Tennessee

PLEASE NOTE: CCHP is providing the following for informational purposes only. We are not providing legal advice or interpretation of the laws and regulations and policies. CCHP encourages you to check with the appropriate state agency for further information and direction. This information should not be construed as legal counsel. Consult with an attorney if you are seeking a legal opinion.

MEDICAID REIMBURSEMENT

• Live Video: Yes
• Store-and-Forward: No
• Remote Patient Monitoring: No
• Audio Only: Yes

PRIVATE PAYER LAW

• Law Exists: Yes
• Payment Parity: No

PROFESSIONAL REQUIREMENTS

• Licensure Compacts: ASLP-IC, CC, EMS, IMLC, NLC, OT, PSY, PTC
• Consent Requirements: Yes

STATE RESOURCES

1. Medicaid Program: TennCare
2. Administrator: Dept. of Human Services
3. Regional Telehealth Resource Center: South Central Telehealth Resource Center

PLEASE NOTE: CCHP is providing the following for informational purposes only. We are not providing legal advice or interpretation of the laws and regulations and policies. CCHP encourages you to check with the appropriate state agency for further information and direction. This information should not be construed as legal counsel. Consult with an attorney if you are seeking a legal opinion.

Private Payer

Last updated 05/03/2024

Definitions

Telehealth means the use of real-time interactive audio, video telecommunications or electronic technology, or store-and-forward telemedicine services by a healthcare services provider to deliver healthcare services to a patient within the scope of practice of the healthcare services provider when:

• Such provider is at a qualified site other than the site where the patient is located; and
• The patient is at a qualified site at a school clinic staffed by a healthcare services provider and equipped to engage in the telecommunications described in this section or a public elementary or secondary school staffed by a health care services provider and equipped to engage in the telecommunications described in this section; and
• Does not include:
  • Audio only conversation;
  • An electronic mail message; or
  • Facsimile transmission;

  “Provider-based telemedicine”: Means the use of Health Insurance Portability and Accountability Act (HIPAA) (42 U.S.C. § 1320d et seq.) compliant real-time, interactive audio, video telecommunications, or electronic technology, or store-and-forward telemedicine services, used over the course of an interactive visit by a healthcare services provider to deliver healthcare services to a patient within the scope of practice of the healthcare services provider when:

  • The healthcare services provider is at a qualified site other than the site where the patient is located and has access to the relevant medical record for that patient;
  • The patient is located at a location the patient deems appropriate to receive the healthcare service that is equipped to engage in the telecommunication described in this section; and
    • The healthcare services provider makes use of HIPAA compliant real-time, interactive audio, video telecommunications or electronic technology, or store-and-forward telemedicine services to deliver healthcare services to a patient within the scope of practice of the healthcare services provider as long as the healthcare services provider, the healthcare services provider’s practice group, or the healthcare system has established a provider-patient relationship by submitting to a health insurance entity evidence of an in-person encounter between the healthcare service provider, the healthcare services provider’s practice group, or the healthcare system and the patient within sixteen (16) months prior to the interactive visit; and
    • The requirement of an in-person encounter between the healthcare services provider, the healthcare services provider’s practice group, or the healthcare system and the patient within sixteen (16) months prior to the interactive visit is tolled for the duration of a state of emergency declared by the governor pursuant to § 58-2-107; provided, that the healthcare services provider or the patient, or both, are located in the geographical area covered by the applicable state of emergency;
    • The requirement of an in-person encounter between the healthcare services provider, the healthcare services provider’s practice group, or the healthcare system and the patient within sixteen (16) months prior to the interactive visit does not apply to a patient who is receiving an initial behavioral health evaluation or assessment.
    • An audio-only conversation;
    • An electronic mail message or phone text message;
    • A facsimile transmission;
    • Remote patient monitoring; or
    • Healthcare services provided pursuant to a contractual relationship between a health insurance entity and an entity that facilitates the delivery of provider-based telemedicine as the substantial portion of the entity’s business.

    Notwithstanding subdivisions (a)(6)(A) and (B), includes Health Insurance Portability and Accountability Act (HIPAA) (42 U.S.C. § 1320d et seq.) compliant audio-only conversation for the provision of behavioral health services or healthcare services when the means described in subdivision (a)(6)(A) are unavailable.

    Workers Compensation

    “Telehealth” means the distribution of health-related services and information via electronic information and telecommunication technologies.

    “Telemedicine” means the use of telehealth by a telehealth provider to provide clinical health care.

    Telehealth: the definitions, licensing and processes for the purpose of these Rules shall be the same as adopted by the Tennessee Department of Health and Medicare. The maximum reimbursement for services provided via telehealth is the lesser of billed charges or the amounts listed in this fee schedule. Services that are eligible to be provided via telehealth are identified with a star (★) in the rate tables.

    Last updated 05/03/2024

    Parity

    SERVICE PARITY

    Provider-based Telemedicine

    A health insurance entity:

    • Shall provide coverage under a health insurance policy or contract for covered healthcare services delivered through provider-based telemedicine;
    • Shall reimburse a healthcare services provider for a healthcare service covered under an insured patient’s health insurance policy or contract that is provided through provider-based telemedicine without any distinction or consideration of the geographic location or any federal, state, or local designation, or classification of the geographic area where the patient is located;
    • Shall not exclude from coverage a healthcare service solely because it is provided through provider-based telemedicine and is not provided through an in-person encounter between a healthcare services provider and a patient; and
    • Shall reimburse healthcare services providers who are out-of-network for provider-based telemedicine care services under the same reimbursement policies applicable to other out-of-network healthcare services providers.

    A health insurance entity shall provide coverage for healthcare services provided during a provider-based telemedicine encounter in a manner that is consistent with what the health insurance policy or contract provides for in-person encounters for the same service, and shall reimburse for healthcare services provided during a provider-based telemedicine encounter without distinction or consideration of the geographic location, or any federal, state, or local designation or classification of the geographic area where the patient is located.

