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Fillable Printable 320 I

Fillable Printable 320 I

320 I

320 I

CHAPTER300
MEDICAL POLICY FOR AHCCCSCOVERED SERVICES
POLICY 320
SERVICES WITH SPECIAL CIRCUMSTANCES
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM320-21
AHCCCSMEDICALPOLICY MANUAL
320-I TELEHEALTHANDTELEMEDICINE
EFFECTIVEDATE: 01/01/2001, 07/01/16
REVISIONDATES: 10/01/01, 07/01/04, 05/01/06, 10/01/06, 12/01/06, 04/01/12, 10/01/15,
10/20/16
DESCRIPTION
AHCCCScoversmedicallynecessaryconsultativeand/or treatmenttelemedicine
servicesforalleligiblememberswithinthe limitationsdescribedinthisPolicywhen
provided byanappropriateAHCCCSregistered provider.
DEFINITIONS
A
SYNCHRONOUS OR
"STORE AND FORWARD"
The transfer of data from one site to another through the
use of a camera o r similar device that records (st ores) an
image that is sent (forwarded) via telecommunication to
another site for consultation. Asynchronous or "store and
forward" app
lications would not be considered
telemedicine but may be utilized to deliver services.
C
ONSULTING
P
ROVIDER
AnyAHCCCSregisteredprovider whoisnotlocatedat
the originatingsitewhoprovides anexpertopinionto
assistinthe diagnosisortreatmentofa member.
D
ISTANT OR
H
UB SITE
The site at which the physician or other licensed
practitioner delivering the service is located at the time
the service is provided via telecommunications system.
O
RIGINATING OR
S
POKE
SITE
The location of the Medicaid memberat the time the
service being furnished via a telecommunications system
occurs. Telepresenters may be needed to facilitate the
delivery of this service.
CHAPTER300
MEDICAL POLICY FOR AHCCCSCOVERED SERVICES
POLICY 320
SERVICES WITH SPECIAL CIRCUMSTANCES
ARIZONA HEALTH CARE COST CONTAINMENTSYSTEM320-22
AHCCCSMEDICALPOLICY MANUAL
T
ELECOMMUNICATIONS
TECHNOLOGY
The transferofmedicaldata fromone sitetoanother
through the use ofa camera,electronicdatacollection
systemsuchasanElectrocardiogram(ECG),orother
similardevice,thatrecords(stores)animagewhichis
thensent(forwarded)viatelecommunicationtoanother
siteforconsultation which includes store and forward.
Servicesdeliveredusing telecommunications
technology, butnot requiringthe membertobepresent
duringtheirimplementation,are not considered
telemedicine. For information about coverageof these
services, seeSectionB ofthe policy.
T
ELEDENTISTRY
The acquisition and transmission of all necessary
subjective and objective diagnostic data through
interactive audio, video or data communications by an
AHCCCS registered dental provider to a distant dentist
for triage, dental treatment planning, and referral.
a.Teledentistry includes the provision of preventive and
other approvedtherapeutic servicesby the AHCCCS
registered Affiliated Practice Dental Hygienist
, who
provides dental hygiene services und
er an affiliated
practice relationship with a dentist.
b.Teledentistry does not replace the dental examination
by the dentist; limited, periodic, and comprehensive
examinations cannot be billed through the use of
Teledentistryalone.
T
ELEHEALTH
(
OR
TELEMONITORING)
The use of telecommunications and information
technology to provide access to health assessment,
diagnosis, intervention, consultation, supervision and
information across distance.
a.
Telehealth includes such technologies as telephones,
facsimile machines, electronic mail systems, and
remote membermonitori ng devices, which are used to
collect and transmit memberdata for monitoring and
interpretation. While they do not meet the Medicaid
definition of telemedicine they are often considered
under the broad umbrella of telehealth services. Even
though such technologies are not considered
"telemedicine," they may nevertheless be covered and
reimbursed as part of a Medicaid coverable service,
such as laboratory service, x-ray service or physician
services (under section 1905(a) of the Social Security
Act).
CHAPTER300
MEDICAL POLICY FOR AHCCCSCOVERED SERVICES
POLICY 320
SERVICES WITH SPECIAL CIRCUMSTANCES
ARIZONA HEALTH CARE COST CONTAINMENTSYSTEM320-23
AHCCCSMEDICALPOLICY MANUAL
T
ELEMEDICINE
The practiceofhealthcaredelivery,diagnosis,
consultation, andtreatment,andthe transferofmedical
datathrough interactiveaudio, videoor data
communications thatoccurin the physicalpresenceof the
member, includin g audio or video communic ations sent to
a health care provider for diagnostic or treatment
consultation. Refer to A.R.S.§36-3601.
T
ELEPRESENTER
A designated individual who is familiar with the
member‘s case and has been asked to present the
member‘s case at the time of telehealth service delivery if
the member‘s originating site provider is not pres ent. The
telepresenter must be familiar, but not necessarily
medicallyexpert, with the member‘s medical condition
in order to present the case accurately.
