Download - Anthem Blue Cross Telehealth Program

Anthem Blue CrossTelehealth Program

Provider Manual

CHHRC1

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September 2014 - version 2.4

CHHRC1

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Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program

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Table of Contents Provider Manual


Chapter 1: Introduction to Telehealth ....................................................................... 7

Overview ........................................................................................................................................... 7

Telehealth Program Objectives ........................................................................................................ 8

Telehealth Consultations .................................................................................................................. 8

Open Access Network Model............................................................................................................ 9

Readiness Disclosure Statement .................................................................................................... 10

Misrouted Protected Health Information ...................................................................................... 10

Chapter 2: Telehealth Contacts ................................................................................ 11

Telehealth Department Contacts .................................................................................................... 11

Technical Support for Systems and Software ................................................................................. 11

Provider/Member Services ............................................................................................................ 12

Utilization Management Services ...................................................................................................13

Vision Service Plan ..........................................................................................................................13

Chapter 3: Frequently Asked Questions ...................................................................14

What is Telehealth? ........................................................................................................................ 14

Why Use Telehealth? ...................................................................................................................... 14

What is Anthem Blue Cross’ Telehealth Program? ......................................................................... 15

What Types of Specialists Are Available? ....................................................................................... 15

How Does It Work? ......................................................................................................................... 15

For Live Video Telehealth: ........................................................................................................... 15

For Store and Forward Telehealth: ............................................................................................. 16

What Documentation is Required? ................................................................................................ 16

Whom Do I Call with Questions? ................................................................................................... 16

Chapter 4: Site Locations ......................................................................................... 17

Step‐By‐Step Instructions ............................................................................................................... 17

Chapter 5: Roles and Responsibilities ......................................................................19

Anthem Blue Cross ......................................................................................................................... 19

Presentation Sites ........................................................................................................................... 19



Specialty Centers ............................................................................................................................ 20

Chapter 6: When to Choose Telehealth .................................................................... 21

Assessing Telehealth Services ........................................................................................................ 21

Evaluating Telehealth Opportunities.......................................................................................... 21

Assessment for Appropriate Type of Telehealth Consultation .................................................. 23

Chapter 7: How to… ................................................................................................ 24

Refer a Patient for Telehealth Services .......................................................................................... 24

Assess the Patient’s Appropriateness for Telehealth Services ................................................... 24

Request Patient’s Verbal Consent for a Telehealth Consult ....................................................... 24

Request a Consultation ............................................................................................................... 25

Determine Appropriate Consultant Type ................................................................................... 25

Prepare and Schedule a Telehealth Encounter .............................................................................. 26

After Sending the Store and Forward Consultation Request ..................................................... 26

Schedule the Telehealth Consultation ........................................................................................ 27

Finalize Details ‐ One Day Prior to the Scheduled Appointment ............................................... 27

Finalize Details ‐ Immediately Before the Scheduled Appointment .......................................... 28

Conduct a Telehealth Consultation ................................................................................................ 28

During the Patient’s Appointment .............................................................................................. 28

Post Consultation ........................................................................................................................... 30

Evaluate and Implement the Recommended Treatment Plan from the Telehealth Specialist .... 30

Chapter 8: Claims and Billing ................................................................................. 32

Overview ......................................................................................................................................... 32

Electronic Professional Billing ....................................................................................................... 33

Anthem Blue Cross Utilization Controls and Procedures ............................................................. 33

Telehealth Billing for California Programs .................................................................................... 34

Fee Schedule ................................................................................................................................ 34

Modifiers ..................................................................................................................................... 34

Billable Codes for Telehealth ...................................................................................................... 35



Telecommunication Charges ...................................................................................................... 35

Billable CPT Codes for Live Video Telehealth Encounters ........................................................ 36

Site Fees for Live Video ............................................................................................................... 36

Billable Codes for Store and Forward Telehealth Encounters ...................................................... 37

Telecommunication Charges ...................................................................................................... 37

Specialists .................................................................................................................................... 37

Site Fees for Store and Forward ................................................................................................. 37

Submitting Telehealth Claims .................................................................................................... 38

Chapter 9: Developing Telehealth Medical Record Documentation ......................... 47

Introduction.................................................................................................................................... 47

Monitoring Usage and Reporting to Anthem Blue Cross .............................................................. 48

What Anthem Blue Cross Monitors ............................................................................................ 48

What You Should Report ............................................................................................................ 49

When You Should Report ........................................................................................................... 49

Telehealth Information Forms ....................................................................................................... 50

Telehealth Consultation Summary Form ................................................................................... 50

Telehealth Utilization Log ........................................................................................................... 50

Instructions for Completing the Utilization Log ........................................................................ 50

Patient Satisfaction Survey .......................................................................................................... 51

Chapter 11: Telehealth Program Glossary ............................................................... 52

Telehealth Information Forms ....................................................................................................... 54


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Chapter 1: Introduction to Telehealth

Provider Manual

Overview Anthem Blue Cross develops, manages, and comprehensively supports a statewide Telehealth

program in California to improve access to care

for rural populations. Anthem Blue Cross

facilitates access to Telehealth services, facilities

and technology through this program. These

Telehealth services are currently available to the

following member populations:

• CalPERS Basic Plan members residing in rural ZIP codes. Anthem Blue Cross administers

the CalPERS Basic Plan on behalf of Anthem Blue Cross Life and Health Insurance

Company. Anthem Blue Cross administers claims on behalf of Anthem Blue Cross Life

and Health Insurance Company but is not financially liable for benefits payable.

• Prudent Buyer PPO members residing in rural ZIP codes. Anthem Blue Cross administers

Prudent Buyer plans on behalf of Anthem Blue Cross Life and Health Insurance

Company. Anthem Blue Cross administers claims on behalf of Anthem Blue Cross Life

and Health Insurance Company but is not financially liable for benefits payable. The

following Prudent Buyer groups are eligible for the Telehealth benefit:

Blue Cross’ PPO Butte Schools Self-funded Program

Blue Cross’ PPO California’s Valued Trust (CVT)

Blue Cross’ PPO Self-Insured Schools of California (SISC)

Blue Cross’ PPO University of California (UC)

• County Medical Services Program (CMSP) with claims administered by Anthem Blue Cross Life and Health Insurance Company

• Anthem Blue Cross Medi-Cal Managed Care Plans

• Access for Infants and Mothers (AIM) program

Please note: the specific terms, conditions and limitations of Telehealth benefits are

dependent on the terms of the member’s particular coverage. Review your Service

Agreement Amendment Exhibit A to check the status of Anthem Blue Cross members

participating in the Telehealth benefit or call the Customer Service Center to check

benefit eligibility.


Provider Manual


Telehealth Program Objectives

The objectives of Anthem Blue Cross’ Telehealth program are to:

• Increase access to care in rural areas

• Improve timeliness to diagnosis and treatment planning

• Improve quality of care

• Support the continued education and retention of rural providers

Telehealth is a health care delivery method that applies high-speed telecommunication

systems, computer technology and specialized medical cameras to examine, diagnose, treat and

educate patients at a distance. For example, through a Telehealth encounter, a patient in the

Sierra Mountains may seek medical treatment from a provider or specialist in Los Angeles or

San Francisco without incurring the expense of traveling to such distant locations.

Telehealth Consultations

While the application of Telehealth varies based on the specialty consultation needed, the two

methods of Telehealth encounters used in Anthem Blue Cross’ Telehealth program are:

Live Video (simultaneous) consultation: Connects the patient, primary care provider

(PCP) and specialist at the same time with video conferencing equipment to discuss

the patient’s medical condition

Store and Forward (asynchronous) consultation: Uses software to store and encrypt

the pertinent medical data and images. The presentation site then transmits the

secured data electronically to the specialist for review and consultation.


Provider Manual


Open Access Network Model

Unlike the traditional Telehealth structure of one specialty location working with multiple

sites, Anthem Blue Cross’ Telehealth Program is based on an innovative Open Access Network

Model. This Open Access Network creates a web of access points throughout the state based on

a combination of strategic alliances with successful existing Telehealth programs and the

creation of new Telehealth locations.

The primary care sites, or presentation sites, are strategically located in areas with high rural

Prudent Buyer PPO, CalPERS Basic Plan, CMSP, AIM and Medi-Cal Managed Care

membership; locations with existing Telehealth programs; and areas with significant barriers

to access. Sites are equipped with computers, video monitors, telephone lines and cameras

needed to present a member’s exam, symptoms and condition to a provider or specialist with

video conference or special software and/or a secure Internet site. The Open Access Network

includes alliances with provider and specialist resources such as large academic medical

centers, tertiary care centers and private practices with high-quality clinical capability, specific

Telehealth technology and the enthusiasm to provide care through this innovative delivery

method. The Open Access Network offers unprecedented health care flexibility:

It enables presentation sites to connect to each other – primary care to primary care for

peer review, collaboration and educational opportunities

It connects presentation sites directly to any one of the specialty locations for diagnosis,

consultations and reviews

If services are not readily available at one specialty location, another location can be

contacted for a Telehealth consultation, essentially creating more support for Prudent

Buyer PPO, CalPERS Basic Plan, CMSP, AIM and Medi-Cal Managed Care rural

members

It enables the addition of new locations or specialty resources as the need arises


Provider Manual


Open Network Model Diagram

Readiness Disclosure Statement

Anthem Blue Cross' latest Health Insurance Portability and Accountability Act of 1996

(HIPAA)-compliant privacy and security statements can be found on our website at

www.anthem.com/ca> Providers > Under Learn More select State Sponsored Plans

> Under Standards and Policies choose HIPAA Readiness Disclosure Statement.