    Telehealth Services

    A health insurance entity:

    • Shall provide coverage under a health insurance policy or contract for covered healthcare services delivered through telehealth;
    • S hall reimburse a healthcare services provider for the diagnosis, consultation, and treatment of an insured patient for a healthcare service covered under a health insurance policy or contract that is provided through telehealth without any distinction or consideration of the geographic location or any federal, state, or local designation, or classification of the geographic area where the patient is located;
    • Shall not exclude from coverage a healthcare service solely because it is provided through telehealth and is not provided through an in-person encounter between a healthcare services provider and a patient; and
    • Sh all reimburse healthcare services providers who are out-of-network for telehealth care services under the same reimbursement policies applicable to other out-of-network healthcare services providers.

    Remote patient monitoring

    A health insurance entity may consider any remote patient monitoring service a covered medical service if the same service is covered by Medicare. The appropriate parties may negotiate the rate for these services in the manner in which is deemed appropriate by the parties.

    Reimbursement of expenses for covered remote patient monitoring services must be established through negotiations conducted by the health insurance entity with the healthcare services provider, healthcare system, or practice group in the same manner as the health insurance entity establishes reimbursement of expenses for covered healthcare services that are delivered by in-person means.

    Worker’s Compensation

    Except when a medical fee waiver in accordance with Rule 0800-02-17-.18 is obtained from the bureau, nothing in this Chapter 0800-02-31 shall require an employer to pay a total reimbursement for a telehealth encounter for workers’ compensation, including the use of telehealth equipment, in an amount exceeding the amount that would be paid for the same service provided by a healthcare services provider during an in-person encounter under the medical fee schedule set forth in Chapters 0800-02-17, 18, and 19. The medical fee schedule, including but not limited to Tennessee specific conversion percentages, shall apply to the providers of telehealth services rendered pursuant to the workers’ compensation law.

    Billing for telehealth services shall be by standard HCFA-1500 using modifier -95 and the appropriate place of service code as specified by CMS for the date of service or their successors as used by CMS. The provider shall append modifier -95 to the CPT® code with the place of service code -02 (telehealth) or -11 (office) as specified by CMS for the date of service. All other modifiers should also be added to the CPT® code as applicable.

    When a procedure is provided using telemedicine, reimbursement shall be as follows: The procedure code is reimbursed at the non-facility Medicare maximum allowable payment or the billed charge, whichever is less, regardless of the practitioner’s physical location at the time of service.

    Coding and billing regulations shall follow the Medicare guidelines in effect for the date of service with no geographic qualifier.

    Telehealth: the definitions, licensing and processes for the purpose of these Rules shall be the same as adopted by the Tennessee Department of Health and Medicare. The maximum reimbursement for services provided via telehealth is the lesser of billed charges or the amounts listed in this fee schedule. Services that are eligible to be provided via telehealth are identified with a star (★) in the rate tables.

    PAYMENT PARITY

    Provider-based Telemedicine

    This section does not require a health insurance entity to pay total reimbursement for a provider-based telemedicine encounter in an amount that exceeds the amount that would be paid for the same service provided by a healthcare services provider for an in-person encounter.

    This section does not require a health insurance entity to provide coverage for healthcare services that are not medically necessary, unless the terms and conditions of an applicable health insurance policy provide that coverage.

    This section does not require a health insurance entity to provide coverage for healthcare services delivered by means of provider-based telemedicine if the applicable health insurance policy would not provide coverage for the same healthcare services if delivered by in-person means.

    This section does not require a health insurance entity to pay total reimbursement for a provider-based telemedicine encounter in an amount that exceeds the amount that would be paid for the same service provided by a healthcare services provider for an in-person encounter.

    This section does not require a health insurance entity to reimburse a healthcare services provider for healthcare services delivered by means of provider-based telemedicine if the applicable health insurance policy would not reimburse that healthcare services provider if the same healthcare services had been delivered by in-person means.

    Insurers shall reimburse healthcare services providers who are out-of-network for provider-based telemedicine care services under the same reimbursement policies applicable to other out-of-network healthcare services providers.

    Telehealth Services

    Health Insurance entities are required to reimburse for the diagnosis, consultation, and treatment of an insured patient for a healthcare service covered under a health insurance policy or contract that is provided through telehealth without any distinction or consideration of the geographic location or any federal, state, or local designation, or classification of the geographic area where the patient is located.

    The shall also reimburse healthcare services providers who are out-of-network for telehealth care services under the same reimbursement policies applicable to other out-of-network healthcare services providers.

    Reimbursement of expenses for covered remote patient monitoring services must be established through negotiations conducted by the health insurance entity with the healthcare services provider, healthcare system, or practice group in the same manner as the health insurance entity establishes reimbursement of expenses for covered healthcare services that are delivered by in-person means.

    Last updated 05/03/2024

    Requirements

    Telehealth Services

    “Qualified site” means the office of a healthcare services provider, a hospital licensed under title 68, a facility recognized as a rural health clinic under federal Medicare regulations, a federally qualified health center, any facility licensed under title 33, or any other location deemed acceptable by the health insurance entity.

    “Healthcare services provider” means an individual acting within the scope of a valid license issued pursuant to title 63 or any state-contracted crisis service provider employed by a facility licensed under title 33.

    A health insurance entity:

    • Shall provide coverage under a health insurance policy or contract for covered healthcare services delivered through telehealth;
    • S hall reimburse a healthcare services provider for the diagnosis, consultation, and treatment of an insured patient for a healthcare service covered under a health insurance policy or contract that is provided through telehealth without any distinction or consideration of the geographic location or any federal, state, or local designation, or classification of the geographic area where the patient is located;
    • Shall not exclude from coverage a healthcare service solely because it is provided through telehealth and is not provided through an in-person encounter between a healthcare services provider and a patient; and
    • Sh all reimburse healthcare services providers who are out-of-network for telehealth care services under the same reimbursement policies applicable to other out-of-network healthcare services providers.

    A health insurance entity shall provide coverage for healthcare services provided during a telehealth encounter in a manner that is consistent with what the health insurance policy or contract provides for in-person encounters for the same service, and shall reimburse for healthcare services provided during a telehealth encounter without distinction or consideration of the geographic location, or any federal, state, or local designation or classification of the geographic area where the patient is located.

