Or. Admin. Code § 410-141-3566
Current through Register Vol. 63, No. 12, December 1, 2024
Section 410-141-3566 - Telemedicine and Telehealth Delivered Health Service and Reimbursement Requirements(1) The following definitions apply to the Divisions administrative rules governing Managed Care Entities (MCEs) as defined in Oregon Administrative Rule (OAR) 410-141-3500; (a) "Asynchronous" means not simultaneous or concurrent in time. For the purpose of this rule, asynchronous telecommunication technologies for telemedicine or telehealth services may include audio and video, audio, or member portal and may include transmission of data from remote monitoring. "Asynchronous" does not include voice messages, facsimile, electronic mail or text messages.(b) "Audio only" means the use of audio technology, permitting real-time communication between a health care provider and a member for the purpose of diagnosis, consultation or treatment. "Audio only" does not include the delivery of health services that are customarily delivered by audio telephone technology and customarily not billed as separate services by a health care provider, such as the sharing of laboratory results.(c) "Meaningful access" means member-centered access reflecting the following statute/and standards: (A) Pursuant to Title VI of the Civil Rights Act of 1964, Section 1557 of the Affordable Care Act and the corresponding Federal Regulation at 45 CFR Part 92 and The Americans with Disabilities Act (ADA), providers telemedicine or telehealth shall accommodate the needs of individuals who have difficulty communicating due to a medical condition, who need accommodation due to a disability, advanced age or who have Limited English Proficiency (LEP) and including providing access to auxiliary aids and services as described in Federal Regulation at 45 CFR Part 92 ;(d) "Synchronous" means an interaction between a provider and a member that occurs at the same time using an interactive technology. This may include audio only, video only, or audio and video and may include transmission of data from remote monitoring.(e) "Telecommunication technologies" means the use of devices and services for telemedicine or telehealth delivered services. These technologies include video conferencing, store-and-forward imaging, streaming media including services with information transmitted using landlines, and wireless communications, including the Internet and telephone networks.(f) "Telehealth" includes telemedicine and includes the use of electronic information and telecommunications technologies to support remote clinical healthcare, member and professional health-related education, public health, and health administration.(g) "Telemedicine" means the mode of delivering remote clinical health services using information and telecommunication technologies to provide consultation and education or to facilitate diagnosis, treatment, care management or self-management of a members healthcare.(h) "Trauma informed approach" as defined in OAR 410-141-3500(i) "Trauma informed services" as defined in OAR 410-141-3500(2) Communications may be between providers, or between one or more providers and one or more members, family members /caregivers /guardians.(3) Coordinated Care Organizations (CCOs) shall ensure that OHP members are offered a choice of how services are received, including services offered using telemedicine or telehealth modalities and in-person services, except where the Authority issues explicit guidance during a declared state of emergency or if a facility has implemented its facility disaster plan.(4) CCOs shall ensure that providers unable to offer in-person services have access to the CCO Provider Directory.(5) CCOs shall ensure that providers unable to offer in-person services inform the CCO upon referring a member to another provider in accordance with the requirements set forth in OAR 410-120-1990 so the CCO can provide any care coordination services necessary to support the member in accessing care.(6) CCOs shall ensure that member choice and accommodation for telemedicine or telehealth shall encompass the following standards and services: (a) CCOs shall ensure that providers offer meaningful access to telemedicine/telehealth services by completing a capacity assessment of members in the use of specific approved methods of telemedicine or telehealth delivery that comply with accessibility standards including alternate formats, and provides the optimal quality of care for the member given considerations of member access to necessary devices, access to a private and safe location, adequate internet, digital literacy, cultural appropriateness of telemedicine or telehealth services, and other considerations of member readiness to use telemedicine or telehealth;(b) CCOs shall ensure that providers offer meaningful access to health care services for members and their families who experience LEP or hearing impairments by working with qualified or certified health care interpreters to provide language access services as described in OAR 950-050-0040. Such services shall not be significantly restricted, delayed, or inferior as compared to programs or activities provided to English proficient individuals;(c) CCOs shall ensure that providers collaborate with members to identify modalities for delivering health care services which best meets the needs of the member and considers the members choice and readiness for the modality of service selected.(d) CCOs shall ensure that telemedicine or telehealth services provided are culturally and linguistically appropriate as described in the relevant standards:(A) National Culturally and Linguistically Appropriate Services (CLAS) Standards;(B) Tribal based practice standards;(C) Trauma-informed approach to care as defined in OAR 410-141-3500.(7) CCOs shall provide reimbursement for telemedicine or telehealth services and reimburse Certified and Qualified Health Care Interpreters (HCIs) as defined in OAR 950-050-0010 for interpretation services provided using telemedicine at the same reimbursement rate as if it were provided in person. This requirement does not supersede the CCOs direct agreement(s) with providers, including but not limited to, alternative payment methodologies, quality and performance measures or Value Based Payment methods described in the CCO contract. Administrative rules and CCO Direct Agreements do not supersede any federal or state requirements with regard to the provision and coverage of health care interpreter services.