Misrouted Protected Health Information

Protected Health Information (PHI) can be misrouted to Providers and facilities by mail, fax, e-

mail, or electronic Remittance Advice. Providers and facilities are required to destroy

immediately any misrouted PHI or safeguard the PHI for as long as it is retained.

Important Note: You are not permitted to use or disclose Protected Health Information about

individuals that you are not currently treating or have enrolled to your practice. This applies to

Protected Health Information accessible in any Anthem Blue Cross online tool, or sent in any

medium including mail, email, fax or other electronic transmission.


Chapter 2: Telehealth Contacts

Provider Manual

Telehealth Department Contacts

The following are contacts for the Telehealth department:

Phone: ..................................................................................... 1-866-855-2271

Fax: .......................................................................................... 1-805-987-0736

Email: ............................................................ca.telemedicine@anthem.com

Website: ....................................................... anthem.com/ca/telemedicine

Mail: ......................................................................................................................

Attn: Telehealth Department

Anthem Blue Cross

One WellPoint Way, CAT201-M002

Thousand Oaks, CA 91361

Contact us when:

You have any questions regarding the Telehealth Program

You need a revised monthly schedule of appointments available by specialty location

Technical Support for Systems and Software

Please contact the Telehealth department if:

You have technical difficulties

You have questions about equipment, such as hardware, software, medical devices or

telephone lines


Provider Manual


Provider/Member Services

Use the following telephone numbers to contact provider and member services:

CalPERS:………………………………………..………………………………………………….……. 1-877-737-7776

Prudent Buyer PPO: …………………………….………………………………………..………… 1-800-627-5342

California Valued Trust (CVT): ……………………………………….….. 1-800-677-6669 (Providers)

1-800-234-4333 (Members)

Self-Insured Schools of California (SISC):

Kern County……………………………………………………………………………………. 1-800-322-5709

Tulare and Kings Counties ……………………………………………………….……….. 1-559-734-1321

Coastal Healthcare Administrators……………………………………………….……. 1-800-564-7475

Rancho Cordova……………………………………………………………………….………. 1-800-365-0020

Los Angeles ……………………………………………………………………………..………. 1-800-825-5541

University of California (UC) ……………………………………………………….……. 1-888-209-7975

County Medical Services Program (CMSP)……………………………………….………… 1-800-670-6133

Medi-Cal (outside Los Angeles County) ………………………………………………………. 1-800-407-4627

Medi-Cal (inside Los Angeles County) ………………………………………………..……… 1-888-285-7801

AIM Program: …………………………………………………………………………………..…….. 1-800-433-2611

Call the appropriate program’s number when:

You need to verify eligibility

You need customer service related to Prudent Buyer PPO, California Public Employees’ Retirement System (CalPERS) Basic Plan, County Medical Services Program (CMSP), AIM Program or Medi-Cal Managed Care plans

You have questions regarding Prudent Buyer PPO, CalPERS Basic Plan, and CMSP, AIM Program or Medi-Cal Managed Care benefits

You have questions or issues regarding billing and claims


Provider Manual


Utilization Management Services

Use the following telephone numbers to contact utilization management services:

County Medical Services Program (CMSP)……………………………………….………… 1-800-273-4193

AIM Program and Medi-Cal Managed Care: ………………………………………………. 1-888-831-2246

CalPERS…………………………………………………………………………………………..……… 1-877-737-7776

Prudent Buyer PPO: …………………………………………………………………………..…….. 1-800-274-7767

Call these numbers when:

You need utilization management

You need preservice review (prior authorization)

Vision Service Plan

Use the following telephone number to contact:

Vision Service Plan (VSP) Customer Care: …………………………………………..……… 1-800-877-7195

Call these numbers when you have questions or issues regarding:

Optometry services

Billing or claims


Chapter 3: Frequently Asked Questions

Provider Manual

What is Telehealth?

“Telehealth” means the mode of delivering health care services and public health utilizing the

combination of HIPAA compliant information and communication technologies to enable the

diagnosis, consultation, treatment, education, care management and self-management of

patient at a distance from health care providers. Telehealth does not include the use of audio-

only telephone, facsimile machine or e-mail pursuant to the provider and/or the member

contract.

A Telehealth consultation can be done in one of two ways:

Live Video: The primary care provider (PCP), the patient and a specialist meet at the same time using video and telephone equipment

Store and Forward/Secure website: An image of the patient’s condition is taken and sent electronically to the specialist for review

Why Use Telehealth?

Telehealth gives a rural patient better access to specialty care. Patients in rural areas often have a difficult time seeing a specialist because:

There are no specialists in the area

They have to travel a great distance to see a specialist

They have to take time off from work or school

They have to wait a long time to schedule an appointment

They are uncomfortable with seeing someone other than their regular doctor

Telehealth helps to address these challenges by connecting the specialist and the patient using technology.

Chapter 3: Frequently Asked Questions Provider Manual


What is Anthem Blue Cross’ Telehealth Program?

Since 1998, Anthem Blue Cross has sponsored a Telehealth network throughout California. The Telehealth program has:

Over 60 presentation sites (clinics, doctor’s offices and other locations)

Over 18 specialty locations (university hospitals, leading medical centers, specialist offices)

Based on how it was developed, any presentation site can meet with any specialist regardless of

where the specialist is located. It is an open network.

What Types of Specialists Are Available?

More than 25 specialties are available for Telehealth appointments. The top five most common

specialties used for Telehealth are optometry, psychiatry, dermatology, endocrinology and

pediatric neurology.

How Does It Work?

There are two main types of Telehealth consultations. We describe both briefly, below.

For Live Video Telehealth:

The following are reasons why PCP’s use Live Video Telehealth consultations:

The patient’s primary care physician decides that a specialist is needed and that it may

be best to use Telehealth equipment

The patient agrees to a Telehealth appointment rather than going to the specialist in person

The presentation site schedules the Telehealth appointment and provides all of the information to the specialist

During the appointment, the patient and his/her medical case are “presented” by the presentation site provider or staff to the specialist using the video camera

The specialist makes recommendations to help the patient

Chapter 3: Frequently Asked Questions Provider Manual


For Store and Forward Telehealth:

The following are reasons why primary care physicians use Store and Forward Telehealth

consultations:

The patient’s primary care physician decides that a specialist should know about the

patient’s condition

The patient agrees to have an electronic image taken of his/her medical condition

The presentation site forwards the patient’s information and images to the specialist for review

The specialist makes recommendations about the patient’s condition to the primary care physician

What Documentation is Required?

The following documentation is required to participate in a Telehealth session:

The patient must give verbal authorization for his/her doctor to use Telehealth, which the doctor then documents in the patient’s medical record

The presentation site submits forms to Anthem Blue Cross to describe what Telehealth events have been done

The presentation site and specialty location submit claim forms to Anthem Blue Cross for payment of the Telehealth consultation

Whom Do I Call with Questions?

Telehealth department toll free number ………………………………………….…… 1-866-855-2271


Chapter 4: Site Locations

Provider Manual

For a list of all Site Locations, click here.

Step‐By‐Step Instructions

To navigate Anthem Blue Cross’ website manually to see specialty and presentation sites, and sites by county, enter anthem.com/ca/telemedicine into your Internet browser, or follow these instructions:

1. Enter anthem.com/ca into your Internet browser.

2. Click Providers.

3. Under the heading Learn More, select the Telehealth Services link.

4. From this page, click the Telemedicine Site Locator link.

5. This opens the Telemedicine Site Locator page. Choose from the following

selections:

Specialty Sites

Presentation Sites

Sites by County

http://w2.anthem.com/bcc_state/tm/info/sites.asp

Chapter 5: Roles and Responsibilities Provider Manual


Covering California – Telehealth Network Site Locations


Chapter 5: Roles and Responsibilities

Provider Manual

Anthem Blue Cross

Anthem Blue Cross’ Telehealth program provides and facilitates:

Training for Telehealth services

Technical support services (one year warranty) for Telehealth systems purchased by

Anthem Blue Cross

Access to discounted high-speed telephone rates

Assistance in identifying appropriate use of Telehealth applications

Assistance in accessing specialty services through Anthem Blue Cross’ Telehealth

Network

Reimbursement

Monitoring of Telehealth services for access and quality

Presentation Sites

The presentation site:

Provides at least one Telehealth site coordinator

Ensures that the Telehealth site coordinator is trained in the use and application of

Telehealth services

Identifies patients who would benefit from the use of Telehealth services

Uses Telehealth services as appropriate for patient care

Discusses use of Telehealth with patients to obtain verbal consent

Clearly identifies the goal of the Telehealth encounter with the patient and specialty care

provider

Organizes the presentation of clinical information with core elements of patient

information including demographics, history of present illness, applicable past

medical/social history, current treatments, reason for the consultation and any other

information needed to meet the goals of the consultation

Facilitates Live Video Telehealth encounters as clinically appropriate

Develops effective Store and Forward Telehealth encounters by capturing and gathering

images and providing complete data that will be needed by the specialist

Coordinates treatments and management of patient care and follow-up as indicated

Maintains electronic medical record files consistent with state and federal standards