    A health insurance entity shall reimburse an originating site hosting a patient as part of a telehealth encounter an originating site fee in accordance with the federal centers for Medicare and medicaid services telehealth services rule 42 C.F.R. § 410.78 and at an amount established prior to August 20, 2020, by the federal centers for medicare and medicaid services.

    This section does not require a health insurance entity to provide coverage for healthcare services that are not medically necessary, unless the terms and conditions of an applicable health insurance policy provide that coverage.

    For a healthcare service for which coverage or reimbursement is provided under the Medical Assistance Act of 1968, compiled in title 71, chapter 5, part 1, or provided under title 71, chapter 3, part 11, “medically necessary” means a healthcare service that is determined by the bureau of TennCare to satisfy the medical necessity standard set forth in 71-5-144; and

    For all other healthcare services, “medically necessary” means healthcare services that a healthcare services provider, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing, or treating an illness, injury, or disease or the symptoms of an illness, injury, or disease, and that are:

    • In accordance with generally accepted standards of medical practice;
    • Clinically appropriate, in terms of type, frequency, extent, site and duration; and considered effective for the patient’s illness, injury or disease; and
    • Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury, or disease excluding any costs paid pursuant to subsection (j).

    Subsection (j): A health insurance entity shall reimburse an originating site hosting a patient as part of a telehealth encounter an originating site fee in accordance with the federal centers for Medicare and Medicaid services telehealth services rule 42 C.F.R. § 410.78 and at an amount established prior to August 20, 2020, by the federal centers for Medicare and Medicaid services.

    Provider-Based Telemedicine

    “Qualified site” means the primary or satellite office of a healthcare services provider, a hospital licensed under title 68, a facility recognized as a rural health clinic under federal medicare regulations, a federally qualified health center, a facility licensed under title 33, or any other location deemed acceptable by the health insurance entity.

    (A provider-based telemedicine provider who seeks to contract with or who has contracted with a health insurance entity to participate in the health insurance entity’s network is subject to the same requirements and contractual terms as any other healthcare services provider in the health insurance entity’s network.

    A health insurance entity:

    • Shall provide coverage under a health insurance policy or contract for covered healthcare services delivered through provider-based telemedicine;
    • Shall reimburse a healthcare services provider for a healthcare service covered under an insured patient’s health insurance policy or contract that is provided through provider-based telemedicine without any distinction or consideration of the geographic location or any federal, state, or local designation, or classification of the geographic area where the patient is located;
    • Shall not exclude from coverage a healthcare service solely because it is provided through provider-based telemedicine and is not provided through an in-person encounter between a healthcare services provider and a patient; and
    • Shall reimburse healthcare services providers who are out-of-network for provider-based telemedicine care services under the same reimbursement policies applicable to other out-of-network healthcare services providers.

    A health insurance entity shall provide coverage for healthcare services provided during a provider-based telemedicine encounter in a manner that is consistent with what the health insurance policy or contract provides for in-person encounters for the same service, and shall reimburse for healthcare services provided during a provider-based telemedicine encounter without distinction or consideration of the geographic location, or any federal, state, or local designation or classification of the geographic area where the patient is located.

    This section does not require a health insurance entity to pay total reimbursement for a provider-based telemedicine encounter in an amount that exceeds the amount that would be paid for the same service provided by a healthcare services provider for an in-person encounter.

    This section does not require a health insurance entity to provide coverage for healthcare services that are not medically necessary, unless the terms and conditions of an applicable health insurance policy provide that coverage.

    A health insurance entity shall provide coverage for healthcare services provided during a provider-based telemedicine encounter in a manner that is consistent with what the health insurance policy or contract provides for in-person encounters for the same service, and shall reimburse for healthcare services provided during a provider-based telemedicine encounter without distinction or consideration of the geographic location, or any federal, state, or local designation or classification of the geographic area where the patient is located.

    This section does not require a health insurance entity to pay total reimbursement for a provider-based telemedicine encounter in an amount that exceeds the amount that would be paid for the same service provided by a healthcare services provider for an in-person encounter.

    This section does not require a health insurance entity to provide coverage for healthcare services that are not medically necessary, unless the terms and conditions of an applicable health insurance policy provide that coverage.

    For a healthcare service for which coverage or reimbursement is provided under the Medical Assistance Act of 1968, compiled in title 71, chapter 5, part 1, or provided under title 71, chapter 3, part 11, “medically necessary” means a healthcare service that is determined by the bureau of TennCare to satisfy the medical necessity standard set forth in 71-5-144; and

    For all other healthcare services, “medically necessary” means healthcare services that a healthcare services provider, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing, or treating an illness, injury, or disease or the symptoms of an illness, injury, or disease, and that are:

    • In accordance with generally accepted standards of medical practice;
    • Clinically appropriate, in terms of type, frequency, extent, site and duration; and considered effective for the patient’s illness, injury or disease; and
    • Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury, or disease.

    This section does not require a health insurance entity to provide coverage for healthcare services delivered by means of provider-based telemedicine if the applicable health insurance policy would not provide coverage for the same healthcare services if delivered by in-person means.

    This section does not require a health insurance entity to reimburse a healthcare services provider for healthcare services delivered by means of provider-based telemedicine if the applicable health insurance policy would not reimburse that healthcare services provider if the same healthcare services had been delivered by in-person means.

    This section does not apply to accident-only, specified disease, hospital indemnity, plans described in § 1251 of the Patient Protection and Affordable Care Act, Public Law 111-148, as amended and § 2301 of the Health Care and Education Reconciliation Act of 2010, Public Law 111-152, as amended (both in 42 U.S.C. § 18011), plans governed by the Employee Retirement Income Security Act of 1974 (ERISA) (29 U.S.C. § 1001 et seq.), Medicare supplement, disability income, long-term care, or other limited benefit hospital insurance policies.

    Notwithstanding § 56-7-1002(e), a health insurance entity shall provide reimbursement for healthcare services provided during a telehealth encounter in a manner that is consistent with what the health insurance policy or contract provides for in-person encounters for the same service, and shall reimburse for healthcare services provided during a telehealth encounter without distinction or consideration of the geographic location, or any federal, state, or local designation or classification of the geographic area where the patient is located.