(8) Consistent with OAR 410-120-1990 privacy and security standards for telemedicine and telehealth services shall be met by satisfying the following: (a) Prior to the delivery of services using a telemedicine or telehealth modality, a members written, oral, or recorded consent to receive services using a telemedicine or telehealth delivery method in a language that the member understands must be obtained by the health system, clinic, or provider and documented in the members health record. Consent must include an assessment of member readiness to access and participate in telemedicine or telehealth delivered services, including conveying all other options for receiving the health care service to the member. Consent must be updated at least annually thereafter. For members and their families with LEP or hearing impairments, providers must use qualified or certified health care interpreters, when obtaining patient consent;(b) Consistent with ORS 109.640, provision of birth control information and services using a telemedicine or telehealth modality shall be provided to any person regardless of age without consent of parent or legal guardian;(c) Consistent with ORS 109.640, provision of any other medical or dental diagnosis and treatment using a telemedicine or telehealth modality shall be provided to any person 15 years of age or older without consent of parent or legal guardian;(e) There is no limitation on the location of the member;(f) Providers may be located in any location where privacy can be ensured;(g) Persons providing interpretive services and supports shall be in any location where member privacy and confidentiality can be ensured.(9) CCOs shall ensure that network providers offering telemedicine or telehealth services, must meet the following requirements: (a) Provide services using telehealth that are within their respective certification or licensing boards scope of practice and comply with telemedicine or telehealth requirements including but not limited to:(A) Documenting patient and provider agreement of consent to receive services;(B) Allowed physical locations of provider and patient;(C) Establishing or maintaining an appropriate provider-patient relationship.(b) Complying with HIPAA and the Authoritys Privacy and Confidentiality Rules and security protections for the member in connection with the telemedicine or telehealth communication and related records requirements (OAR chapter 943 division 14 and 120, OAR 410-120-1360 and 1380, 42 CFR Part 2, if applicable, and ORS 646A.600 to 646A.628 (Oregon Consumer Identity Theft Protection Act)) except as noted in section (11) of this rule;(c) Obtaining and maintaining technology used in telemedicine/telehealth communication that is compliant with privacy and security standards in HIPAA and the Authoritys Privacy and Confidentiality Rules described in subsection (b) except as noted in section (11) of this rule;(d) Ensuring policies and procedures are in place to prevent a breach in privacy or exposure of member health information or records (whether oral or recorded in any form or medium) to unauthorized persons and timely breach reporting as described in OAR 943-014-0440;(e) Maintaining clinical and financial documentation related to telemedicine or telehealth services as required in OAR 410-120-1360 and any program specific rules in OAR Ch 309 and Ch 410;(f) Complying with all federal and state statutes as required in OAR 410-120-1380.(10) CCO reimbursement to network providers offering telemedicine or telehealth services shall meet the following requirements:(a) Services provided shall be medically and clinically appropriate for covered conditions within the Health Evidence Review Commissions (HERC) prioritized list and in compliance with relevant guideline notes;(b) Dependent on individual certification or licensing boards scope of practice standards, telemedicine or telehealth delivered services for covered conditions are covered for establishing a patient-provider relationship, and when an established relationship exists between a provider and patient as defined by a patient who has received in person professional services from the physician or other qualified health care professional within the same practice within the past three (3) years;(c) For all claim types except dental, CCOs shall ensure that encounter submissions for telehealth or telemedicine delivered services covered using synchronous audio and video include modifiers GT or 95 and can be billed with either telephone codes (e.g. 99441) or regular in-person codes. For all telehealth services including dental, CCOs shall ensure that encounter submissions include Place of Service code 02;(d) All physical and behavioral telemedicine and telehealth and oral teledentistry telehealth services except School Based Health Services (SBHS) shall include Place of Service code 02 when the client or member is located in a location other than their home. When the client or member is located in their home, the claim shall include Place of Service code 10.(e) All claim types except Dental services, shall include modifier 95 when the telemedicine or telehealth delivered service utilizes a real-time interactive audio and video telecommunication system. When provision of delivered using real-time interactive audio only telecommunication system, the encounter submissions shall include modifier 93.(11) In the event of a declared emergency or changes in federal requirements, the Authority may adopt flexibilities to remove administrative barriers and support telemedicine, or telehealth delivered services:(a) The Authority shall follow guidance from the US Department of Health and Human Services (HHS) Office for Civil Rights (OCR) which may allow enforcement discretion related to privacy or security requirements;(b) The Authority may expand network capacity through remote care and telemedicine, or telehealth services provided across state lines;(c) Should the Authority exercise option in this section (11), all CCO obligations for Network Adequacy requirements as described in OAR 410-141-3515 remain in full effect;(d) The Authority may expand the definition of an established patient-provider relationship beyond the standard of an in-person encounter every three (3) years.Or. Admin. Code § 410-141-3566
DMAP 16-2020, temporary adopt filed 03/26/2020, effective 03/26/2020 through 09/21/2020; DMAP 43-2020, adopt filed 09/01/2020, effective 9/10/2020; DMAP 62-2020, amend filed 12/16/2020, effective 1/1/2021; DMAP 56-2021, amend filed 12/30/2021, effective 1/1/2022; DMAP 79-2022, minor correction filed 09/30/2022, effective 9/30/2022; DMAP 48-2023, minor correction filed 06/05/2023, effective 6/5/2023; DMAP 75-2023, amend filed 09/13/2023, effective 9/13/2023; DMAP 98-2024, minor correction filed 06/11/2024, effective 6/11/2024Statutory/Other Authority: ORS 413.042, 414.572, 414.591, 414.605 & 414.615
Statutes/Other Implemented: ORS 414.572