Educates staff in the appropriate use, application and processes of Telehealth

Assumes a leadership role in guiding development of administrative support functions

for Telehealth applications in your facility

Chapter 5: Roles and Responsibilities Provider Manual


Specialty Centers

The specialty center:

Ensures that all specialists are trained in

the use and application of Telehealth

Utilizes Telehealth services as

appropriate for patient care (diagnosis

and treatment)

Establishes protocols to accomplish

either a Live Video or Store and Forward

Telehealth encounter

Facilitates Live Video Telehealth

encounters by guiding physical exam

activities with the presentation site in a

manner that supports meeting the diagnostic and treatment goals for the patient

Evaluates Store and Forward Telehealth encounter requests and provides timely

response to the presentation site

Maintains respect for the presentation site primary care physician, presenter and

patient at all times

Informs the presentation site of the appropriate use, application and processes of

Telehealth for your specific specialty’s needs for the consultation

Adheres to strict confidentiality standards for all electronic medical records and

consultations

Maintains electronic medical record files consistent with state and federal standards


Chapter 6: When to Choose Telehealth

Provider Manual

Assessing Telehealth Services

Assessing the appropriateness for Telehealth services for a patient is a professional role and the

responsibility of the primary care physician, or mid-level and above medical provider (such as

physician, nurse practitioner or physician’s assistant).

Assessment consists of identifying a clinical problem or symptom that a specialist can examine

using Telehealth technology. Clinical problems amenable to Telehealth consist of those where

data, images and a Live Video Telehealth encounter with a specialist provides a solution (such

as a treatment plan) or meets the medical need for on-going management of a non-acute

condition.

Evaluating Telehealth Opportunities

The following list helps in the selection of conditions suitable for Live Video and Store

and Forward Telehealth (see the following table):

Identify clinical conditions suited for visual presentation

Identify conditions suited for audio presentation

Identify conditions where use of the Telehealth technology will lead to a definitive

diagnosis or management decision

Ensure that conditions to be presented are within the technical capabilities and the

scope of Telehealth training for the presenter. A presenter can be a physician, nurse

practitioner, physician’s assistant or in some cases, a staff member assisting the

presentation site in the consultation

Ensure that technical capabilities of the Telehealth system supports a diagnosis and on-

going treatment management

Examples of disease states within a specialty that may be applicable to Telehealth are given in

the following table; however, these are not inclusive of all specialty applications nor should

these supersede the determination of the primary care provider regarding the appropriateness

for Telehealth services. In general, acute conditions evidencing emergent symptoms should be

seen in an emergency room.

Telehealth services may not be provided to CMSP members who have not yet met their

share of cost.


Provider Manual


Conditions Generally Suitable for Telehealth Consultations

Specialty Conditions

Dermatology Most dermatology patients can be evaluated with Telehealth.

Store and Forward Telehealth – works well for patients with clinically apparent skin lesions (rashes, wounds, lesions)

Follow-up of non-apparent lesions

Ear, Nose, and Throat (ENT)

Post-operative follow-up

Follow up of a chronic or on-going condition

Monitoring a diagnosed condition

New patients who probably will not require immediate surgical intervention

Gastroenterology Dysphasia

Non-acute gastrointestinal symptomology

Chronic hepatitis

Encopresis

Chronic abdominal pain

Malabsorption

Pre-and post-procedural evaluations

Post-surgical follow-up

Internal Medicine / Pediatrics

Ongoing treatment and management of most chronic conditions (hypertension, liver disease, diabetes, heart disease and others)

Post-hospital follow-up

Infectious diseases

Hematology / Oncology

Allergy

Pre-surgical evaluation Neurology

Back and neck pain

Arm and leg pain

Pre-surgical evaluation

On-going treatment of chronic conditions

Clinic follow-up of a prior diagnostic evaluation

Seizure control issues

Attention Deficit Hyperactivity Disorder (ADHD) / Developmental conditions


Provider Manual


Specialty Conditions

Orthopedics Post-operative examination

Post-operative follow-up

Follow-up of a chronic or on-going condition

Monitoring a diagnosed condition

New Patients who probably will not require immediate surgical intervention

Psychiatry / Psychology Any psychiatric patient who is medically and mentally unstable

Pulmonology Chronic lung conditions – Chronic Obstructive Pulmonary

Disease (COPD), asthma, cystic fibrosis, interstitial disease, lung infections, sleep apnea

Follow-up of prior diagnostic evaluation

Post-operative and post-treatment follow-up

Non-acute pulmonary disease

Assessment for Appropriate Type of Telehealth Consultation

After determining that a patient’s medical condition is appropriate for Telehealth, the next

step is to determine which method of Telehealth (Live Video or Store and Forward) is

appropriate based on what is both medically appropriate and most convenient for the patient.

Some general evaluation questions to consider when determining the appropriate type of

consultation include the following:

If…. Thin it’s best suited for:

The specialist need to interact with the patient Live Video

The specialist need the presenter to manipulate the patient

Live Video

Sufficient information (such as images, data, dictated comments, lab results) about the patient’s condition can be assembled

Store and Forward

Contact Anthem Blue Cross’ Telehealth department at 1-866-855-2271 with any

questions about either the Live Video or Store and Forward methods.


Chapter 7: How to…

Provider Manual

Refer a Patient for Telehealth Services

The following information in this chapter identifies primary care physician (PCP), presentation

site and specialty site responsibilities throughout the Telehealth encounter, depending on

whether the consultation is a Store and Forward or a Live Video.

Assess the Patient’s Appropriateness for Telehealth Services

This is a professional role performed by the PCP and consists of identifying the clinical

condition or symptom that a specialist can examine using Telehealth technology (such as

where data/image exchange or a Live Video consultation with a specialist may produce a

consultation or second opinion.)

Request Patient’s Verbal Consent for a Telehealth Consult

It is no longer necessary to obtain written patient consent prior to a Telehealth consultation;

however, verbal consent is required. It is recommended that the presenting site representative

document the verbal consent exchange in the patient’s medical record and include the

following information:

Patient Name

Date of Birth

Patient ID Number

Provider Name

Signature of Provider/Representative Obtaining Verbal Consent

The doctor or his/her representative has recommended the use of a Telehealth consultation for

the above named patient’s medical condition. I explained what will happen during the

consultation. I have also informed the patient of the following:

The risk and benefits of the consultation

The risk and benefits of other choices

The results of not having the consultation

A patient receiving a Store and Forward consultation has the right to receive interactive

communication with the specialist. If requested, interactive communication with the

specialist may occur at the time of the consultation or within 30 days of the patient’s

notification of the results of the consultation.


Provider Manual


The patient had a chance to ask questions about the consultation and received

satisfactory answers to those questions

The patient understands he/she may stop or take away their consent to the consultation

at any time for any reason; this will not change their right to future care or treatment;

this decision will not change their rights to benefits under their insurance program

He/she understands that all confidentiality protections apply to the Telehealth

consultation

The patient verbally consented did not consent to the Telehealth consultation

Request a Consultation

After determining the consultation is appropriate for Telehealth services, the PCP contacts the

selected Telehealth presentation site to request a consultation and determine the type of

consultation most appropriate for the patient.

Determine Appropriate Consultant Type

The presentation site helps to determine the most appropriate consultation type – Store and

Forward or Live Video.

Presentation sites can perform Store and Forward consultations for referrals that do not

require extensive specialist and patient interaction (for example, dermatology). Since Store and

Forward Telehealth encounters do not require the specialist, the presenter and the patient to

be present simultaneously, this technology removes the burden of coordinating schedules. The

availability of specialists accepting Store and Forward Telehealth encounters varies by specialty

center.

Telehealth encounters coordinated through Live Video conferencing require coordination of

three entities – the patient, the presenter and the specialist.

For presentation sites only: If the referred patient is assigned to another PCP, you must

get authorization from the independent physician association (IPA) responsible for

paying the claim before presenting the patient to a specialist.

For assistance in determining access to Store and Forward and Live Video presentation

site locations, and specialties location sites available, please contact Anthem Blue Cross’

Telehealth department at 1-866-855-2271.


Provider Manual


Once the appropriateness and consultation type is determined by the presentation site, the

PCP forwards all the requested patient information to the presentation site. A list of the

probable information requested is below.

Once the presentation site has been contacted, they are responsible for several duties to

prepare for the Telehealth encounter, from scheduling the appointment to performing the

consultation.

Prepare and Schedule a Telehealth Encounter

In preparing the Telehealth documentation for the specialist location site, the presentation site:

Requests patient information required to schedule the consultation with the specialty

center, including:

Medical history

Chief complaint

History of current condition

Specific questions to be answered

Coordinates scheduling the appointment between the patient and the specialty location

site, including confirmation of the appointment date and time, and the address of the

presentation site

Obtains a verbal consent to participate in a Telehealth consultation from the patient

prior to the consultation

The consultation request is then sent by encrypted e-mail by the presentation site to the

desired specialist. The specialist site reviews the consultation request and sends scheduling

recommendations back to the presentation site through the Telehealth software.