    Notwithstanding § 56-7-1003(e), a health insurance entity shall provide reimbursement for healthcare services provided during a provider-based telemedicine encounter in a manner that is consistent with what the health insurance policy or contract provides for in-person encounters for the same service, and shall reimburse for healthcare services provided during a provider-based telemedicine encounter without distinction or consideration of the geographic location, or any federal, state, or local designation or classification of the geographic area where the patient is located.

    This section does not require a health insurance entity to provide reimbursement for healthcare services that are not medically necessary, unless the terms and conditions of an applicable health insurance policy provide that coverage.

    For a healthcare service for which coverage or reimbursement is provided under the Medical Assistance Act of 1968, compiled in title 71, chapter 5, part 1, or provided under title 71, chapter 3, part 11, “medically necessary” means a healthcare service that is determined by the bureau of TennCare to satisfy the medical necessity standard set forth in §71-5-144; and

    For all other healthcare services, “medically necessary” means healthcare services that a healthcare services provider, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing, or treating an illness, injury, or disease or the symptoms of an illness, injury, or disease, and that are:

    • In accordance with generally accepted standards of medical practice;
    • Clinically appropriate, in terms of type, frequency, extent, site and duration; and considered effective for the patient’s illness, injury or disease; and
    • Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.

    This section does not require a healthcare services provider to seek reimbursement from a health insurance entity for healthcare services provided by telehealth or provider-based telemedicine.

    A health insurance entity may consider any remote patient monitoring service a covered medical service if the same service is covered by Medicare. The appropriate parties may negotiate the rate for these services in the manner in which is deemed appropriate by the parties.

    Reimbursement of expenses for covered remote patient monitoring services must be established through negotiations conducted by the health insurance entity with the healthcare services provider, healthcare system, or practice group in the same manner as the health insurance entity establishes reimbursement of expenses for covered healthcare services that are delivered by in-person means.

    Remote patient monitoring services are subject to utilization review under the Health Care Service Utilization Review Act, compiled in chapter 6, part 7 of this title.

    This section does not apply to a health incentive program operated by a health insurance entity that utilized an electronic device for physiological monitoring.

    Workers Compensation

    Telehealth for workers’ compensation is an available option for medically appropriate healthcare services to be provided with the voluntary consent and agreement of the injured worker and the willingness of the healthcare services provider as provided in these rules. Medically appropriate healthcare services do not include treatment where an in-person physical examination is necessary (see rule for examples).

    Telehealth providers shall be held to the same standard of care as healthcare services providers providing the same healthcare services through in-person encounters.

    An employer shall provide coverage for workers’ compensation medical services provided during a telehealth encounter in a manner that is consistent with what the workers’ compensation law requires for in-person encounters for the same healthcare service(s). Payment shall be in accordance with the Tennessee workers’ compensation medical fee schedule in Rule 0800-02-18 and corresponding rules for medical payments in Rule 0800-02- 17 in effect on the date of service.

    Records/recordings requirements for telehealth services shall be the same as if the visit with the provider were in person and face-to-face. A telehealth provider shall be compliant with all federal and state of Tennessee laws for records/recordings. A recording shall not substitute for a written record.

    Telehealth services are subject to any and all appropriate utilization review protocols or other protocols for healthcare treatment adopted by the bureau, shall be based on evidence-based guidelines, and shall be in accordance with the Tennessee standards of medical practice.

    All services shall be delivered to the eligible employee at no cost to the employee in accordance with the provisions of section 50-6-204.

    The provision of medical services via telehealth does not change or in any way affect the requirements for causation, date of maximum medical improvement, or permanent impairment ratings required of an authorized treating physician pursuant to the workers’ compensation law. In all workers’ compensation claims, statements of causation, date of maximum medical improvement, permanent restrictions, and permanent impairment rating(s) must be provided by a medical doctor, doctor of osteopathy, or doctor of chiropractic in accordance with the workers’ compensation law.

    Telehealth: the definitions, licensing and processes for the purpose of these Rules shall be the same as adopted by the Tennessee Department of Health and Medicare. The maximum reimbursement for services provided via telehealth is the lesser of billed charges or the amounts listed in this fee schedule. Services that are eligible to be provided via telehealth are identified with a star (★) in the rate tables.

    

    Medicaid

    Last updated 05/03/2024

    Consent Requirements

    Privacy policies must be reviewed with the individual before beginning a telehealth assessment and the review must be documented in the patient record. The patient must be informed about privacy policies and given an opportunity to request an in-person assessment before receiving a telehealth assessment.

    The individual being evaluated via telehealth must be informed of the process and given an opportunity to request an in-person face-to-face assessment before conducting a telehealth assessment. This should be documented in his/her record.

    Explanation of the process shall include a statement that services will not be withheld if the telehealth encounter is refused and the individual may terminate the telehealth assessment at any time.

    Documentation must contain a statement that the telehealth process was explained to the individual and whether or not an objection was raised.

    Last updated 05/03/2024

    Definitions

    Telehealth means the use of real-time interactive audio, video telecommunications or electronic technology, or store-and-forward telemedicine services by a healthcare services provider to deliver healthcare services to a patient within the scope of practice of the healthcare services provider when:

    • Such provider is at a qualified site other than the site where the patient is located; and
    • The patient is at a qualified site at a school clinic staffed by a healthcare services provider and equipped to engage in the telecommunications described in this section or a public elementary or secondary school staffed by a health care services provider and equipped to engage in the telecommunications described in this section; and
    • Does not include:
      • Audio only conversation;
      • An electronic mail message; or
      • Facsimile transmission;

      “Provider-based telemedicine”: Means the use of Health Insurance Portability and Accountability Act (HIPAA) (42 U.S.C. § 1320d et seq.) compliant real-time, interactive audio, video telecommunications, or electronic technology, or store-and-forward telemedicine services, used over the course of an interactive visit by a healthcare services provider to deliver healthcare services to a patient within the scope of practice of the healthcare services provider when:

