10 Colo. Code Regs. § 2505-10-8.095

Current through Register Vol. 47, No. 20, October 25, 2024

Section 10 CCR 2505-10-8.095 - TELEMEDICINE

8.095.1.ADEFINITIONS

1. Electronic Consultation (eConsult) means an asynchronous dialogue initiated by a Treating Practitioner seeking a Consulting Practitioner's expert opinion without a face-to-face member encounter with the Consulting Practitioner.

2. Electronic Consultation Platform (eConsult Platform) means a web-based and application-based electronic system authorized by the Department that allows for an asynchronous exchange between a Treating Practitioner and a Consulting Practitioner to securely share health information and discuss member care. An eConsult Platform may be either:

a. State Platform: A platform contracted with the Department as the state's eConsult Platform.

b. Approved Platform: Any platform other than the State Platform that meets the criteria identified by the Department.

3. Electronic Health Entity (eHealth Entity) means a group practice that delivers services exclusively through telemedicine and is enrolled in a provider type that has an eHealth specialty. eHealth entities:

a. Cannot be Primary Care Medical Providers;

b. Can be either in-state or out-of-state.

4. Facilitated Visit means a Telemedicine visit where the rendering provider is at a distant site and the member is physically present with a support staff team member who can assist the provider with in-person activities.

5. HIPAA means the federal "Health Insurance Portability and Accountability Act of 1996", PUB. L. 104-191, as amended, which is incorporated herein by reference. Pursuant to C.R.S. § 24-4-103 (12.5) (2022), the Department maintains copies of this incorporated text in its entirety, available for public inspection during regular business hours at: Colorado Department of Health Care Policy and Financing, 1570 Grant Street, Denver, CO 80203. Certified copies of incorporated materials are provided at cost upon request.

6. Primary Care Medical Provider (PCMP) means an individual physician, advanced practice nurse or physician assistant, who contracts with a Regional Accountable Entity (RAE) in the Accountable Care Collaborative (ACC), with a focus on primary care, general practice, internal medicine, pediatrics, geriatrics, or obstetrics and gynecology.

7. Consulting Practitioner means a provider who has education, training, or qualifications in a specialty field other than primary care

8. Telemedicine means the delivery of medical and health-care services and any diagnosis, consultation, or treatment using interactive audio (including but not limited to telephone and relay calls), interactive video (including but not limited to interactive audiovisual modalities), or interactive data communication (including but not limited to live chat and excluding text messaging, electronic mail, and facsimile transmission).

9. Treating Practitioner means a member's treating physician or other qualified health care practitioner who is a primary care provider contracted with a Regional Accountable Entity to participate in the Accountable Care Collaborative as a Network Provider.

8.095.2CLIENT ELIGIBILITY

8.095.2.A. All Colorado Medicaid clients are eligible for medical and behavioral services delivered by telemedicine.

8.095.3 PROVIDER ELIGIBILITY

8.095.3.A. Any licensed provider enrolled with Colorado Medicaid is eligible to provide telemedicine services within the scope of the provider's practice.

8.095.3.B. Providers that meet the definition of an eHealth Entity shall enroll as the eHealth specialty.

8.095.4COVERED SERVICES

8.095.4.A. Covered Telemedicine services must:

1. Meet the same standard of care as in-person care;

2. Be compliant with state and federal regulations regarding care coordination;

3. Be services the Department has approved for delivery through Telemedicine;

4. Be within the provider's scope of practice and for procedure codes the provider is already eligible to bill;

5. Be provided only where contact with the provider was initiated by the member for the services rendered; and

6. Be provided only after the member's consent, either verbal or written, to receive telemedicine services is documented.

8.095.4.B. eHealth Entities shall only provide:

1. Covered Telemedicine services, including Facilitated Visits.

8.095.4.C. Beginning February 1, 2024, a Treating Practitioner may request an eConsult with a Consulting Practitioner. eConsult services must:

1. Be requested by the Treating Practitioner through an eConsult Platform;

2. Be responded to by the Consulting Practitioner through an eConsult Platform;

a. The Consulting Practitioner may send the eConsult to another Consulting Practitioner in a different specialty practice through an eConsult Platform, when clinically appropriate.

3. The Consulting Practitioner must, when clinically appropriate, provide clinical guidance pertaining to the eConsult electronically to the requesting Treating Practitioner through an eConsult Platform; and,

4. All dialogue between the Treating Practitioner and the Consulting Practitioner pertaining to an eConsult must be through an eConsult Platform.

8.095.5PRIOR AUTHORIZATION REQUIREMENTS

8.095.5.A. The use of Telemedicine does not change prior authorization requirements for the underlying services provided.

8.095.6RECORDKEEPING.

8.095.6.A. eHealth Entities must maintain a Release of Information in compliance with current HIPAA standards to facilitate communication with the member's PCMP.

8.095.7REIMBURSEMENT

8.095.7.A Pursuant to C.R.S. §25.5-5-320(2) (2022), the reimbursement rate for a Telemedicine service shall, as a minimum, be set at the same rate as the Colorado Medicaid rate for a comparable in-person service.

8.095.7.B. eConsults

1. eConsults are reimbursed after the eConsult is closed by the requesting Treating Practitioner and the following conditions are met:

a. The eConsult is conducted instead of face-to-face in-person visit referral to a Consulting Practitioner;

b. The eConsult is provided to the Treating Practitioner by the Consulting Practitioner through an eConsult Platform, with clinical guidance where appropriate; and,

c. The eConsult is closed after the Treating Practitioner reviews the care plan provided by the Consulting Practitioner.

2. Treating Practitioners may directly submit a procedure code specific fee-for-service claim for reimbursement.

3. Consulting Practitioners who utilize an Approved Platform may directly submit a procedure code specific fee-for-service claim for reimbursement for all closed eConsults that meet the criteria in Section 8.095.7.B.1.

4. Consulting Practitioners who utilize the State Platform must only be reimbursed through the State Platform for all closed eConsults that meet the criteria in Section 8.095.7.B.1.

5. eConsults must be delivered through an eConsult Platform to be eligible for reimbursement.

8.095.8NON-COVERED SERVICES

8.095.8.A Services not otherwise covered by Colorado Medicaid are not covered when delivered through Telemedicine.

8.095.8.B eConsults that are not delivered, and responded to, through an eConsult Platform.

10 CCR 2505-10-8.095

47 CR 01, January 10, 2024, effective 1/30/2024