After Sending the Store and Forward Consultation Request

If the specialist has not replied within a reasonable period, follow-up with a courtesy phone

call to confirm receipt and discuss the response time line.


Provider Manual


Schedule the Telehealth Consultation

Follow these steps when scheduling a consultation:

Verify with the specialty center that the patient’s condition is appropriate for a Store and

Forward or Live Video Telehealth consultation

If a Store and Forward consultation, note this and that the case is being presented on

behalf of the referring provider

Coordinate and schedule the Telehealth consultation between the presentation site,

specialty center and the patient

Fax all required patient medical information and test results to the specialty center

Finalize Details ‐ One Day Prior to the Scheduled Appointment

Follow these steps the day before a scheduled appointment:

Confirm the appointment date and time with the patient at least one day prior to the

Telehealth consultation

Remind the patient of the importance to arrive early in order to prepare for the

Telehealth consultation, answer questions and complete required forms

Confirm that the specialty center has received the faxed patient medical information and

any additional information needed by the specialty center

Remember (if applicable): Include a copy of the patient’s Anthem Blue Cross ID card

(front and back) so the specialty center knows where to send claims. If the patient

cancels the appointment, immediately contact the specialty center and cancel the

appointment with the telehealth site coordinator. This courtesy ensures that the

specialist can accommodate as many appointments as possible.

For Live Video presentation appointment, the appointment time is the time when the

specialist will see the patient – such as when the video conference will be placed. It is

important that the patient, primary care physician and equipment are ready at that

time.


Provider Manual


Finalize Details ‐ Immediately Before the Scheduled Appointment

Follow these steps immediately before the scheduled appointment:

Confirm you have obtained verbal consent from the patient

Answer all questions that the patient may have about the Telehealth process

Gather the necessary Telehealth materials (for example, clinical data, patient

information and medical records)

Confirm that the Telehealth system and medical instruments are working properly

For Store and Forward consultations, confirm availability of Store and Forward services

with the specialty center

For Live Video consultation, confirm teleconference connection by calling the specialty

center a few minutes prior to the scheduled appointment time. Once you confirm the

connection, mute the audio and the video until the patient and PCP /presenter are

ready.

Situate the patient in the Telehealth room, being mindful of patient privacy and

confidentiality

Conduct a Telehealth Consultation

Store and Forward consultations transmit information and appropriate medical images by

secure e-mail from the presentation site to the specialist for review. Live Video consultations

are conducted in real-time.

During the Patient’s Appointment

During the consultation, be cognizant of the following:

Use the appropriate software, scopes and cameras to capture the pertinent images and

medical information

Maintain a professional environment that respects the patient’s privacy and

confidentiality

Introduce all persons participating in the consultation at both locations

Limit distraction by eliminating background noise as much as possible

Prevent unknown people from entering the room during the consultation

During a Store and Forward consultation, it is not necessary for the specialist to be

present during the PCP or presenter’s presentation. It also is not necessary during this

type of presentation for the PCP to be present during the specialist’s response.


Provider Manual


Identify the site as the presenting site only

Provide the specialist with the name, phone and fax number of the patient’s referring

physician

Provide the referring PCP with the name phone and number of the specialist

Introduce the patient to the specialist

If the patient has an assigned PCP outside of the presenting site, introduce the patient:

“This is _______________. I am presenting this patient for their PCP,

Dr. _______________.”

Present medical history, previous treatments and goals for the consultation (for

example, second opinion, diagnosis, medication recommendation)

If this is a Store and Forward consultation, the presentation site saves images and

information to be shared with the specialist as part of the patient’s medical record

Create the electronic patient Store and Forward consultation using the appropriate

software, scopes and cameras to capture the pertinent images and medical information

Remember: Thoroughly complete the Demographics Form in the Store and Forward

software to include:

The referring site information – name of the PCP, phone number and other

information

The patient information – identification, health plan; if necessary, fax a copy of

the patient’s ID card (front and back) to the specialty center

Thoroughly complete the Referral Form in the Store and Forward software to include:

Medical history

Chief complaint

History of current condition

Specific questions to be answered

During a Store and Forward consultation or a Live Video consultation, the telehealth

encounter should be treated with the same professional courtesy as a traditional office

visit.


Provider Manual


Send the Store and Forward consultation to the desired specialty care provider using

HIPAA compliant e-mail

Post Consultation

After you complete the consultation, perform the following:

Mute the audio and disconnect the phone call

Address any patient questions or concerns

If the patient has another PCP outside of the presenting site, explain that the specialist’s

recommendations will be sent to their PCP for treatment management and prescription

needs; the patient should be referred to this outside PCP for follow-up needs

Coordinate the communication of the patient’s treatment/management plan and follow-

up needs to the appropriate PCP

Maintain all images and information from the Telehealth consultation as part of the

patient’s medical record; back-up the files in accordance with clinic policies and

procedures

Evaluate and Implement the Recommended Treatment Plan from the Telehealth Specialist

Once the specialist has completed his or her evaluation of the Telehealth consultation, the

presentation site or the specialist directly sends the recommendations to the referring

physician.

Include the telephone number where the specialist can call to verify receipt of the Store

and Forward consultation, or to discuss the consultation with the PCP. If your site is a

presenting site only, please identify your site as presenting only and include the name of

the patient’s assigned PCP and the phone number.

If you are the presenting site only, please make a copy of the request for consultation

and the specialist’s consultation report. Send these reports to the patient’s assigned

PCP for implementation of the treatment / management plan.


Provider Manual


It remains the referring physician’s role to be responsible for the patient’s care and to

implement the recommended treatment plan for the patient, including the ordering of any

tests and prescriptions. The referring physician can contact the specialist directly for further

discussion or clarification of recommendations.

Document any final actions taken concerning the patient’s care; maintain the specialist

consultation as part of the patient’s medical record.

The presentation site provides a service to present patients for timely specialty assessments.

You know your patients best and can provide continuity of care needed to improve their health

outcomes. Together, through Anthem Blue Cross’ Telehealth program, we can improve access

to care throughout California.


Chapter 8: Claims and Billing

Provider Manual

Overview

The following is designed to give providers information regarding the submission of claims for

Telehealth office visits/consultation services that are rendered to members of Prudent Buyer

PPO eligible groups, CalPERS Basic Plan, County Medical Services Program (CMSP), AIM

Program or Medi-Cal Managed Care1. For detailed information regarding member benefits,

benefit limitations, share of cost, eligibility and billing instructions, please refer to the

appropriate Anthem Blue Cross Prudent Buyer PPO, CalPERS Basic Plan, County Medical

Services Program (CMSP), AIM Program and Medi-Cal Managed Care Provider Manuals.

In order to facilitate timely claims processing and payment, Anthem Blue Cross requires that

standardized billing procedures be followed when submitting claims.

The provider bills using the appropriate forms and in a manner acceptable to Anthem Blue

Cross within the filing limit specified in the provider’s contract. Claims are processed within 30

working days of receipt of the claim, provided the claim is complete containing all of the

required elements outlined for submission of the CMS-1500 or CMS-UB-04/1450, or Anthem

Blue Cross will send a written explanation to the provider stating the reason for the delay.

1Anthem Blue Cross facilitates access to Telehealth services, facilities and technology through this program. The benefits available, if any, for

Telehealth services, and the terms, conditions and limitations on those benefits will depend on the terms of the member’s particular coverage.

Chapter 8: Claims and Billing Provider Manual


Electronic Professional Billing

Submit claims electronically through your current electronic billing system. If you are not

currently submitting your claims electronically and want to do so, please call the Electronic

Data Interchange (EDI) at Anthem Blue Cross at 1-800-227-3983.

Anthem Blue Cross Utilization Controls and Procedures

All benefits are subject to the member’s contract benefits and limitations at the time services

are rendered. To be eligible for reimbursement, Telehealth services must be medically

appropriate covered services that are suitable in a Telehealth setting when the Member’s Plan

includes Telehealth benefits. Telehealth includes any HIPAA compliant technology that can

facilitate the diagnosis, consultation, treatment, education, care management and self-

management of a patient’s health care, including both synchronous (direct, real-time) and

asynchronous (medical information that is compiled and sent to the provider to review at a

later time) interaction.

In order for Telehealth services to be eligible for reimbursement, the provider’s services must

be rendered from one of the following locations:

Provider’s office

Hospital

Rural Health Clinic

Federally Qualified Health Center

Other location with prior plan approval

The following are examples of services not eligible for reimbursement as Telehealth services:

Non-direct patient services (e.g., coordination of care rendered before or after patient

interaction)

Services rendered by audio-only telephone communication; facsimile, e-mail or any

other non-secure electronic communication (provided these restrictions are specified in

the provider contract and/or the Evidence of Coverage document)

Any service that is not eligible for separate reimbursement when rendered to the patient

in person

Distant site facility fee (the County Medical Services Program does reimburse for this

benefit)



Transmission cost (Access for Infants and Mothers (AIM) Program, Medi-Cal Managed

Care, and County Medical Services Program (CMSP) do reimburse for this benefit.

