activities qualify as Telemonitoring Services:

1. Evaluation of the Member to determine if Telemonitoring Services are medically necessary for the Member. Prior to conducting an evaluation, the Home Health Agency must assure that a Health Care Provider's order or note demonstrating the necessity of Telemonitoring Services, is included in the Member's Plan of Care.

2. Evaluation of the Member to assure that the Member is cognitively and physically capable of operating the Telemonitoring equipment or assurance that the Member has a caregiver willing and able to assist with the equipment;

3. Evaluation of the Member's residence to determine suitability for Telemonitoring Services. If the residence appears unable to support Telemonitoring Services, the Home Health Agency may not implement Telemonitoring Services in the Member's residence unless necessary adaptations are made. Adaptations are not reimbursable by MaineCare;

4. Education and training of the Member and/or caregiver on the use, maintenance and safety of the Telemonitoring equipment, the cost of which is included in the monthly flat rate paid by MaineCare to the Home Health Agency;

5. Remote monitoring and tracking of the Member's health data by a registered nurse, nurse practitioner, physician's assistant, or physician, and response with appropriate clinical interventions. The Home Health Agency and Health Care Provider utilizing the data shall maintain a written protocol that indicates the manner in which data shall be shared in the event of emergencies or other medical complications;

6. At least monthly Interactive Telehealth Services or Telephonic Services with the Member;

7. Maintenance of equipment, the cost of which is included in the monthly flat rate paid by MaineCare to the Home Health Agency; and

8. Removal/disconnection of equipment from the Member's home when Telemonitoring Services are no longer necessary or authorized.

4.04-4Virtual Check-In

Virtual Check-in is a brief communication where an established patient checks in with a Health Care Provider using a telephone or other telecommunications device for 5-10 minutes to determine the status of a chronic clinical condition(s) and to determine whether an office visit is needed. Modalities permitted for Virtual Check-Ins include Telephonic Services or Interactive Services to deliver clinical services at a distance for the purpose of diagnosis, disease monitoring, or treatment.

Communications exclusively by email, text, or voicemail are not reimbursable.

The Health Care Provider must document a Virtual Check-In in the Member's record, including the length of the Virtual Check-In, an overview and outcome of the conversation, and the modality of the interaction.

If the Virtual Check-In takes place within seven (7) days after an in-person visit or triggers an in-person office visit within 24 hours (or the soonest available appointment), the Virtual Check-In is not billable under this Section.

4.04-5Telephone Evaluation and Management Services

The Department will reimburse providers for Telephone Evaluation and Management Services provided to members.

Telephone Evaluation and Management Services are not to be billed if clinical decision-making dictates a need to see the member for an office visit within 24 hours or at the next available appointment. In those circumstances, the telephone service shall be considered a part of the subsequent office visit. If the telephone call follows an office visit performed and reported within the past seven (7) days for the same diagnosis, then the telephone services are considered part of the previous office visit and are not separately billable.

C.M.R. 10, 144, ch. 101, ch. I, § 144-101-I-4, subsec. 144-101-I-4.04