      • The healthcare services provider is at a qualified site other than the site where the patient is located and has access to the relevant medical record for that patient;
      • The patient is located at a location the patient deems appropriate to receive the healthcare service that is equipped to engage in the telecommunication described in this section; and
        • The healthcare services provider makes use of HIPAA compliant real-time, interactive audio, video telecommunications or electronic technology, or store-and-forward telemedicine services to deliver healthcare services to a patient within the scope of practice of the healthcare services provider as long as the healthcare services provider, the healthcare services provider’s practice group, or the healthcare system has established a provider-patient relationship by submitting to a health insurance entity evidence of an in-person encounter between the healthcare service provider, the healthcare services provider’s practice group, or the healthcare system and the patient within sixteen (16) months prior to the interactive visit;
        • The requirement of an in-person encounter between the healthcare services provider, the healthcare services provider’s practice group, or the healthcare system and the patient within sixteen (16) months prior to the interactive visit is tolled for the duration of a state of emergency declared by the governor pursuant to § 58-2-107; provided, that the healthcare services provider or the patient, or both, are located in the geographical area covered by the applicable state of emergency; and
        • The requirement of an in-person encounter between the healthcare services provider, the healthcare services provider’s practice group, or the healthcare system and the patient within sixteen (16) months prior to the interactive visit does not apply to a patient who is receiving an initial behavioral health evaluation or assessment;
        • An audio-only conversation;
        • An electronic mail message or phone text message;
        • A facsimile transmission;
        • Remote patient monitoring; or
        • Healthcare services provided pursuant to a contractual relationship between a health insurance entity and an entity that facilitates the delivery of provider-based telemedicine as the substantial portion of the entity’s business.

        Notwithstanding subdivisions (a)(6)(A) and (B), includes Health Insurance Portability and Accountability Act (HIPAA) (42 U.S.C. § 1320d et seq.) compliant audio-only conversation for the provision of:

        • behavioral health services or
        • healthcare services when the means described in subdivision (a)(6)(A) are unavailable.

        TN Department of Mental Health and Substance Abuse Services

        “Telehealth is the use of electronic information and telecommunication technologies to support clinical care between an individual with mental illness and/or substance abuse issues and a healthcare practitioner.”

        “Telehealth systems provide a live, interactive audio-video communication or videoconferencing connection between the individual in need of services and the crisis service delivery system.”

        Last updated 05/03/2024

        Email, Phone & Fax

        “Provider-based telemedicine” does not include:

        • • An audio-only conversation;
          • An electronic mail message or phone text message;
          • A facsimile transmission;
          • Remote patient monitoring; or
          • Healthcare services provided pursuant to a contractual relationship between a health insurance entity and an entity that facilitates the delivery of provider-based telemedicine as the substantial portion of the entity’s business.

          Provider-based telemedicine includes Health Insurance Portability and Accountability Act (HIPAA) (42 U.S.C. § 1320d et seq.) compliant audio-only conversation for the provision of behavioral health services or healthcare services when the means described in subdivision (a)(6)(A) are unavailable.

          A healthcare provider, office staff, or party acting on behalf of the healthcare provider submitting for reimbursement of an audio-only encounter under subdivision (a)(6)(C)(ii) shall:

          Confirm and maintain documentation that the patient:

          Does not own the video technology necessary to complete an audio-video provider-based telemedicine encounter;

          Is at a location where an audio-video encounter cannot take place due to lack of service; or Has a physical disability that inhibits the use of video technology; and

          Telehealth does not include:

          • An audio-only conversation;
          • An electronic mail message; or
          • A facsimile transmission

          School-Based Services

          All TennCare medically necessary, covered services provided on school grounds shall be billed with the place of service code (03), defined by CMS as any facility whose primary purpose is education. School-based services rendered via telehealth shall be billed with place of service code (02), indicating telehealth was provided other than the student’s home or place of service code (10) indicating telehealth was provided in the student’s home. Additionally, the appropriate modifier should be used to indicate whether the telehealth service was delivered via a televisual visit (append using the GT modifier) or delivered via audio-only (append using the 93 modifier or FQ modifier as appropriate).

          See manual for additional information.

          Last updated 05/03/2024

          Live Video

          POLICY

          Telehealth Services

          A health insurance entity shall provide coverage for healthcare services provided during a telehealth encounter in a manner that is consistent with what the health insurance policy or contract provides for in-person encounters for the same service, and shall reimburse for healthcare services provided during a telehealth encounter without distinction or consideration of the geographic location, or any federal, state, or local designation or classification of the geographic area where the patient is located.

          Notwithstanding § 56-7-1002(e), a health insurance entity shall provide reimbursement for healthcare services provided during a telehealth encounter in a manner that is consistent with what the health insurance policy or contract provides for in-person encounters for the same service, and shall reimburse for healthcare services provided during a telehealth encounter without distinction or consideration of the geographic location, or any federal, state, or local designation or classification of the geographic area where the patient is located.

          Provider-based Telemedicine

          A health insurance entity shall provide coverage for healthcare services provided during a provider-based telemedicine encounter in a manner that is consistent with what the health insurance policy or contract provides for in-person encounters for the same service, and shall reimburse for healthcare services provided during a provider-based telemedicine encounter without distinction or consideration of the geographic location, or any federal, state, or local designation or classification of the geographic area where the patient is located.

          This section does not require a health insurance entity to pay total reimbursement for a provider-based telemedicine encounter in an amount that exceeds the amount that would be paid for the same service provided by a healthcare services provider for an in-person encounter.

          T his section does not require a health insurance entity to provide coverage for healthcare services that are not medically necessary, unless the terms and conditions of an applicable health insurance policy provide that coverage.

          The healthcare services provider makes use of HIPAA compliant real-time, interactive audio, video telecommunications or electronic technology, or store-and-forward telemedicine services to deliver healthcare services to a patient within the scope of practice of the healthcare services provider as long as the healthcare services provider, the healthcare services provider’s practice group, or the healthcare system has established a provider-patient relationship by submitting to a health insurance entity evidence of an in-person encounter between the healthcare service provider, the healthcare services provider’s practice group, or the healthcare system and the patient within sixteen (16) months prior to the interactive visit.

