Anthem Blue Cross Telehealth Program. Provider Manual

Anthem Blue Cross Telehealth Program

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Table of Contents 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 Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 3

Table of Contents 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 Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 4

Table of Contents 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 Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 5

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Chapter 1: Introduction to Telehealth 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. Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 7

Chapter 1: Introduction to Telehealth 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. Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 8

Chapter 1: Introduction to Telehealth 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 Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 9

Chapter 1: Introduction to Telehealth 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. Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 10

Chapter 2: Telehealth Contacts 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:... Contact us when: Attn: Telehealth Department Anthem Blue Cross One WellPoint Way, CAT201-M002 Thousand Oaks, CA 91361 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 Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 11

Chapter 2: Telehealth Contacts 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 1-800-677-6669 (Providers) California Valued Trust (CVT):... 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 Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 12

Chapter 2: Telehealth Contacts 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 Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 13

Chapter 3: Frequently Asked Questions 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 audioonly 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. Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 14

Chapter 3: Frequently Asked Questions 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 Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 15

Chapter 3: Frequently Asked Questions 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 Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 16

Chapter 4: Site Locations 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 Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 17

Chapter 5: Roles and Responsibilities Covering California Telehealth Network Site Locations Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 18

Chapter 5: Roles and Responsibilities 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 Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 19

Chapter 5: Roles and Responsibilities 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 Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 20

Chapter 6: When to Choose Telehealth 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). Telehealth services may not be provided to CMSP members who have not yet met their share of cost. 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 ongoing 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. Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 21

Chapter 6: When to Choose Telehealth Conditions Generally Suitable for Telehealth Consultations Specialty Dermatology Ear, Nose, and Throat (ENT) Gastroenterology Internal Medicine / Pediatrics Neurology Conditions 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 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 Dysphasia Non-acute gastrointestinal symptomology Chronic hepatitis Encopresis Chronic abdominal pain Malabsorption Pre-and post-procedural evaluations Post-surgical follow-up 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 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 Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 22

Chapter 6: When to Choose Telehealth 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. The specialist need to interact with the patient The specialist need the presenter to manipulate the patient Sufficient information (such as images, data, dictated comments, lab results) about the patient s condition can be assembled Thin it s best suited for: Live Video Live Video 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. Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 23

Chapter 7: How to 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. Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 24

Chapter 7: How to 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 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. 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 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. Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 25

Chapter 7: How to 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. Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 26

Chapter 7: How to 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 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. 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 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. Confirm that the specialty center has received the faxed patient medical information and any additional information needed by the specialty center Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 27

Chapter 7: How to 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 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. 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 Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 28

Chapter 7: How to 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. 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 Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 29

Chapter 7: How to 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. 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 followup 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. 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. Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 30

Chapter 7: How to 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. Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 31

Chapter 8: Claims and Billing 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 Care 1. 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 s. 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. 1 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. Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 32

Chapter 8: Claims and Billing 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 selfmanagement 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) Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 33

Chapter 8: Claims and Billing 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. 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. Modifier GT Modifier GQ Live Video Telehealth Encounter Service Type Live Video Telehealth encounter for eligible members Store and Forward Telehealth Encounter Service Type 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. Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 34

Chapter 8: Claims and Billing 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. Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 35

Chapter 8: Claims and Billing 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. 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. Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 36

Chapter 8: Claims and Billing 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 Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 37

Chapter 8: Claims and Billing 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) Field 1a (R) Medicare/Medicaid/TRICARE /CHAMPUS/CHAMPVA/Group Health Plan/FECA Blk Lung/Other ID Insured s ID Number 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. 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. Enter date of birth as MM/DD/YY (Month/Day/Year). For example, enter September 1, 1993 as Field 3 (R) Patient s Birth Date / Patient s Sex 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. Enter the name of the insurance with the group and Field 9a (R) Other Insured s Policy or Group Number 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. Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 38

Chapter 8: Claims and Billing Field Number Title Explanation Check Y or N. If insurance is related to workers Field 10a (R) Related to Employment? compensation, check Y. Field 10b (R) Related to Auto Accident / Place? Field 10c (R) Related to Other Accident? Check Y or N. Check Y or N. Enter the state abbreviation in which the accident occurred. 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) Field 14 (R) Field 15 Field 16 Field 17 (R) Insured s or Authorized Person s Signature Date of Current First Date Dates Patient Unable to Work in Current Occupation (From - To) Name of Referring Physician or Other Source Sign and date the form. ( Signature on file is acceptable for this field.) Enter the date of the injury, illness or pregnancy (if applicable). For professional emergency services billing, enter the Injury Date. Enter the date of the first consultation for the patient s condition. Date format is MM/DD/YY. Date format is MM/DD/YY. 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) Field 20 Field 21 (R) Field 22 Reserved for Local Use Outside Lab? (Yes or No); $ Charge Diagnosis or Nature of Illness or Injury Medicaid Resubmission 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. Check Yes if lab services were sent to an outside lab; check No if not. Enter the appropriate diagnosis code or nomenclature. Check with a coding expert if you aren t sure. 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. Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 39

