Subsection 144-101-I-4.07 - REIMBURSEMENT4.07-1General ConditionsA. Services are to be billed in accordance with applicable Sections of the MBM. Providers must submit claims in accordance with Department billing instructions.B. Telehealth Services are subject to all conditions and restrictions described in Chapter I, Section 1, of the MBM.C. Telehealth Services are subject to co-payment requirements for the underlying Covered Service, if applicable, as established in Chapter I, Section 1, of the MBM. However, there shall be no separate co-payment for telehealth services.4.07-2Telehealth ServicesA. Receiving (Provider) Site 1. Except as described below, only the Health Care Provider at the Receiving (Provider) Site may receive payment for Telehealth Services.2. When billing for Telehealth Services, Health Care Providers at the Receiving (Provider) Site must bill for the underlying Covered Service using the same claims they would if it were delivered face-to-face and must add the GT modifier for Interactive Telehealth Services and the 93 modifier for Telephonic Services.3. When billing for Telephone Evaluation and Management Services, Health Care Providers at the Receiving (Provider) Site must use the appropriate E& M code. The GT and 93 modifier should not be used.4. No separate transmission fees will be paid for Telehealth Services. The only services that may be billed by the Health Care Provider at the Receiving (Provider) Site are the fees for the underlying Covered Service delivered with the GT or 93 modifier.B.Originating (Member) Site1. If the Health Care Provider at the Originating (Member) Site supports the Member's access to Telehealth Services the Health Care Provider at the Originating (Member) Site may bill MaineCare for an Originating Facility Fee using code Q3014 for the service of supporting access to the Telehealth Service. Supporting access to telehealth services means providing a room and/or telecommunications equipment and/or helping a Member use audio or video conferencing software or equipment to enable the Member to utilize telehealth.2. The Health Care Provider at the Originating (Member) Site may not bill for assisting the Health Care Provider at the Receiving (Provider) Site with an examination.3. No separate transmission fees will be paid for Telehealth Services.4. The Health Care Provider at the Originating (Member) Site may bill for any clinical services provided on-site on the same day that a Telehealth Service claim is made, except as specifically excluded elsewhere in this Section.5. Telehealth Services may be included in a Federally Qualified Health Center (FQHC), Rural Health Clinic (RHC), or Indian Health Center (IHC) scope of practice, as approved by the State. If approved, these facilities may serve as the provider site and bill under the encounter rate. When an FQHC or RHC serves as the Originating (Member) Site, the Originating Facility Fee is paid separately from the center or clinic all-inclusive rate.6. In the event an interpreter is required, the Health Care Provider at either the Originating (Member) Site or the Receiving (Provider) site must provide and may bill for interpreter services in accordance with the provisions of Chapter I, Section 1, of the MBM. Members may not bill or be reimbursed by the Department for interpreter services utilized during a telehealth encounter.7. If the technical component of an X-ray, ultrasound, or electrocardiogram is performed at the Originating (Member) Site during a Telehealth Service, the technical component and the Originating Facility Fee are billed by the Health Care Provider at the Originating (Member) Site. The professional component of the procedure and the appropriate visit code are billed by the Receiving (Provider) Site.
C. The Health Care Providers at the Receiving and Originating Sites may be part of the same organization. A Health Care Provider at the Originating (Member) Site may bill MaineCare and receive payment for Telehealth Services if the service is provided by a Treating Provider who is under a contractual arrangement with the Originating (Member) Site.4.07-3Telemonitoring ServicesA. Only the Health Care Provider at the Receiving (Provider) Site will be reimbursed for Telemonitoring Services.B. No Originating Facility Fee will be paid for Telemonitoring Services.C. Only a Home Health Agency may receive reimbursement for Telemonitoring Services.D. Telemonitoring Services shall be billed using code S9110, which provides for a flat monthly fee for services, which is inclusive of all Telemonitoring Services, including, but not limited to: 1. equipment installation;2. training the Member on the equipment's use and care;4. consultations with the primary care physician; and5. equipment removal when the Telemonitoring Service is no longer medically necessary. Except as described in this policy, no additional reimbursement beyond the flat fee is available for Telemonitoring Services.
E. MaineCare will not reimburse separately for Telemonitoring equipment purchase, installation, or maintenance.F. If in-person visits are required, these visits must be billed separately from the Telemonitoring Service in accordance with Chapters II and III, Section 40, Home Health Services, of the MBM.G. If an interpreter is required, the Home Health Agency may bill for interpreter services in accordance with another billable service and the requirements of Chapter I, Section 1, of the MBM.4.07-4Reimbursement RatesThe rate for Telehealth Originating Facility Fee, per visit, code Q3014, is listed on the MaineCare Provider fee schedule, which is posted on the Department's website in accordance with 22 MRSA Section3173-J(7) at https://mainecare.maine.gov/Provider%20Fee%20Schedules/Forms/Publication.aspx.
Specific reimbursement rates for other telehealth services can be found in the appropriate Sections of the MBM or the MaineCare Provider fee schedules on the MaineCare Health PAS Portal.
C.M.R. 10, 144, ch. 101, ch. I, § 144-101-I-4, subsec. 144-101-I-4.07