(1) Purpose and scope.
(a) This section identifies the requirements and limitations for coverage, authorization, and payment of health care services provided through telemedicine or store and forward technologies as defined in subsection (2) of this section.
(b) This section applies to health care services, including behavioral health services, provided to clients enrolled in:
(i) An agency-contracted managed care organization (MCO) and fee-for-service programs; and
(ii) Other agency-contracted programs, including grant-funded health care services and health care services administered by behavioral health administrative services organizations (BH-ASOs).
(2)
Definitions. The following definitions and those found in RCW
71.24.335,
74.09.325, and chapter
182-500 WAC apply to this section.
(a) "Audio-only telemedicine" means the delivery of health care services through the use of audio-only technology, permitting real-time communication between the client at the originating site and the provider, for the purposes of diagnosis, consultation, or treatment.
(d) "Hospital" means a facility licensed under chapter
70.41, 71.12, or
72.23 RCW.
(e) "In person" means the client and the provider are in the same location.
(h) "Telemedicine" means the delivery of health care services using interactive audio and video technology, permitting real-time communication between the client at the originating site and the provider, for the purpose of diagnosis, consultation, or treatment. Telemedicine includes audio-only telemedicine, but does not include the following services:
(i) Email and facsimile transmissions;
(ii) Installation or maintenance of any telecommunication devices or systems;
(iii) Purchase, rental, or repair of telemedicine equipment; and
(iv) Incidental services or communications that are not billed separately, such as communicating laboratory results.
(3) Requirements and authorized use of telemedicine and store and forward technology.
(a)
Governing authority. The medicaid agency determines the health care services that may be paid for when provided through telemedicine or store and forward technology as authorized by state law, including RCW
71.24.335,
74.09.325, and
74.09.327.
(b) Coverage, authorization, and payment. Health care services approved for delivery through telemedicine or store and forward technology must comply with the agency's program rules. The program rules include coverage, authorization, and payment by the agency or the agency's designee, including an agency-contracted managed care entity (managed care organization or behavioral health administrative services organization).
(c) Billing requirements. Providers must bill for health care services as required by the program rules and provider guides of the agency or the agency's designee, including a contracted managed care entity.
(d) Criteria for health care services.
(i) The agency determines the health care services that may be provided through telemedicine or store and forward technology based on whether the health care service is:
(A) A covered service when provided in person by the provider;
(B) Medically necessary;
(C) Determined to be safely and effectively provided through telemedicine or store and forward technology based on generally accepted health care practices and standards; and
(D) Provided through a technology that meets the standards required by state and federal laws governing the privacy and security of protected health information.
(ii) For health care services provided by audio-only telemedicine, the provider and client must have an established relationship.
(iii) For behavioral health services authorized for delivery through store and forward technology, there must be an associated visit between the referring provider and the client.
(4) Health care services authorized for telemedicine and store and forward technology.
(a) Health care services that are authorized to be provided through telemedicine or store and forward technology are identified in the agency's provider guides and fee schedules.
(b) For covered health care services approved for delivery through telemedicine or store and forward technology, the agency or the agency's designee, including an agency-contracted managed care entity (managed care organization (MCO) or behavioral health administrative services organization (BH-ASO)), may require:
(i) Utilization review;
(ii) Prior authorization; and
(iii) Deductible, copayment, or coinsurance requirements that are applicable to coverage of a comparable in-person health care service.
(5) Payment of health care services delivered through telemedicine or store and forward technology.
(a) The agency's designee, including an agency-contracted managed care entity (managed care organization (MCO) or behavioral health administrative services organization (BH-ASO)), pays providers for health care services delivered through telemedicine or store and forward technology in the same amount as when the health care services are provided in person, except as provided in these rules, RCW
71.24.335, and
74.09.325.
(b) The agency or the agency's designee, including an agency-contracted managed care entity (managed care organization or behavioral health administrative services organization) pays for encounter-eligible health care services authorized for delivery through telemedicine at the encounter rate when provided by:
(i) Rural health clinics;
(ii) Federally qualified health centers; or
(iii) Direct Indian health service clinics, tribal clinics, or tribal federally qualified health centers.
(6) Client consent for audio-only telemedicine services.
(a) To receive payment for an audio-only telemedicine service, a provider must obtain client consent before delivering the service to the client.
(b) The client's consent to receive services via audio-only telemedicine must:
(i) Acknowledge the provider will bill the agency or the agency's designee, including an agency-contracted managed care entity (managed care organization or behavioral health administrative services organization) for the service; and
(ii) Be documented in the client's medical record.
(c) A provider may only bill a client for services if they comply with the requirements in WAC
182-502-0160.
(7) Originating site and distant site.
(a) Originating sites and distant sites must be located within the 50 United States, the District of Columbia, or United States territories.
(b) Originating sites may be paid facility fee for infrastructure and client preparation except as noted in (c) of this subsection.
(c) Originating sites facility fees are not paid when the:
(i) Service is provided by audio-only telemedicine;
(ii) Service is store and forward;
(iii) Originating site is:
(A) The client's home;
(B) A hospital, for inpatient services;
(C) A hospital or a hospital provider-based clinic that is an originating site for audio-only telemedicine;
(D) A skilled nursing facility;
(E) Any other location receiving payment for the client's room and board;
(F) Unable to qualify as a provider as defined in WAC
182-500-0085; or
(G) A provider employed by or affiliated with the same entity as the distant site.
(d) A facility fee payment may be subject to a negotiated agreement between the originating site and the managed care organization or the behavioral health administrative services organization.
(e) A distant site may not charge or be paid a facility fee for infrastructure and client preparation.
(8) Recordkeeping.
(a) Providers who furnish a health care service through telemedicine or store and forward technology must comply with the recordkeeping requirements in WAC
182-502-0020.
(b) Providers using telemedicine or store and forward technology must document in the client's medical record the:
(i) Technology used to deliver the health care service by telemedicine or store and forward technology (audio, visual, or other means) and any assistive technologies used;
(ii) Client's location for telemedicine only. This information is not required when a provider uses store and forward technology;
(iii) People attending the appointment with the client (e.g., family, friends, or caregivers) during the delivery of the health care service;
(iv) Provider's location;
(v) Names and credentials (MD, ARNP, RN, PA, CNA, LMHP, etc.) of all originating and distant site providers involved in the delivery of the health care service;
(vi) Start and end time or duration of service when billing is based on time;
(vii) Client's consent for the billing of audio-only telemedicine services.