Asynchronous technology for other than teledermatology, teleopthalmology and

teleoptometry

Telehealth Billing for California Programs

Fee Schedule

Your rate of reimbursement or compensation for serving Anthem Blue Cross Prudent Buyer,

CalPERS, AIM, Medi-Cal, and CMSP members is dependent upon your professional or

participating medical group agreement (Agreement) reimbursement rates. Refer to your copy of

the Agreement and the fee schedules online. Fee schedules are proprietary and only available on

our secure website, Provider Access. You will need an ID and password to access this website

and these fee schedules.

Modifiers

Prepare the claim according to instructions in the Plan’s Provider Manual. Processing Telehealth

claims for Prudent Buyer PPO, CalPERS Basic Plan, Access for Infants and Mothers (AIM), Medi-

Cal Managed Care, and County Medical Services Program (CMSP) members is the same as

processing standard office visit claims except a Telehealth modifier must be added to the Current

Procedural Terminology (CPT®) code: GT for Live Video, GQ for Store and Forward. 2, 3

Do not offer Telehealth to CMSP members who have not met their share of cost.

Live Video Telehealth Encounter Modifier Service Type

GT Live Video Telehealth encounter for eligible members

Store and Forward Telehealth Encounter Modifier Service Type

GQ Store and Forward Telehealth encounter for eligible members

Refer to the Telehealth Sample Section from CMS-1500 (Bottom) and Telehealth

Sample Section from UB-04/CMS-1450.



Billable Codes for Telehealth Please call the Customer Care Center identified on the back of the members’ insurance card or

refer to Important Contact Information if you have questions about covered benefits.

Telecommunication Charges Only the site that initiates the Live Video Telehealth encounter may bill for telecommunication

charges using code T1014-GT.

Prudent Buyer PPO and CalPERS Basic Plan do not reimburse telecommunication charges after

January 1, 2012. AIM, Medi-Cal, County Medical Services Program (CMSP) pay claims for

members’ Integrated Services Digital Network (ISDN) telecommunication charges for Live Video

Telehealth encounters only. A Live Video encounter may require using high-speed ISDN

telecommunications lines, which are more expensive than a regular, long-distance call. This

reimbursement only applies to Integrated Services Digital Network (ISDN) lines.

Only the site that initiates the Live Video Telehealth encounter may bill for telecommunication

charges, code T1014-GT. Prudent Buyer PPO and CalPERS Basic Plan do not reimburse

telecommunication charges. Indicate the start and stop time of each Live Video Telehealth

encounter on the claim.

Bill number of units

Each minute (or part thereof) is equal to one unit of occurrence

A maximum of 90 minutes of occurrence may be billed per Live Video Telehealth

encounter (1.5 hours billable maximum)

2 Administrative Services Only product offered by Anthem Blue Cross Life and Health Insurance Company. Anthem Blue Cross Life

and Health Insurance Company provides administrative services and does not assume any financial risk or obligation with respect

to claims. Anthem Blue Cross administers claims on behalf of Anthem Blue Cross Life and Health Insurance Company, but is not

financially liable for benefits payable. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are

Independent Licensees of the Blue Cross Association. Anthem Blue Cross, on behalf of Anthem Blue Cross Life and Health

Insurance Company, administers claims for the Prudent Buyer PPO, CalPERS Care Basic, PERS Choice Basic Plan and PERS

Select Plan members. Payment of CalPERS claims is issued by the California State Controller’s Office.

3 Anthem Blue Cross facilitates access to Telehealth services, facilities and technology through this program. The benefits

available, if any, for Telehealth services, and the terms, conditions and limitations on those benefits will depend on the terms of the

member’s particular coverage.



Billable CPT Codes for Live Video Telehealth Encounters

Primary Care Physicians

99201-99205 New patient office visit

99211-99215 Established patient office visit

Specialists

99241-99245 Consultations

99211-99215 Follow-up visits

Psychiatry

90801-90809 Psychiatric diagnosis

90810-90815 Individual psychotherapy

90816-90819 Individual psychotherapy (inpatient)

90821-90829 Individual psychotherapy (inpatient)

90853 Medical psychoanalysis

90862 Pharmacological psychiatric mgmt.

99241-99245 Consultations

99211-99215 Established member office visit

Limitations may exist regarding billable CPT codes for Live Video Telehealth encounters. For

detailed information regarding member benefits, benefit limitations, share of cost, eligibility,

preservice review and billing instructions, refer to the appropriate Plan’s Provider Manual. You

may call the Customer Care Center identified on the back of the members’ insurance card or refer

to Important Contact Information if you have questions about covered benefits.

Site Fees for Live Video

Distant Site Fees Specialty Sites may not bill for a Telehealth site fee. Prudent Buyer PPO, CalPERS Basic Plan,

AIM, and Medi-Cal do not reimburse site fees for Specialty Sites.

County Medical Services Program (CMSP) does reimburse Distant Sites fees.



Presenting Site Fees Billing entities serving eligible Anthem Blue Cross Prudent Buyer PPO and CalPERS Basic Plan

members will not be reimbursed for site fees. Billing entities serving eligible AIM, Medi-Cal,

County Medical Services Program (CMSP) members may bill for Presenting site fees.

Live Video Site Fee Billing Code

CMS-1500 CMS-1450

Presentation Site Q3014 Q3014

Specialty Location G9002 G9002

Billable Codes for Store and Forward Telehealth Encounters

Telecommunication Charges Store and Forward is accomplished using secured e-mail communication. As such, there are no

telecommunication charges applicable. Therefore, there is no telecommunication reimbursement.

Primary Care Physicians Bill the preparation of the Store and Forward consultation as part of the primary care physician’s

office visit. Use the appropriate CPT code based on total amount of time necessary to complete the

office visit and the Store and Forward consultation preparation.

Specialists Anthem Blue Cross pays claims for the review of patient files for a Store and Forward consultation

under codes 99241-99245 Consultations.

Site Fees for Store and Forward Specialty Sites may not bill a Telehealth site fee for Store and Forward consultations.

Presenting sites serving eligible Prudent Buyer PPO and CalPERS Basic Plan members will not be

reimbursed for site fees after January 1, 2012.

Presenting sites serving eligible AIM, Medi-Cal, and County Medical Services Program members

may bill site fees for Store and Forward consults.

Store and Forward Site Fee Billing Code

CMS-1500 CMS-1450

Presentation Site Q3014 Q3014

Specialty Location Not covered Not covered



Submitting Telehealth Claims Submit claims electronically through your clearinghouse, or mail all hard copy claims to the

address listed on the member’s ID card.

CMS-1500 Claim Form All professional providers, including behavioral health practitioners and third party billing agents

(except Federally Qualified Health Centers, Rural Health Clinics and Tribal Health Clinics) should

bill using the most current version of the CMS-1500 claim form.

Fields to Complete f o r C M S - 1 5 0 0 Claim F o r m

The following guidelines will help in completing the CMS-1500 Claim form. The letter R indicates

a required field.

Field Number Title Explanation

Field 1 (R)

Medicare/Medicaid/TRICARE /CHAMPUS/CHAMPVA/Group Health Plan/FECA Blk Lung/Other ID

If claim is for Medicare, put an X in the Medicare box. If the member has both Medicare and Medicaid, put an X in both boxes. Attach a copy of the form submitted to Medicare to the claim.

Field 1a (R)

Insured’s ID Number

Use the member’s ID number from the Anthem

Blue Cross ID card.

Field 2 (R)

Patient’s Name

Enter the last name first, then the first name, then middle

initial (if known). Do not use nicknames or full middle

names.

Field 3 (R)

Patient’s Birth Date / Patient’s Sex

Enter date of birth as MM/DD/YY (Month/Day/Year). For example, enter September 1, 1993 as 09/01/1993. Check the appropriate box for the patient’s sex.

Field 4 (R) Insured’s Name “Same” is acceptable if the insured is the patient.

Field 5 (R)

Patient’s Address / Telephone

Enter complete address and telephone number. Include any unit or apartment number. Abbreviations for road, street, avenue, boulevard, place or other common ending to the street name are acceptable.

Field 6 (R) Patient Relationship to Insured Enter the relationship to the member or subscriber.

Field 7 (R) Insured’s Address “Same” is acceptable if the insured is the patient.

Field 8 (R)

Patient Status

Check Single, Married or Other for marital status. If

applicable, check Employed, Full-Time Student or Part-

Time Student.

Field 9 (R)

Other Insured’s Name

If there is other insurance coverage in addition to the

member’s Anthem Blue Cross coverage, enter the name

of the insured.

Field 9a (R)

Other Insured’s Policy or Group Number

Enter the name of the insurance with the group and

policy number.

Field 9b (R) Other Insured’s Date of Birth Use the date of birth format, MM/DD/YY.

Field 9c (R)

Employer’s or School Name Enter the name of other insured’s employer or school.

Field 9d (R) Insurance Plan Name or Program Name Enter the name of plan carrier.

Field 10 (R)

Patient’s Condition Related To

Describe the injury or accident, including whether or not

it occurred at work.




Field 10a (R)

Related to Employment?

Check Y or N. If insurance is related to workers’

compensation, check Y.

Field 10b (R)

Related to Auto Accident / Place?

Check Y or N. Enter the state abbreviation in which the

accident occurred.

Field 10c (R) Related to Other Accident? Check Y or N.

Field 10d Reserved for local use If applicable, use for member copay.

Field 11 (R)

Insured’s Policy Group or FECA Number

Insured’s group number. Complete information about

insured, even if same as patient.

