Fillable Printable 320 I
Fillable Printable 320 I
320 I
CHAPTER 300
MEDICAL POLICY FOR AHCCCS COVERED SERVICES
POLICY 320
SERVICES WITH SPECIAL CIRCUMSTANCES
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM 320-21
AHCCCS MEDICAL POLICY MANUAL
320-I TELEHEALTH AND TELEMEDICINE
EFFECTIVE DATE: 01/01/2001, 07/01/16
REVISION DATES: 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
AHCCCS covers medically necessary consultative and/or treatment telemedicine
services for all eligible members within the limitations described in this Policy when
provided by an appropriate AHCCCS registered 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
Any AHCCCS registered provider who is not located at
the originating site who provides an expert opinion to
assist in the diagnosis or treatment of a 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 member at the time the
service being furnished via a telecommunications system
occurs. Telepresenters may be needed to facilitate the
delivery of this service.
CHAPTER 300
MEDICAL POLICY FOR AHCCCS COVERED SERVICES
POLICY 320
SERVICES WITH SPECIAL CIRCUMSTANCES
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM 320-22
AHCCCS MEDICAL POLICY MANUAL
T
ELECOMMUNICATIONS
TECHNOLOGY
The transfer of medical data from one site to another
through the use of a camera, electronic data collection
system such as an Electrocardiogram (ECG), or other
similar device, that records (stores) an image which is
then sent (forwarded) via telecommunication to another
site for consultation which includes store and forward.
Services delivered using telecommunications
technology, but not requiring the member to be present
during their implementation, are not considered
telemedicine. For information about coverage of these
services, see Section B of the 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 approved therapeutic services by 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
Teledentistry alone.
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 member monitori ng devices, which are used to
collect and transmit member data 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).
CHAPTER 300
MEDICAL POLICY FOR AHCCCS COVERED SERVICES
POLICY 320
SERVICES WITH SPECIAL CIRCUMSTANCES
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM 320-23
AHCCCS MEDICAL POLICY MANUAL
T
ELEMEDICINE
The practice of health care delivery, diagnosis,
consultation, and treatment, and the transfer of medical
data through interactive audio, video or data
communications that occur in the physical presence of 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
medically expert, with the member‘s medical condition
in order to present the case accurately.
A. USE OF TELEMEDICINE
Contractors shall develop 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 covered medically necessary services that can be
provided via telemedicine are 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
CHAPTER 300
MEDICAL POLICY FOR AHCCCS COVERED SERVICES
POLICY 320
SERVICES WITH SPECIAL CIRCUMSTANCES
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM 320-24
AHCCCS MEDICAL POLICY 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, a separate 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
CHAPTER 300
MEDICAL POLICY FOR AHCCCS COVERED SERVICES
POLICY 320
SERVICES WITH SPECIAL CIRCUMSTANCES
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM 320-25
AHCCCS MEDICAL POLICY 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. The Contractors 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 policy for more information on disclosure of
behavioral health information and telemedicine.
B. USE OF TELECOMMUNICATIONS
Services delivered using telecommunications are generally not covered by AHCCCS
as a telemedicine service. The exceptions to this are described below:
1. A provider in the role of telepresenter may be providing a separately billable
service under their scope of practice such as performing an ECG or an x-ray. In
this case, that separately billable service would be covered, but the specific act
of telepresenting would not be covered.
2. A consulting provider at the distant site may offer a service that does not require
real time interaction with the member. Reimbursement for this type of
consultation is limited to dermatology, radiology, ophthalmology, and
pathology and is subject to review by AHCCCS Medical Management.
CHAPTER 300
MEDICAL POLICY FOR AHCCCS COVERED SERVICES
POLICY 320
SERVICES WITH SPECIAL CIRCUMSTANCES
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM 320-26
AHCCCS MEDICAL POLICY MANUAL
3. In the special circumstance of the onset of acute stroke symptoms within three
hours of presentation, AHCCCS recognizes the critical need for a neurology
consultation in rural areas to aid in the determination of suitability for
thrombolytic administration. Therefore, when a member presents within three
hours of onset of stroke symptoms, AHCCCS will reimburse the consulting
neurologist if the consult is placed for assistance in determining appropriateness
of thrombolytic therapy even when the members’ condition is such that real-
time video interaction cannot be achieved due to an effort to expedite care.
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 431 for more information on Oral Health Care for
EPSDT aged members including covered dental services.
Conditions, Limitations and Exclusions
1. Both the referring and consulting providers must be registered with AHCCCS.
2. A consulting service delivered via teledentistry by other than an Arizona
licensed provider must be provided to a specific member by an AHCCCS
registered provider licensed to practice in the state or jurisdiction from which
the consultation is provided or, if employed by an Indian Health Services (IHS),
Tribal or Urban Indian health program, be appropriately licensed based on IHS
and 638 Tribal facility requirements.
3. At the time of service delivery via real time teledentistry, the member’s dental
provider may designate a trained telepresenter to present the case to the
consulting dentist if the member’s primary dentist or other dental
professional who is familiar with the member‘s dental condition, is not
present. The telepresenter must be familiar with the member‘s dental
condition in order to present the case accurately. Dental questions may be
submitted to the referring dentist when necessary but no payment is made for
such questions.
CHAPTER 300
MEDICAL POLICY FOR AHCCCS COVERED SERVICES
POLICY 320
SERVICES WITH SPECIAL CIRCUMSTANCES
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM 320-27
AHCCCS MEDICAL POLICY MANUAL
D. TELEMONITORING
Telemonitoring services are considered medically necessary 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 Coronary Intervention (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.
CHAPTER 300
MEDICAL POLICY FOR AHCCCS COVERED SERVICES
POLICY 320
SERVICES WITH SPECIAL CIRCUMSTANCES
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM 320-28
AHCCCS MEDICAL POLICY MANUAL
6. Member has daily visiting nurse for other than CHF indication.
E. ADDITIONAL INFORMATION
Refer to AMPM Policy 310 and to the AHCCCS Covered Behavioral Health Services
Guide for complete information regarding covered behavioral health services for
Title XIX and Title XXI members.
AHCCCS Division of Fee-for-Service Management does not require Prior
Authorization (PA) for medically necessary telemedicine services performed by Fee-
For-Service (FFS) providers. Refer to AMPM Chapter 800 for complete information
regarding PA requirements. Refer to the AHCCCS FFS P rovider B illing Manual, the
IHS/Tribal Provider Billing Manual and the AHCCCS Telehealth Training Manual
for complete information regarding billing procedures. These manuals are available
on the AHCCCS website.