          The requirement of an in-person encounter between the healthcare services provider, the healthcare services provider’s practice group, or the healthcare system and the patient within sixteen (16) months prior to the interactive visit is tolled for the duration of a state of emergency declared by the governor pursuant to § 58-2-107; provided, that the healthcare services provider or the patient, or both, are located in the geographical area covered by the applicable state of emergency.

          The requirement of an in-person encounter between the healthcare services provider, the healthcare services provider’s practice group, or the healthcare system and the patient within sixteen (16) months prior to the interactive visit does not apply to a patient who is receiving an initial behavioral health evaluation or assessment.

          Notwithstanding § 56-7-1003(e), a health insurance entity shall provide reimbursement for healthcare services provided during a provider-based telemedicine encounter in a manner that is consistent with what the health insurance policy or contract provides for in-person encounters for the same service, and shall reimburse for healthcare services provided during a provider-based telemedicine encounter without distinction or consideration of the geographic location, or any federal, state, or local designation or classification of the geographic area where the patient is located.

          ELIGIBLE SERVICES/SPECIALTIES

          This section does not require a health insurance entity to provide coverage for healthcare services that are not medically necessary, unless the terms and conditions of an applicable health insurance policy provide that coverage.

          For a healthcare service for which coverage or reimbursement is provided under the Medical Assistance Act of 1968, compiled in title 71, chapter 5, part 1, or provided under title 71, chapter 3, part 11, “medically necessary” means a healthcare service that is determined by the bureau of TennCare to satisfy the medical necessity standard set forth in 71-5-144; and

          For all other healthcare services, “medically necessary” means healthcare services that a healthcare services provider, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing, or treating an illness, injury, or disease or the symptoms of an illness, injury, or disease, and that are:

          • In accordance with generally accepted standards of medical practice;
          • Clinically appropriate, in terms of type, frequency, extent, site and duration; and considered effective for the patient’s illness, injury or disease; and
          • Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease, excluding any costs paid pursuant to subsection (j).

          Section (j): A health insurance entity shall reimburse an originating site hosting a patient as part of a telehealth encounter an originating site fee in accordance with the federal centers for Medicare and medicaid services telehealth services rule 42 C.F.R. § 410.78 and at an amount established prior to August 20, 2020, by the federal centers for Medicare and medicaid services.

          SOURCE: TN Code Annotated, Sec. 56-7-1002 & Sec. 56-7-1012 [excludes reference to section (j)], (Accessed May 2024).

          A health insurance entity:

          • Shall provide coverage under a health insurance policy or contract for covered healthcare services delivered through provider-based telemedicine;
          • Shall reimburse a healthcare services provider for a healthcare service covered under an insured patient’s health insurance policy or contract that is provided through provider-based telemedicine without any distinction or consideration of the geographic location or any federal, state, or local designation, or classification of the geographic area where the patient is located;
          • Shall not exclude from coverage a healthcare service solely because it is provided through provider-based telemedicine and is not provided through an in-person encounter between a healthcare services provider and a patient; and
          • Shall reimburse healthcare services providers who are out-of-network for provider-based telemedicine care services under the same reimbursement policies applicable to other out-of-network healthcare services providers.

          A health insurance entity shall provide coverage for healthcare services provided during a provider-based telemedicine encounter in a manner that is consistent with what the health insurance policy or contract provides for in-person encounters for the same service, and shall reimburse for healthcare services provided during a provider-based telemedicine encounter without distinction or consideration of the geographic location, or any federal, state, or local designation or classification of the geographic area where the patient is located.

          This section does not require a health insurance entity to pay total reimbursement for a provider-based telemedicine encounter in an amount that exceeds the amount that would be paid for the same service provided by a healthcare services provider for an in-person encounter.

          This section does not require a health insurance entity to provide coverage for healthcare services that are not medically necessary, unless the terms and conditions of an applicable health insurance policy provide that coverage.

          For a healthcare service for which coverage or reimbursement is provided under the Medical Assistance Act of 1968, compiled in title 71, chapter 5, part 1, or provided under title 71, chapter 3, part 11, “medically necessary” means a healthcare service that is determined by the bureau of TennCare to satisfy the medical necessity standard set forth in 71-5-144; and For all other healthcare services, “medically necessary” means healthcare services that a healthcare services provider, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing, or treating an illness, injury, or disease or the symptoms of an illness, injury, or disease, and that are:

          • In accordance with generally accepted standards of medical practice;
          • C linically appropriate, in terms of type, frequency, extent, site and duration; and considered effective for the patient’s illness, injury or disease; and
          • N ot more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury, or disease.

          This section does not require a health insurance entity to provide coverage for healthcare services delivered by means of provider-based telemedicine if the applicable health insurance policy would not provide coverage for the same healthcare services if delivered by in-person means.

          This section does not require a health insurance entity to reimburse a healthcare services provider for healthcare services delivered by means of provider-based telemedicine if the applicable health insurance policy would not reimburse that healthcare services provider if the same healthcare services had been delivered by in-person means.

          Any provisions not required by this section are governed by the terms and conditions of the health insurance policy or contract.

          Provider-based telemedicine is subject to utilization review under the Health Care Service Utilization Review Act, compiled in chapter 6, part 7 of this title.

          School-Based Services

          All TennCare medically necessary, covered services provided on school grounds shall be billed with the place of service code (03), defined by CMS as any facility whose primary purpose is education. School-based services rendered via telehealth shall be billed with place of service code (02), indicating telehealth was provided other than the student’s home or place of service code (10) indicating telehealth was provided in the student’s home. Additionally, the appropriate modifier should be used to indicate whether the telehealth service was delivered via a televisual visit (append using the GT modifier) or delivered via audio-only (append using the 93 modifier or FQ modifier as appropriate).

          See manual for additional information.

          Mental Health & Substance Abuse Services

          TennCare will reimburse for live video for crisis-related services or an assessment for emergency admission by an in-patient psychiatric facility.

          Please see Telecommunications Guidelines for policy guidance.