Field 11a (R)

Insured’s Date of Birth / Sex

Use the date of birth format – MM/DD/YY. Check

M (male) or F (female).

Field 11b (R)

Employer’s Name or School Name

Enter the name of the organization from which the insured

obtained the policy.

Field 11c (R) Insurance Plan Name or Program Name Enter the name of the plan carrier.

Field 11d (R) Is There Another Health Benefit Plan? Check Y or N. If yes, complete items 9A-9D.

Field 12 (R) Patient’s or Authorized Person’s Signature

Sign and date the form. (“Signature on file” indicates that

the appropriate signature obtained by the provider is

acceptable for this field.)

Field 13 (R)

Insured’s or Authorized Person’s Signature

Sign and date the form. (“Signature on file” is acceptable

for this field.)

Field 14 (R)

Date of Current

Enter the date of the injury, illness or pregnancy (if

applicable). For professional emergency services

billing, enter the Injury Date.

Field 15 First Date Enter the date of the first consultation for the

patient’s condition. Date format is MM/DD/YY.

Field 16 Dates Patient Unable to Work in Current

Occupation (From - To) Date format is MM/DD/YY.

Field 17 (R) Name of Referring Physician or Other

Source

Enter the name of physician, clinic or facility referring the

patient to the provider.

Field 17a - This field is available to enter another identification number.

Field 17b (R)

NPI Enter the provider’s National Provider Identifier number.

Field 18 Hospitalization Dates Related to Current

Services (From - To) Date format is MM/DD/YY.

Field 19 (R) Reserved for Local Use

Enter rendering NPI of mid-level practitioners such as

nurse practitioners and physicians assistants here.

For multiple transfers, indicate that the claim is part of a multiple transfer and provide the other client’s complete name and Medicaid number. Provide information about the accident, including date occurred, how it happened, and whether it was self-inflicted or employment-related.

Field 20

Outside Lab? (Yes or No); $ Charge Check Yes if lab services were sent to an outside lab;

check No if not.

Field 21 (R) Diagnosis or Nature of Illness or Injury Enter the appropriate diagnosis code or nomenclature.

Check with a coding expert if you aren’t sure.

Field 22 Medicaid Resubmission

Under “Original Ref. No.” enter the 17-digit

transaction control number (TCN) associated with

any claim being resubmitted that is older than one

year (365 days). Use field 19 if you need

additional space.




Field 23 (R) Prior Authorization Number

Enter authorization information in this field, which can be a preservice review or reference number, or on-call

physician NPI - enter rendering physician NPI when

provider is not the PCP, but is “covering for,” on-call or has received permission from the PCP to provide services that day.

Field 24a (R) Date(s) of Service If dates of service cross over from one year to

another, submit two separate claims (example: one

claim for services in 2005, one claim for services in

2006). Itemize each date of service on the claim;

avoid spanning dates.

Field 24b (R) Place of Service This is a 2-digit code. Use current coding as indicated in

the CPT Manual.

Field 24c EMG Enter the appropriate EMG number.

Field 24d (R) Procedure, Services, or Supplies Enter the appropriate CPT codes or nomenclature.

Indicate appropriate modifier when applicable. Do not use NOC codes unless there is no specific CPT code available. If you use an NOC code, include a narrative description.

Field 24e (R)

Diagnosis Pointer

Use the most specific ICD-9 code available. After

October 1, 2013, use the most specific ICD-10 code

available.

Field 24f (R) $ Charges Charge for each single line item.

Field 24g (R)

Days or Units Enter the quantity of services for each itemized line.

Field 24h EPSDT Family Plan Indicate if the services were the result of Early

Periodic Screening, Diagnostic and Treatment

(EPSDT) Services checkup or a family planning referral.

Field 24i (R)

ID Qualifier / NPI

Enter the provider’s National Provider Identifier number.

Field 24j (R) Rendering Provider NPI. Entering the rendering provider NPI in the

unshaded field of Box 24J.

Field 25 (R) Federal tax identification number (TIN) This is the 9-digit number listed on your W-9.

Field 26 Patient’s Account Number This is for the provider’s use in identifying patients and

allows up to nine numbers or letters (no other characters

are allowed).

Field 27 (R)

Accept Assignment? All providers of Medicaid services are required to

check Y.

Field 28 (R) Total Charge Enter the total charge for each single line item.

Field 29 (R)

Amount Paid Enter any payment that you have received for this claim.

Field 30 Balance Due The balance due has to equal the amount in box 28 less

the amount in box 29.

Field 31 (R) Full Name and Title of Physician or

Supplier

Either the actual signature or typed / printed designation is

acceptable.

Field 32 (R) Service Facility Location Information Include suite or office number. Abbreviations for road,

street, avenue, boulevard, place or other common ending

to the street name are acceptable.

Field 32a (R)

NPI Enter the service facility’s National Provider

Identifier number, (if appropriate).

Field 32b This field is available for you to enter another identification

number.




Field 33 (R) Billing Provider Info and PH # Enter the provider name, street, city, state, ZIP code and

telephone number.

Field 33a (R)

NPI Enter the provider’s National Provider Identifier number.

Field 33b

This field is available for you to enter another identification

number.



Enter appropriate procedure codes (Box 24 D) for:

Telecommunication charge (if applicable) *

Service

Presenting site fee (Live Video or Store and Forward) *

Specialist site fee (CMSP benefit/Live Video only) *

* CMSP - Additional form is required, bill site fees on a separate claim form. No reimbursement for telecommunication

or site fees for Prudent Buyer PPO/CalPERS eligible members.

Enter the appropriate Telehealth modifier (Box 24 D):

GT - Live Video Telehealth encounter

GQ - Store and Forward Telehealth encounter

UB-04 Claim Form

All facilities, including Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs)

and Tribal Health Clinics (THCs), should bill using the most current version of the UB-04

(CMS-1450) claim form. Refer to the table below for information to include on the UB-04.

Use the member’s ID number when billing, whether submitting electronically or by

paper.

Fields to Complete for the UB-04 The following guidelines will help you in completing the UB-04 (also known as the CMS-1450)

claim form. The letter R indicates a required field for all members; RI indicates a required field for

inpatient; RO indicates a required field for outpatient; and C indicates a conditional field).

Locator # Box Title Description

1 (R) Facility name and address Enter the facility name and address

2 **blank**

3 Patient Control No. Enter the member’s account number

4 (R) Type of Bill Type of bill (TOB) code

5 (R) Fed Tax No. The provider’s federal tax identification number (TIN)

6 (R)

Statement Covers Period

From/Through The FROM and THROUGH dates covered by the claim being

submitted

7 Cov D. Covered days

8 N-C D. Non-covered days




9 C-I D. Coinsurance days

10 L-R D. Lifetime reserve days

11 **blank**

12 (R)

Patient Name

Enter the member’s name as it appears on the member’s

ID card.

13

Patient Address Enter the member’s complete address (number, street, city, state

and ZIP code).

14 (R)

Birth Date Enter the member’s date of birth in MM/DD/YY format.

15 (R) Sex Enter the member’s gender (M or F).

16

MS

Enter the member’s marital status: Single Married Other

17 (R)

Admission Date

Enter the member’s admission date to the facility in

MM/DD/YY format.

18 (R)

Admission Hr

Enter the member’s admission hour to the facility in military time (00 to 23) format.

19 (R) Admission Type Enter the type of admission.

20 (R) Admission SRC Enter the source of admission.

21 (R)

D. Hr

Enter the member’s discharge hour from the facility in military time (00 to 23) format.

22 (R) Status Enter the patient’s status.

23 Medical Record No. Optional medical record number

24-30 (R) Condition Codes Condition code (81) X0 – X9

31 **blank**

32-35 (R) Occurrence Codes / Dates Occurrence codes (42), if applicable

36

Occurrence Span (Code, From

& Through Date)

Days in MM/DD/YY format

37 **blank**

38 **blank**

39-41 (R) Value Codes (Code / Amount) Value codes and amounts

42 (R) Rev CD Revenue Code (required for all institutional claims)


43 (R) Description Description of services rendered

44 (R)

HCPCS/Rates

The accommodation rate per day for inpatient services or

HCPCS/CPT code for outpatient and FQHC services

45 (R) Serv Date Date of services rendered

46 (R)

Serv Units

Number/units of occurrence for each line or service being billed

47 (R) Total Charges Total charge for each line of service being billed

48 Non Covered Charges Enter non-covered charges




49 **blank**

50 Payor Payor Identification (third party payors)

51 (R)

Provider No

Medicare Provider ID number. Enter Medicaid qualifier

1D on electronic claims.

52 Rel Info. Release of information certification indicator

53 Asg Ben Assignment of benefits certification indicator

54 Prior Payments Prior payments

55 Est Amount Due Estimated Amount Due

56 (R) **blank** Enter facility NPI

57 Due from Patient

58 (R) Insured’s Name Member’s Name

59

P. Rel

Patient’s relationship to insured (N/A if member is the

insured)

60 (R)

CERT.-SSN-HIC.-ID NO.

Insured’s ID number. Be sure to Include XDI prefix for CMSP members.

61

Group Name

Insured Group Name (the name of any other health plan)

62

Insurance Group No.

