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What is Telehealth?

Telehealth is the use of technology (computers, smartphones, or tablets) to provide healthcare services remotely. Telehealth does not include communication between a provider and a member that consists solely of an email, text, or fax transmission.

Why is telehealth important?

It allows patients to connect with healthcare providers for appointments, consultations, and follow-up care without having to visit a clinic or hospital in person. This approach improves access to medical care, especially for those in rural or underserved areas.

According to a 2022 survey published by the American Telemedicine Association, up to 85% of providers reported that telehealth allowed them to sustain or improve the continuity of their relationships with patients, even in rural or remote areas. This indicates a significant positive impact in maintaining engagement and care consistency through virtual visits.

Delivery of Telehealth Services

Telehealth services must be delivered with sufficient quality as to be the same level of service as an in-person visit. Transmission of voices, images, data, or video must be clear and understandable.

Health care services include:

Assessments
Diagnosis
Consultation
Treatment
Transfer of medically relevant data

Please note: Telehealth does not replace provider choice and/or member preference for in-person service delivery.

Allowable Providers

There are no limitations on what provider types may be reimbursed for telehealth services.

Out of State Providers

Out-of-State Providers are required to enroll in Wisconsin Medicaid.

Providers who meet the definition of a border-status provider as described in Wis. Admin. Code § DHS 101.03(19) and who provide services to Wisconsin Medicaid members only via telehealth, may apply for enrollment as Wisconsin telehealth-only border-status providers if they are licensed in Wisconsin under applicable Wisconsin statute and administrative code.

Providers who do not have border status enrollment with Wisconsin Medicaid are required to obtain PA before providing services via telehealth to BadgerCare Plus or Medicaid members.

Please note: Wisconsin Medicaid is prohibited from paying providers located outside of the United States and its territories, including the District of Columbia, Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa.

Allowable Services

Telehealth is a good choice for common conditions that have standard treatments.

Here are some examples:

Doctor office visits
Mental health services
Substance abuse services
Dental consultations
Behavioral health services

The Max Fee Schedules include a complete list of services allowed under permanent telehealth policy.

To ensure correct reimbursement, claims for telehealth services must include all necessary modifiers as outlined in the benefit coverage policy.

Indicate telehealth delivery by using POS code 02 or 10 and add the appropriate telehealth modifier (below) along with any other required modifiers—unless the procedure code already specifies the delivery method.
Use modifier 93 for audio-only telehealth services and use modifier 95 for use with real-time, audio/visual visits.

POS code 02: Telehealth Provided Other Than in Patient's Home

The location where health services and health related services are provided or received through telecommunication technology. Patient is not located in their home when receiving health services or health related services through telecommunication technology.

POS code 10: Telehealth Provided in Patient's Home

The location where health services and health related services are provided or received through telecommunication technology. Patient is located in their home (which is a location other than a hospital or other facility where the patient receives care in a private residence) when receiving health services or health related services through telecommunication technology.

Requirements & Restrictions

We require providers who offer our members telehealth services to:

Maintain documentation in accordance with HIPAA requirements for healthcare services delivered through telehealth
Deliver services in accordance with rules set forth by their respective licensing board and accepted standards of clinical practice
Document the specific telehealth modality used

Please note: Providers cannot make telehealth a mandatory requirement for treating members. Each provider must create and use their own process to ensure members give informed consent before receiving telehealth services. These consent procedures must follow all applicable federal and state laws and guidelines.

Noncovered Services

Services that are not covered when delivered in person are not covered as telehealth services. In addition, services that are not functionally equivalent to the in-person service when provided via telehealth are not covered.

Ensuring Safe, Accessible, and Informed Telehealth Care

Patient Preparation and Technology Requirements:

Technology Check: Have them test their device (phone, tablet, computer), camera, microphone, and internet connection
Connectivity: Confirm they have reliable internet; have a backup plan (like a phone call or different app) if needed.
Platform Prep: Provide simple, clear instructions or a video on how to download/use the app.

Accessibility and Language Services:

Title VI of the Civil Rights Act of 1964 requires recipients of federal financial assistance to take reasonable steps to make their programs, services, and activities accessible by eligible persons with limited English proficiency.
The Americans with Disabilities Act requires that health care entities provide full and equal access for people with disabilities.

Member Consent Guidelines:

Providers must annually document that members understand their right to decline telehealth services and have given informed consent to receive care via telehealth.
Providers may use methods such as educating members and obtaining verbal consent before treatment or including telehealth consent in privacy notices, and may select the approach that best fits their practice for documenting member consent

Privacy and Security:

Providers must follow federal laws to ensure member privacy and security during telehealth services.
Group telehealth leaders must inform members of the risks, benefits, and confidentiality limits, obtain consent before the first session, and ensure participation is voluntary with alternative services available for those who opt out.

Evaluation and Management of Services:

A virtual check-in is a short communication initiated by the patient using phone, video, or secure portal (Synchronous), to decide if an office visit or other care is needed. The provider may review and respond to concerns through calls, video, images, or messages. This service includes both reviewing videos or images sent by the patient and providing follow-up guidance.

An e-visit is communication using an online HIPPA-compliant patient portal between a member and their provider. The patient starts the conversation, and messages may be exchanged over up to seven days (Asynchronous)

Please note: Only providers who already have an established relationship with the patient can offer e-visits. Providers may bill for these services using specific online codes, depending on their credentials.

Allowable procedure codes for virtual check-in and e-visit services can be found in the manual Topic #22742.

Telehealth Definitions

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Telehealth

The use of telecommunications technology, including real-time interactive audio-only communication, to deliver health care services such as assessment, diagnosis, consultation, treatment, and the transfer of medically relevant data.

Examples:

A patient has a video appointment with their doctor for a routine checkup.
A psychiatrist conducts counseling sessions via telephone.

Asynchronous

Synchronous

Two-way, real-time, interactive communications. They may include audio-only or audio-visual communications.

Examples:

A real-time video call between a patient and a cardiologist for immediate consultation.
A telephone call with a physician to discuss symptoms and receive advice immediately.

Functionally equivalent

When a service is provided via telehealth, the transmission of information must be of sufficient quality as to be the same level of service as an in-person visit. Transmission of voices, images, data, or video must be clear and understandable.

Examples:

An online video physical therapy session offering the same exercises as an in-person appointment.
A remote behavioral health counseling session providing the same level of care as an office visit.

In-person vs. Face-to-Face

In-person means the provider and patient are physically together in the same location, and these services do not count as telehealth unless certain supervision requirements are met remotely.

Face-to-face means a service requirement can be fulfilled either in-person or through live, interactive audio-visual telehealth that provides the same quality, safety, and effectiveness as in-person care; however, audio-only or delayed (asynchronous) telehealth does not meet this requirement.