          ELIGIBLE PROVIDERS

          Provider based telemedicine

          A provider-based telemedicine provider who seeks to contract with or who has contracted with a health insurance entity to participate in the health insurance entity’s network is subject to the same requirements and contractual terms as any other healthcare services provider in the health insurance entity’s network.

          “Healthcare services provider” means an individual acting within the scope of a valid license issued pursuant to title 63 or title 68, chapter 24, part 6, or any state-contracted crisis service provider employed by a facility licensed under title 33 .

          A health insurance entity: … Shall reimburse healthcare services providers who are out-of-network for provider-based telemedicine care services under the same reimbursement policies applicable to other out-of-network healthcare services providers.

          Telehealth Services

          “Healthcare services provider” means an individual acting within the scope of a valid license issued pursuant to title 63 or any state-contracted crisis service provider employed by a facility licensed under title 33.

          ELIGIBLE SITES

          Telehealth Services

          “Qualified site” means the office of a healthcare services provider, a hospital licensed under title 68, a facility recognized as a rural health clinic under federal Medicare regulations, a federally qualified health center, any facility licensed under title 33, or any other location deemed acceptable by the health insurance entity.

          “Originating site” means the location where a patient is located pursuant to subdivision (a)(7)(A) and that originates a telehealth service to another qualified site.

          Telehealth means the use of real-time, interactive audio, video telecommunications or electronic technology, or store-and-forward telemedicine services by a healthcare services provider to deliver healthcare services to a patient within the scope of practice of the healthcare services provider when:

          • Such provider is at a qualified site other than the site where the patient is located; and
          • The patient is at a qualified site, at a school clinic staffed by a healthcare services provider and equipped to engage in the telecommunications described in this section, or at a public elementary or secondary school staffed by a healthcare services provider and equipped to engage in the telecommunications described in this section.

          Provider-Based Telemedicine

          “Qualified site” means the primary or satellite office of a healthcare services provider, a hospital licensed under title 68, a facility recognized as a rural health clinic under federal Medicare regulations, a federally qualified health center, a facility licensed under title 33, or any other location deemed acceptable by the health insurance entity.

          “Healthcare provider” means a person who is licensed, certified, or authorized or permitted by the laws of this state to administer health care in the ordinary course of business or practice of a profession; and

          “Telehealth provider group” means two (2) or more healthcare providers that share a common employer and provide healthcare services exclusively via telehealth.

          This chapter does not require:

          • A vendor or healthcare provider who provides healthcare services exclusively via telehealth to maintain a physical address or site in this state in order to be eligible to enroll as a vendor or provider for the medical assistance program; or
          • A telehealth provider group to have a service address in this state in order to be eligible to enroll as a vendor or provider group for the medical assistance program, as long as the healthcare providers that comprise the telehealth provider group are licensed with the appropriate healthcare licensing authority in this state or are otherwise authorized by law to provide healthcare services in this state.

          School-Based Services

          All TennCare medically necessary, covered services provided on school grounds shall be billed with the place of service code (03), defined by CMS as any facility whose primary purpose is education. School-based services rendered via telehealth shall be billed with place of service code (02), indicating telehealth was provided other than the student’s home or place of service code (10) indicating telehealth was provided in the student’s home. Additionally, the appropriate modifier should be used to indicate whether the telehealth service was delivered via a televisual visit (append using the GT modifier) or delivered via audio-only (append using the 93 modifier or FQ modifier as appropriate).

          See manual for additional information.

          Mental Health & Substance Abuse Services

          Crisis service providers may connect from:

          • Emergency departments;
          • Jails;
          • Detention centers; and
          • Other similar locations

          All telehealth sites shall ensure that telehealth equipment is located in a space conducive to a clinical environment.

          GEOGRAPHIC LIMITS

          A health insurance entity … Shall reimburse a healthcare services provider for the diagnosis, consultation, and treatment of an insured patient for a healthcare service covered under a health insurance policy or contract that is provided through telehealth without any distinction or consideration of the geographic location or any federal, state, or local designation, or classification of the geographic area where the patient is located.

          A health insurance entity shall provide coverage for healthcare services provided during a telehealth encounter in a manner that is consistent with what the health insurance policy or contract provides for in-person encounters for the same service, and shall reimburse for healthcare services provided during a telehealth encounter without distinction or consideration of the geographic location, or any federal, state, or local designation or classification of the geographic area where the patient is located.

          A health insurance entity: … Shall reimburse a healthcare services provider for a healthcare service covered under an insured patient’s health insurance policy or contract that is provided through provider-based telemedicine without any distinction or consideration of the geographic location or any federal, state, or local designation, or classification of the geographic area where the patient is located.

          A health insurance entity shall provide coverage for healthcare services provided during a provider-based telemedicine encounter in a manner that is consistent with what the health insurance policy or contract provides for in-person encounters for the same service, and shall reimburse for healthcare services provided during a provider-based telemedicine encounter without distinction or consideration of the geographic location, or any federal, state, or local designation or classification of the geographic area where the patient is located.

          FACILITY/TRANSMISSION FEE

          A health insurance entity shall reimburse an originating site hosting a patient as part of a telehealth encounter an originating site fee in accordance with the federal centers for Medicare and Medicaid services telehealth services rule 42 C.F.R. § 410.78 and at an amount established prior to August 20, 2020, by the federal centers for Medicare and Medicaid services.

          Last updated 05/03/2024

          Miscellaneous

          No reference found.

          Last updated 05/03/2024

          Out of State Providers

          “Healthcare provider” means a person who is licensed, certified, or authorized or permitted by the laws of this state to administer health care in the ordinary course of business or practice of a profession; and

          “Telehealth provider group” means two (2) or more healthcare providers that share a common employer and provide healthcare services exclusively via telehealth.

          This chapter does not require:

          • A vendor or healthcare provider who provides healthcare services exclusively via telehealth to maintain a physical address or site in this state in order to be eligible to enroll as a vendor or provider for the medical assistance program; or
          • A telehealth provider group to have a service address in this state in order to be eligible to enroll as a vendor or provider group for the medical assistance program, as long as the healthcare providers that comprise the telehealth provider group are licensed with the appropriate healthcare licensing authority in this state or are otherwise authorized by law to provide healthcare services in this state.