Insurance Group Number (the policy number of any other

health plan)

63 Treatment Authorization Codes Authorization number or authorization information

64 ESC Employment status code

65

Employer Name

Name of organization from which the insured obtained the other policy

66 Employer Location Organization’s complete address

67 (R)

Prin. Diag. CD.

Principal ICD-9 diagnostic codes. After October 1, 2013, use the principal ICD-10 diagnostic codes.

68-75 (R)

Other Diag. Codes

ICD-9 diagnostic code. After October 1, 2013, use the

ICD-10 diagnostic codes.




67 (R)

Prin. Diag. CD.

Principal ICD-9 diagnostic codes. After October 1, 2013, use the principal ICD-10 diagnostic codes.

68-75 (R)

Other Diag. Codes

ICD-9 diagnostic code. After October 1, 2013, use the

ICD-10 diagnostic codes.

76 Attending Enter attending physician’s NPI.

77 E-Code External cause of injury code

78 **blank**

79 (R) P.C. Procedure coding method used

80 (R)

Principal Procedure (Code/Date)

ICD-9 principal procedure code and dates, if applicable After October 1, 2013, ICD-10 principal procedure code and dates, if applicable.

81 (R) Other Procedure (Code/Date) Enter taxonomy codes.

82 (R) Attending Phys. ID The attending physician’s ID number

83 (R) Other Phys. ID Other physician ID

84

Remarks

Use this field to explain special situations. For claims that include share of cost, include the EVS number in this field.

85 (R) Provider Representative Provider representative signature

86 (R) Date Signature date



Telehealth Sample Section CMS-1450/UB-04


Chapter 9: Developing Telehealth Medical Record Documentation

Provider Manual

Introduction

Telehealth are patient encounters using special technology (such as Live Video Conference,

Store and Forward Software and secure Internet sites). As such, documenting Telehealth

encounters should be accomplished in the same manner as a patient office visit – through

medical records.

The medical record standard in some clinics is the traditional paper record. Most clinics have

an electronic medical record system. If you use electronic medical records, you should already

have policies and procedures in place to safeguard the electronic record. Clinics not currently

using an electronic record need to consider how they monitor and maintain the electronic

records created by Telehealth technology.

The principles of confidentiality and laws governing medical records remain the same for all

records whether created electronically or in paper form. Anthem Blue Cross’ Telehealth

program is a point-to-point system that preserves confidentiality through encryption. This

means that the presentation site controls the medical record and patient data. Only specialists

you choose, receive the medical files. Because Anthem Blue Cross’ Telehealth program builds

on existing systems of care and administrative processes, existing policies need only be

amended to include the additional dimension of electronic data and storage. A system of rights

and authorities to the computer software is built into the Telehealth software. It requires login

security for all users. Your policy should consider designating levels of access to the electronic

record as a safeguard.

All clinical encounters have a patient folder. Each encounter is identified and a date and time

stamp applied that cannot be changed. It is necessary to back up these electronic records on a

routine basis to prevent a loss of data. A regular routine, and well-defined procedures, easily

support this aspect of medical record keeping.

Label electronic patient folders similarly to how you label paper-based patient folders. Give

captured images unique names that identify the patient, date the image was captured, and a

number, such as “Smith, Josephine 131107_01”. This indicates that this is the first image taken

of Josephine Smith’s condition on November 7, 2013.


Provider Manual


All Telehealth encounters require that verbal informed consent be obtained and documented.

This documentation is part of the medical record and you should keep it with other

documentation. Consultation reports are sent from specialty centers to your facility as well as

audio clips of the dictated report. Maintain both for the medical record.

Complete the Telehealth Consultation Summary Form after a consultation in order to

document the consultation in the patient’s paper-based medical record or scan the document

into the electronic medical record.

Monitoring Usage and Reporting to Anthem Blue Cross

What Anthem Blue Cross Monitors

In order to meet the goals of this Telehealth program, Anthem Blue Cross monitors and

identifies barriers to care and attempts to identify solutions. Anthem Blue Cross evaluates

pertinent information as the Telehealth Program moves forward to identify areas where

Anthem Blue Cross can affect the success of the program by assisting with training, expanding

the network of specialists or addressing infrastructure requirements and other needs.

Adaptations and development of the Telehealth program occur based on monitoring and

evaluation by Anthem Blue Cross of the results of your program. The monitoring of Telehealth

services is an on-going process.

Anthem Blue Cross monitors the following items:

Telehealth accomplishments and problems

Telehealth encounters (number, type, referrals, specialties, sites)

Satisfaction of patients (voluntary)

Difficulties with referral process

Needs (instrumentation, specialties, providers)

Monitoring by Anthem Blue Cross occurs through the monthly utilization log submission by

the presentation sites. Additional monitoring may include completed Patient Satisfaction

Forms (voluntary), telephone calls and informal discussions and meetings.


Provider Manual


What You Should Report

Complete and submit the following to Anthem Blue Cross on a monthly basis.

Completed Telehealth Utilization Log (number and type of encounters, specialties and

sites)

Completed Patient Satisfaction Survey (voluntary)

Complete and submit the Telehealth Utilization Log for reporting consultations and the

Telehealth Patient Satisfaction Survey Form every month. Please feel free to submit a

narrative description of any Telehealth problem you have had during the month or any

achievements that you would like to share with us.

When You Should Report

Unless otherwise stipulated in Anthem Blue Cross’ Telehealth Agreement, complete reports

monthly and submit by the 10th day of the following month. Reporting continues in

accordance with the contract between Anthem Blue Cross and your organization. You may e-

mail, fax or mail us your reports.

E-mail: [email protected]

Fax: 1-805-987-0736, Attn: Telehealth Program

Mail:

Attn: Telehealth Department Anthem Blue Cross One WellPoint Way, CAT201-M002 Thousand Oaks, CA 91362

Please feel free to e-mail any comments, accomplishments or problems to

[email protected].


Chapter 10: Forms and Logs Provider Manual

Telehealth Information Forms

Thank you for your participation in Anthem Blue Cross’ Telehealth Program.

Anthem Blue Cross monitors the Telehealth Program to meet regulatory and internal

commitments through regular data submissions found in the following reports, forms and

surveys. If you have any further input, please feel free to contact the Telehealth Program at

1-866-855-2271.

You will find all forms mentioned in this chapter at the end of this Manual.

Telehealth Consultation Summary Form

Complete the Telehealth Consultation Summary Form after a consultation in order to

document the consultation in the patient’s paper-based medical record or scan the document

into the electronic medical record.

Telehealth Utilization Log

The Telehealth Utilization Log tracks the Telehealth events, both clinical and non-clinical,

for each presentation site. This log provides general information regarding the application and

result of each event. Following are the instructions to complete the utilization log.

Site Name: Name of your facility

For the Month of: Month being reported (for example, May, 2012)

Name of the person completing the log

Signature of the person completing the log

Date log was sent to Anthem Blue Cross Telehealth Department

Instructions for Completing the Utilization Log

Complete one row per Telehealth event (clinical and non-clinical).

Field Instructions

Date For Live Video, enter the date of the consultation or non-clinical use. For Store and Forward, presentation sites should note the date that the information was forwarded to the specialist.

Patient ID Include the patient ID for Anthem Blue Cross members only; otherwise, note “non-Anthem Blue Cross for Patient ID. Do not provide any other patient identifying information.

Chapter 10: Forms and Logs Provider Manual


Patient Satisfaction Survey

This is a voluntary Telehealth Patient Satisfaction Survey Form for each patient. We

provide this form in both English and Spanish.

Do not include the patient’s name unless the patient agrees to a personal follow-up.

Unless otherwise instructed, submit these forms to Anthem Blue Cross’ Telehealth

department every month.

You can choose one of the following ways to submit the forms:

E-mail reports to [email protected] (For Utilization Logs only)

Fax reports to 1-805-987-0736

Mail reports to:

Attn: Telehealth Department Anthem Blue Cross One WellPoint Way, CAT201-M002 Thousand Oaks, CA 91362

For questions or comments, call the Telehealth department at 1-866-855-2271.

Field Instructions

Live Video or Store and Forward Enter the Telehealth application code:

LV – Live Video

SF – Store and Forward

Specialty Center Enter the location to which you connected for this event (for example, XYZ Specialty Center)

Definitions

(A) Specialty Enter the appropriate choice from Section A. Specialty (for example, 3 – Dermatology). If the specialty is not listed, enter “39” for other and note the specific specialty on the line below.

(B) Payment Source Enter the appropriate choice from Section B, Payment Source (for example, 2-Grant Funded Consult.)

(C) Non-Clinical Usage Enter the appropriate choice from Section E, Non-Clinical Usage (for example, 3-Continuing Education / Clinical Conference)


Chapter 11: Telehealth Program Glossary

Provider Manul

Term Definition

CalPERS California Public Employees Retirement System, which added Anthem Blue Cross’

Telehealth Program to the PERS Care Basic Plan and PERS Choice Basic Plan.

CMS‐1500 Center for Medicare and Medicaid Medical Claim Form

GQ HIPAA‐approved insurance claim modifier for Store and Forward consultations.

GT HIPAA‐approved insurance modifier for Live Video consultations.