A.USE OF TELEMEDICINE
Contractors shalldevelop and maintain a network of providers that utilizes
telemedicine to support an adequate provider network.
Telemedicine shall not replace provider choice and/or member preference for
physical delivery.AHCCCS coveredmedically necessary servicesthat can be
provided via telemedicineare listed below. Services must be real-time visits
otherwise reimbursed by AHCCCS.
The following medical services are covered:
1.Cardiology
2.Dermatology
3.Endocrinology
4.Hematology/oncology
5.Infectious diseases
6.Neurology
7.Obstetrics/gynecology
8.Oncology/radiation
9.Ophthalmology
CHAPTER300
MEDICAL POLICY FOR AHCCCSCOVERED SERVICES
POLICY 320
SERVICES WITH SPECIAL CIRCUMSTANCES
ARIZONA HEALTH CARE COST CONTAINMENTSYSTEM320-24
AHCCCSMEDICALPOLICY MANUAL
10.Orthopedics
11.Pain clinic
12.Pathology
13.Pediatrics and pediatric subspecialties
14.Radiology
15.Rheumatology
16.Surgery follow-up and consultations
17.Behavioral Health
INFORMED CONSENT
If a recording of the interactive video service is to be made, aseparate consent to
record shall be obtained.The responsibility of ensuring the informed consent is
completed lies with the provider delivering the service. Items to be included in the
consent are:
1.Identifying information,
2.A statement of understanding that participation in telemedicine is voluntary,
3.A statement of understanding that a re cording of i nformation and i mages from the
interactive video service will be made,and likely viewed by other persons for a
specific clinical or educational purpose.
4.A description of the purpose(s) for the recording,
5.A statement of the person’s right to rescind the use of the recording at any time,
6.A date upon which permission to use the recording will be void unless otherwise
renewed by signature of the person receiving the recorded service,
7.A statement of understanding that the person has the right to inspect all
information obtained and recorded in the course of a telemedicine interaction, and
may receive copies of the information for a reasonable fee,
8.A statement of understanding that providers will have access to any relevant
medical information about the person, including psychiatric and/or psychological
information, alcohol and/or drug use, and mental health records. However, if the
person is receiving services related to alcohol and other drugs or HIV status, no
CHAPTER300
MEDICAL POLICY FOR AHCCCSCOVERED SERVICES
POLICY 320
SERVICES WITH SPECIAL CIRCUMSTANCES
ARIZONA HEALTH CARE COST CONTAINMENTSYSTEM320-25
AHCCCSMEDICALPOLICY MANUAL
material, including video recordings, may be re-disclosed unless further
disclosure is expressly permitted by the person under 42 CFR Part 2 or A.R.S. 36-
664, and
9.A statement of understanding that the Informed Consent document will become a
part of the person’s medical record.
If a telemedicine session is recorded, the recording must be maintained as a
component on the member’s medical record, in accordance with 45 CFR Part 164.524
and AMPM Policy 940. TheContractors and TRBHAs will establish a process that
allows members to attain telemedicine information in their medical records.
CONFIDENTIALITY
At the time services are being delivered through interactive video equipment, no
person, other than those agreed to by the person receiving services will observe or
monitor the service either electronically or from “off camera.”To ensure
confidentiality of telemedicine sessions providers must do the following when
providing services via telemedicine:
1.The videoconferencing room door must remain closed at all times,
2.If the room is used for other purposes, a sign must be posted on the door, stating
that a clinical session is in progress, and
3.Implement any additional safeguards to ensure confidentiality in accordance with
AMPM Policy 550. See this policyfor more information on disclosure of
behavioral health information and telemedicine.
B.USE OF TELECOMMUNICATIONS
Servicesdeliveredusingtelecommunicationsaregenerallynot coveredbyAHCCCS
asa telemedicineservice.Theexceptionstothisaredescribedbelow:
1.A provider inthe roleof telepresentermaybe providing a separatelybillable
serviceunder theirscope ofpracticesuchasperforminganECGoranx-ray.In
thiscase,thatseparatelybillableservicewouldbecovered,butthe specificact
oftelepresentingwouldnotbecovered.
2.A consulting provider at the distantsitemayoffera servicethatdoes notrequire
realtimeinteractionwiththe member.Reimbursement forthistypeof
consultation islimitedtodermatology,radiology, ophthalmology, and
pathology andissubjecttoreviewbyAHCCCSMedicalManagement.
CHAPTER300
MEDICAL POLICY FOR AHCCCSCOVERED SERVICES
POLICY 320
SERVICES WITH SPECIAL CIRCUMSTANCES
ARIZONA HEALTH CARE COST CONTAINMENTSYSTEM320-26
AHCCCSMEDICALPOLICY MANUAL
3.Inthe specialcircumstanceofthe onset ofacutestroke symptomswithinthree
hours ofpresentation,AHCCCSrecognizesthe criticalneedfora neurology
consultation inruralareastoaidinthe determinationofsuitabilityfor
thrombolytic administration.Therefore,whena memberpresentswithinthree
hours ofonset ofstroke symptoms,AHCCCSwillreimburse the consulting
neurologist ifthe consultisplacedforassistanceindeterminingappropriateness
ofthrombolytictherapyevenwhenthe memberscondition issuchthatreal-
timevideointeraction cannot beachieved due toanefforttoexpeditecare.