          Last updated 05/03/2024

          Overview

          A law requires TennCare (Medicaid) reimbursement for telehealth services and provider-based telemedicine, which includes store-and-forward. Remote patient monitoring may be offered by health insurance entities. Audio-only conversation is allowed for provider based telemedicine for the provision of behavioral health services or healthcare services when other means are unavailable.

          TennCare services are offered through managed care entities. Each MCO has its own telehealth policy. Coverage and reimbursement for live video and store-and-forward may vary between MCOs.

          Last updated 05/03/2024

          Remote Patient Monitoring

          POLICY

          “Remote patient monitoring services” means using digital technologies to collect medical and other forms of health data from a patient and then electronically transmitting that information securely to healthcare providers in a different location for interpretation and recommendation.

          A health insurance entity may consider any remote patient monitoring service a covered medical service if the same service is covered by Medicare. The appropriate parties may negotiate the rate for these services in the manner in which is deemed appropriate by the parties.

          CONDITIONS

          No later than December 31, 2024, the bureau of TennCare shall amend existing rules, or promulgate new rules, on fee-for-service and medicaid managed care plans regarding reimbursement to allow for the reimbursement of remote ultrasound procedures and remote fetal nonstress tests utilizing established CPT codes for such procedures when the patient is in a residence or other off-site location that is separate from the patient’s provider and the same standard of care is met.

          PROVIDER LIMITATIONS

          No Reference Found

          OTHER RESTRICTIONS

          Reimbursement of expenses for covered remote patient monitoring services must be established through negotiations conducted by the health insurance entity with the healthcare services provider, healthcare system, or practice group in the same manner as the health insurance entity establishes reimbursement of expenses for covered healthcare services that are delivered by in-person means.

          Remote patient monitoring services are subject to utilization review under the Health Care Service Utilization Review Act, compiled in chapter 6, part 7 of this title.

          This section does not apply to a health incentive program operated by a health insurance entity that utilized an electronic device for physiological monitoring.

          When amending or promulgating rules pursuant to subsection (b), the bureau shall ensure that: A remote ultrasound procedure or remote fetal nonstress test is only reimbursable when the provider uses digital technology:

          • To collect medical and other forms of health data from a patient and electronically transmit that information securely to a healthcare provider who is in a separate location for the purpose of interpretation and making recommendations;
          • That is compliant with the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) (42 U.S.C. § 1320d et seq.); and
          • That is approved by the federal food and drug administration; and

          A fetal nonstress test is only reimbursable with a place of service modifier for at-home monitoring with remote monitoring solutions that are cleared by the federal food and drug administration for on-label use for monitoring fetal heart rate, maternal heart rate, and uterine activity.

          Last updated 05/03/2024

          Store and Forward

          POLICY

          “Store-and-forward telemedicine services”: (A) Means the use of asynchronous computer-based communications between a patient and healthcare services provider at a distant site for the purpose of diagnostic and therapeutic assistance in the care of patients; and (B) Includes the transferring of medical data from one (1) site to another through the use of a camera or similar device that records or stores an image that is sent or forwarded via telecommunication to another site for consultation.

          This section does not require a health insurance entity to provide coverage for healthcare services that are not medically necessary, unless the terms and conditions of an applicable health insurance policy provide that coverage.

          This section does not require a health insurance entity to provide coverage for healthcare services delivered by means of telehealth if the applicable health insurance policy would not provide coverage for the same healthcare services if delivered by in-person means.

          This section does not require a health insurance entity to reimburse a healthcare services provider for healthcare services delivered by means of telehealth if the applicable health insurance policy would not reimburse that healthcare services provider if the same healthcare services had been delivered by in-person means.

          This section does not require a health insurance entity to pay total reimbursement for a provider-based telemedicine encounter in an amount that exceeds the amount that would be paid for the same service provided by a healthcare services provider for an in-person encounter.

          This section does not require a health insurance entity to provide coverage for healthcare services that are not medically necessary, unless the terms and conditions of an applicable health insurance policy provide that coverage.

          This section does not require a health insurance entity to provide coverage for healthcare services delivered by means of provider-based telemedicine if the applicable health insurance policy would not provide coverage for the same healthcare services if delivered by in-person means.

          This section does not require a health insurance entity to reimburse a healthcare services provider for healthcare services delivered by means of provider-based telemedicine if the applicable health insurance policy would not reimburse that healthcare services provider if the same healthcare services had been delivered by in-person means.

          Mental Health & Substance Abuse Services

          TennCare will not reimburse for store-and-forward based upon definition of “telehealth systems” which describes it as “live interactive audio-video”.

          ELIGIBLE SERVICES/SPECIALTIES

          No Reference Found

          GEOGRPAHIC LIMITS

          A health insurance entity … Shall reimburse a healthcare services provider for the diagnosis, consultation, and treatment of an insured patient for a healthcare service covered under a health insurance policy or contract that is provided through telehealth without any distinction or consideration of the geographic location or any federal, state, or local designation, or classification of the geographic area where the patient is located.

          A health insurance entity shall provide coverage for healthcare services provided during a telehealth encounter in a manner that is consistent with what the health insurance policy or contract provides for in-person encounters for the same service, and shall reimburse for healthcare services provided during a telehealth encounter without distinction or consideration of the geographic location, or any federal, state, or local designation or classification of the geographic area where the patient is located.

          A health insurance entity: … Shall reimburse a healthcare services provider for a healthcare service covered under an insured patient’s health insurance policy or contract that is provided through provider-based telemedicine without any distinction or consideration of the geographic location or any federal, state, or local designation, or classification of the geographic area where the patient is located.

          A health insurance entity shall provide coverage for healthcare services provided during a provider-based telemedicine encounter in a manner that is consistent with what the health insurance policy or contract provides for in-person encounters for the same service, and shall reimburse for healthcare services provided during a provider-based telemedicine encounter without distinction or consideration of the geographic location, or any federal, state, or local designation or classification of the geographic area where the patient is located.