HPSA Health Professional Shortage Area

ISDN Lines

High‐speed telecommunication lines installed by the telephone company that are plugged

into the Telehealth workstation at some Telehealth sites (presentation site and specialty

centers) to transmit and receive Live Video Telehealth consultations.

Live Video (Simultaneous) Connects the patient, primary care physician (PCP) and specialist at the

same time by video conferencing equipment to discuss the patient’s medical condition.

MSSA

Medical Service Study Area – Classified in three categories: Frontier, Rural and Urban:

• Frontier – an area with a population density equal to or less than 11 persons per square

mile.

• Rural – an area with a population density of 250 persons or less per square mile and

having no incorporated area greater than 50,000 persons.

• Urban – based on a series of exception definitions, an area not designated as

Frontier or Rural.

MUA Medically Underserved Area

MUP Medically Underserved Population

Open Access Network

The Open Access Network allows presentation sites to connect to each other, primary

care to primary care, for peer review, collaboration and educational purposes. It also

connects presentation sites directly to multiple specialty centers for diagnosis,

consultation and reviews.

Originating site

The location where the patient or patient’s condition is presented by Telehealth. Originating

sites are:

• Office of a physician or practitioner

• Hospital

• Critical Access Hospital

• Rural Health Clinic

• Federally Qualified Health Center

• Hospital‐based renal dialysis center

• Skilled nursing facility

• Community mental health centers

PCP Primary care physician

Presentation Site

A health care facility at which the patient is present and from which the patient, patient’s

history, medical case and particular referral questions are presented to a specialist through

Telehealth technologies.

Chapter 11: Telehealth Program Glossary Provider Manual


Term Definition

Presenter Primary care physician, mid‐level or office staff member assisting the presentation site in

presenting the patient to the specialist.

Presentation Communication of patient’s history, demographic information, necessary images, and

data to facilitate diagnosis, treatment and education of the patient.

Specialty Calendar A monthly calendar of all specialists in the Telehealth Network, scheduled Telehealth clinics, and specialties they provide. Sent by e‐mail each month to all Telehealth sites in

the network.

Specialty Center

A health care facility with an independent specialist or group of specialists to whom a patient, patient’s history, medical case and particular referral questions are presented by Telehealth originating site staff seeking consultative services, diagnosis, treatment

recommendations and patient education.

Store and Forward (Asynchronous) Uses software to store and encrypt the pertinent medical data and images. The secured data is then transmitted electronically to the specialist for review

and consultation.

Telehealth A health care delivery method that applies high‐speed telecommunications systems, computer technology and specialized medical cameras to examine, diagnose, treat and

educate patients at a distance.

Telehealth Site Coordinator

The Telehealth site coordinator:

• Competently uses Telehealth equipment and software

• Coordinates and schedules referrals between the presentation site, specialist and the patient

• Manages the technical aspects of the presentation (patient positioning, introductions, camera, scopes)

• Coordinates completion of required forms

• Maintains a log of all Telehealth usage for Live Video and Store and Forward

• Provides monthly Utilization Log reports to Anthem Blue Cross

Utilization Log A report that tracks the Telehealth events, both clinical and non‐clinical for each

presentation site. The utilization log is submitted every month.


Provider Manual



As is discussed in Chapter 10 – Telehealth Forms and Logs – the following forms are available:

.

Telehealth Consultation Summary Form


Telehealth Patient Satisfaction Survey Form

Blue Cross of California, doing business as Anthem Blue Cross, is contracted with L.A. Care Health Plan to provide Medi-Cal managed care services in Los Angeles County. In all other areas, Medi-Cal managed care services are provided by Blue Cross of California Partnership Plan, doing business as Anthem Blue Cross Partnership Plan. Independent licensees of the Blue Cross Association. ® ANTHEM is a registered trademark. ® The Blue Cross name and symbol are registered marks of the Blue Cross Association. 0608 CAW2228 05012012

Telehealth Consultation

Summary Form

Patient Information

Patient Name: Patient ID Number:

Address:

City: State: ZIP Code:

Date of Birth:

Allergies:

Home Telephone Number: Work Telephone Number:

Primary Care Physician Information

Primary Care Physician:

Phone Number:

Specialist Information

Physician Name:

Specialty:

Phone Number: Location:

Telehealth Consultation Summary

Date of Service:

Chief Complaint:

Pertinent Past Medical History:

Current Medications:

Summary Report with Recommendations:

Follow-up:

Signature Date

Anthem Blue Cross is the trade name of Blue Cross of California and Anthem Blue Cross Partnership Plan is the trade name of Blue Cross of California Partnership Plan, Inc. Independent licensees of the Blue Cross Association. ®ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association. Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County. CAW2234S 082014

Presentation Site: _____________________________________________ For the month of: ___________________________________________

Name of person completing log: ____________________________Signature:__________________________________ Date: ________________

Fax reports to Anthem Blue Cross’ Telehealth department at 1-805-987-0736 or e-mail to [email protected].

Date Patient ID Number (Anthem Members Only) Otherwise enter “Non-Anthem”

Live Video or

Store and Forward

Specialty Center Consulted

(A) Specialty

(B) Payment Source

(C) Non-Clinical Usage

1.

2.

3.

4.

5.

6.

7.

8.

9.

Definitions

(A) Specialty (B) Payment Source (C) Non-Clinical Usage

1. Behavioral Health 14. Nutrition Services 29. Hematology 1. Blue Cross Medi-Cal 1. Admin. Conference Meeting

2. Cardiology 15. Oncology 30. Neurology Peds. 2. Other Medi-Cal/Fee-for-Service 2. Community Use

3. Dermatology 16. OB/GYN 31. Optometry 3. CalPERS 3. Continuing Education/Clinical Conference

4. DDS Service 17. Ophthalmology 32. Pallative Care 4. Blue Cross PPO 4. College Courses/Nursing Classes

5. Dentistry 18. Orthopedics 33. Social Services 5. Blue Cross CMSP 5. Other Training

6. Gastroenterology (GI) 19. Pain Management 34. Substance Abuse 6. Other CMSP 6. Patient Education

7. General Surgery 20. Pediatrics 35. Therapies (PT, OT, ST) 7. Medicare 7. Professional Committees

8. Hepatology 21. Plastic Surgery 36. Diabetic Retinopathy Screening 8. Other Private Insurance 8. Supervision Staff/Students

9. HIV/AIDs 22. Psychiatry 37. Other 9. Patient Self-Pay 9. Support Groups

10. Infectious Disease 23. Pulmonology 38. Diabetes Education 10. Uninsured 10. Test Calls

11. Internal Medicine 24. Rheumatology 39. Pediatric Psychiatry 11. Veterans Administration (VA) 11. Distance Education

12. Nephrology 25. Urology 12 Other CalPERS 12. Test Calls

12. Neurology 28. Genetics 13. Other


mailto:[email protected]

Telehealth Patient Satisfaction Survey

Blue Cross of California, doing business as Anthem Blue Cross, is contracted with L.A. Care Health Plan to provide Medi-Cal managed care services in Los Angeles County. In all other areas, Medi-Cal managed care services are provided by Blue Cross of California Partnership Plan doing business as Anthem Blue Cross Partnership Plan. Independent licensees of the Blue Cross Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. ® The Blue Cross name and symbol are registered marks of the Blue Cross Association. 0608 CAW2233 082014

Please check or circle the most appropriate response and answer all questions.

Please respond to the following statements if you had a Live Video Telehealth encounter.

Other comments:

This survey is voluntary and confidential. If you have any questions, please call Anthem Blue Cross’

Telehealth Program at 1-866-855-2271. Completed survey’s may be se submitted to Anthem Blue Cross by

faxing to 805-987-0736, emailing to [email protected] or mailed directly to Anthem Blue Cross

at 1 WellPoint Way, Thousand Oaks, CA 91363 Attn: Telehealth Department. Thank you for your time.

Date: ____________________ Telehealth Site: ____________________________________________

Method of Telehealth encounter (please check one) Store and Forward Live Video

For Which Specialty: ___________________________________________________________________

1a. I would have had to wait to see a

specialist doctor:

1 to 14 days 15 to 30 days 31 to 60 days

61 to 90 days more than 90 days N/A

1b. The wait time for my Telehealth

appointment was:

1 to 14 days 15 to 30 days 31 to 60 days

61 to 90 days more than 90 days N/A

Disagree Neutral Agree N/A

2. The care I received using Telehealth

was as good as seeing the specialty

doctor in person.

3. It was not difficult scheduling a

Telehealth appointment.

4. I would use Telehealth again.

5. My questions about Telehealth were

answered by the doctor or nurse at my

clinic.

Disagree Neutral Agree N/A

1. I was introduced to all the

doctors/nurses in both locations.

2. The specialty doctor told me what was

wrong with me or what to do to

improve my condition.

3. The picture was clear, I could see the

doctor.

4. I could hear the doctor.

Telehealth is a collaborative project to improve access to care.

Anthem Blue Cross is the trade name of Blue Cross of California. Independent licensee of the Blue Cross Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association. Anthem Blue Cross facilitates access to Telehealth services, facilities and technolo-gy through this program. The benefits available, if any, for Telehealth services, and the terms, conditions and limitations on those benefits will depend on the terms of the member’s particular coverage.

ACA-PM-0006-14 08.14

Download - Anthem Blue Cross Telehealth Program

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