Chapter 8: Claims and Billing Field Number Title Explanation 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. Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 40

Chapter 8: Claims and Billing Field Number Title Explanation 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. Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 41

Chapter 8: Claims and Billing 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 7 Cov D. Covered days 8 N-C D. Non-covered days The FROM and THROUGH dates covered by the claim being submitted Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 42

Chapter 8: Claims and Billing Locator # Box Title Description 9 C-I D. Coinsurance days 10 L-R D. Lifetime reserve days 11 **blank** 12 (R) Patient Name 13 Patient Address 14 (R) Birth Date Enter the member s name as it appears on the member s ID card. Enter the member s complete address (number, street, city, state and ZIP code). 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 18 (R) Admission Hr Enter the member s admission date to the facility in MM/DD/YY format. 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 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** Enter the member s discharge hour from the facility in military time (00 to 23) format. 32-35 (R) Occurrence Codes / Dates Occurrence codes (42), if applicable 36 37 **blank** 38 **blank** Occurrence Span (Code, From & Through Date) Days in MM/DD/YY format 39-41 (R) Value Codes (Code / Amount) Value codes and amounts 42 (R) Rev CD Revenue Code (required for all institutional claims) Locator # Box Title Description 43 (R) Description Description of services rendered 44 (R) HCPCS/Rates 45 (R) Serv Date Date of services rendered 46 (R) Serv Units The accommodation rate per day for inpatient services or HCPCS/CPT code for outpatient and FQHC services 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 Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 43

Chapter 8: Claims and Billing Locator # Box Title Description 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 60 (R) CERT.-SSN-HIC.-ID NO. Patient s relationship to insured (N/A if member is the insured) 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. Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 44

Chapter 8: Claims and Billing Locator # Box Title Description 67 (R) Prin. Diag. CD. 68-75 (R) Other Diag. Codes Principal ICD-9 diagnostic codes. After October 1, 2013, use the principal ICD-10 diagnostic 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) 81 (R) Other Procedure (Code/Date) Enter taxonomy codes. ICD-9 principal procedure code and dates, if applicable After October 1, 2013, ICD-10 principal procedure code and dates, if applicable. 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 Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 45

Chapter 8: Claims and Billing Telehealth Sample Section CMS-1450/UB-04 Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 46

Chapter 9: Developing Telehealth Medical Record Documentation 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. Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 47

Chapter 9: Developing Telehealth Medical Record Documentation 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. Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 48

Chapter 9: Developing Telehealth Medical Record Documentation 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: ca.telemedicine@anthem.com 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 ca.telemedicine@anthem.com. Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 49

Chapter 10: Forms and Logs 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). Date Patient ID Field Instructions 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. 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. Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 50

Chapter 10: Forms and Logs Field Live Video or Store and Forward Specialty Center Instructions Enter the Telehealth application code: LV Live Video SF Store and Forward Enter the location to which you connected for this event (for example, XYZ Specialty Center) (A) Specialty (B) Payment Source (C) Non-Clinical Usage Definitions 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. Enter the appropriate choice from Section B, Payment Source (for example, 2-Grant Funded Consult.) Enter the appropriate choice from Section E, Non-Clinical Usage (for example, 3-Continuing Education / Clinical Conference) 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 ca.telemedicine@anthem.com (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. Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 51

Chapter 11: Telehealth Program Glossary Provider Manul Term CalPERS CMS 1500 GQ GT HPSA ISDN Lines Live Video MSSA MUA MUP Open Access Network Originating site PCP Presentation Site Definition California Public Employees Retirement System, which added Anthem Blue Cross Telehealth Program to the PERS Care Basic Plan and PERS Choice Basic Plan. Center for Medicare and Medicaid Medical Claim Form HIPAA approved insurance claim modifier for Store and Forward consultations. HIPAA approved insurance modifier for Live Video consultations. Health Professional Shortage Area 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. (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. 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. Medically Underserved Area Medically Underserved Population 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. 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 Primary care physician 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. Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 52

Chapter 11: Telehealth Program Glossary Presenter Term Presentation Definition Primary care physician, mid level or office staff member assisting the presentation site in presenting the patient to the specialist. Communication of patient s history, demographic information, necessary images, and data to facilitate diagnosis, treatment and education of the patient. Specialty Calendar Specialty Center Store and Forward Telehealth Telehealth Site Coordinator Utilization Log 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. 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. (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. 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. 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 A report that tracks the Telehealth events, both clinical and non clinical for each presentation site. The utilization log is submitted every month. Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 53

Telehealth Information Forms Telehealth Information Forms As is discussed in Chapter 10 Telehealth Forms and Logs the following forms are available:. Telehealth Consultation Summary Form Telehealth Utilization Log Telehealth Patient Satisfaction Survey Form Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 54

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 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 Utilization Log 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 ca.telemedicine@anthem.com. Date 1. 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 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 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