4.The following are additional exceptions, as noted in the AHCCCS Covered
Behavioral Services Guide:
a.Home Care Training Family Services (Family support)
b.Self-Help/Peer Services (Peer Supp or t)
c.Skills Training and Development,
d.Psychosocial Rehabilitation Services (Living Skills Training)
e.Case Management
C.USE OF TELEDENTISTRY SERVICES
AHCCCS covers Teledentistry for Early and Periodic Screening, Diagnostic and
Treatment (EPSDT) aged members when provided by an AHCCCS registered dental
provider. Refer to AMPM Policy 431for more information on Oral Health Care for
EPSDT aged members including covered dental services.
Conditions,Limitations and Exclusions
1.Both thereferringandconsultingprovidersmustberegisteredwithAHCCCS.
2.A consulting servicedeliveredviateledentistrybyother thananArizona
licensedprovidermustbeprovided toa specificmemberbyanAHCCCS
registeredproviderlicensedtopracticeinthe stateor jurisdictionfromwhich
the consultationisprovidedor,ifemployedbyanIndian HealthServices(IHS),
TribalorUrbanIndian healthprogram,beappropriately licensedbasedon IHS
and 638 Tribalfacility requirements.
3.Atthe timeofservicedeliveryviarealtimeteledentistry, the member’s dental
provider maydesignatea trainedtelepresentertopresentthe casetothe
consultingdentist ifthemember’s primarydentist orother dental
professional whoisfamiliarwiththe member‘sdentalcondition,isnot
present.Thetelepresentermustbefamiliarwiththe member‘sdental
condition inorder topresentthecaseaccurately.Dentalquestions maybe
submittedtothe referringdentist whennecessarybutnopaymentismadefor
such questions.
CHAPTER300
MEDICAL POLICY FOR AHCCCSCOVERED SERVICES
POLICY 320
SERVICES WITH SPECIAL CIRCUMSTANCES
ARIZONA HEALTH CARE COST CONTAINMENTSYSTEM320-27
AHCCCSMEDICALPOLICY MANUAL
D.TELEMONITORING
Telemonitoring services are considered medicallynecessary for members with
Congestive Heart Failure (CHF) when the following conditions are met:
1.Observation/inpatient Utilization
a.Observation/inpatient admission with primary or secondary discharge
diagnosis of CHF within the past two months,
OR
b.Readmission to observation/inpatient with primary or secondary discharge
diagnosis of CHF within the past six months.
AND
2.Symptom Level
New York Heart Association (NYHA) class II or greater
3.CHF is identified by one of the following ICD-10 diagnostic codes:
Congestive Heart Failure (I50.20 to I50.9); or
Cardiomyopathy (I42.0 to I43); or
Fluid overload (E8770; E8779; E877)
LIMITATIONS
Telemonitoring for CHF is not covered under the following conditions:
1.Member does not wish to participate
2.Inability to participate in biometrics
3.Member has elected hospice care.
4.Members with planned readmission for definitive treatment of CHF (e.g.,
Invasive therapies for heart failure include electrophysiologic intervention such as
Cardiac Resynchronization Therapy (CRT), pacemakers, and implantable
cardioverter-defibrillators; revascularization procedures such as Coronary Artery
Bypass Grafting (CABG) and Percutaneous CoronaryIntervention (PCI); valve
replacement or repair; and ventricular restoration, etc.)
5.Members whose hospitalization in the past six months has principally been for:
a.Device implant malfunction (e.g. pacemaker, VAD, etc.),
b.Presence of severe aortic stenosis and no surgical option,
c.Severe pulmonary disease,
d.Chronic hemodialysis,
e.End-stage liver disease.
CHAPTER300
MEDICAL POLICY FOR AHCCCSCOVERED SERVICES
POLICY 320
SERVICES WITH SPECIAL CIRCUMSTANCES
ARIZONA HEALTH CARE COST CONTAINMENTSYSTEM320-28
AHCCCSMEDICALPOLICY MANUAL
6.Member has daily visiting nurse for other than CHF indication.
E.ADDITIONAL INFORMATION
Refer toAMPM Policy 310 and to the AHCCCS Covered Behavioral Health Services
Guideforcompleteinformationregardingcoveredbehavioralhealthservicesfor
TitleXIXandTitleXXImembers.
AHCCCSDivisionofFee-for-ServiceManagementdoes notrequirePrior
Authorization (PA)formedicallynecessarytelemedicineservicesperformedbyFee-
For-Service(FFS)providers.RefertoAMPMChapter800 forcompleteinformation
regardingPArequirements.Referto the AHCCCSFFSP rovider B illingManual,the
IHS/TribalProviderBillingManual andthe AHCCCSTelehealthTrainingManual
forcompleteinformationregardingbillingprocedures. Thesemanualsareavailable
onthe AHCCCSwebsite.
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