RULE SUMMARY: The Health Evidence Review Commission (HERC) has updated guidelines for coverage of telehealth services. These updates support appropriate response to an outbreak or epidemic of an infectious disease through increased access to appropriate health care resources. This temporary rule amendment authorizes the Authority and Division to operationalize the intent of the revisions to telehealth services.
(1) Telemedicine is defined as the use of telephonic or electronic communications of medical information from one site to another regarding a patient's health status.
(2) Telemedicine encompasses different types of programs, services and delivery mechanisms for medically appropriate covered services within the patient's benefit package.
(3) Coverage for physical health telemedicine services include Telehealth (synchronous audio/video visits), Patient to Clinician services (electronic/telephonic) and Clinician to Clinician Consultations (electronic/telephonic).
(a) Telehealth patient visits using a synchronous (live two-way interactive) video and audio transmission resulting in real time communication between a licensed health care provider located in a distant site and the recipient being evaluated located in an alternate site, are covered when billed services comply with the guideline notes set forth by the Health Evidence Review Commission (HERC) and correct coding standards;
(b) Patient to clinician services using electronic and telephone communications are covered when billed services comply with HERC guideline notes and correct coding standards;
(c) Clinician to clinician consultations using electronic and telephone communications are covered when billed services comply with HERC guideline notes;
(d) For purposes of physical health services, the Authority shall provide coverage for telemedicine services to the same extent that the services would be covered if they were provided in person subject to the requirements outlined in the Prioritized List and associated guideline notes.
(4) During an outbreak or epidemic, the Authority shall provide coverage and reimbursement of patient to clinician telephonic and electronic services for established patients using the Division's maximum allowable rate setting methodology:
(a) Relative Value Unit (RVU) weight-based rates for Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes assigned an RVU weight are calculated on the current year's published value multiplied by a state-wide factor;
(b) The Division may reimburse telephonic and electronic services to the same extent that the services would be covered if they were provided in person consistent with HERC guideline notes and correct coding standards.
(5) Unless authorized in OAR 410-120-1200 Exclusions, other types of telecommunications are not covered, such as telephone calls without medical decision making, images transmitted via facsimile machines and electronic mail:
(a) When those types are not being used in lieu of videoconferencing, due to limited videoconferencing equipment access, or
(b) When those types and specific services are not specifically allowed in this rule per the Oregon Health Evidence Review Commission's Prioritized List of Health Services and Guideline Notes.
(6) Providers billing for covered physical health telemedicine services shall:
(a) Comply with HIPAA and the Authority's Confidentiality and Privacy Rules and security protections for the patient in connection with the telemedicine communication and related records;
(b) Obtain and maintain technology used in the telemedicine communication that is compliant with privacy and security standards in HIPAA and the Authority's Privacy and Confidentiality Rules set forth in OAR 943 division 14;
(c) Ensure policies and procedures are in place to prevent a breach in privacy or exposure of patient health information or records (whether oral or recorded in any form or medium) to unauthorized individuals;
(d) Comply with the relevant HERC guideline note for telehealth, teleconsultation and electronic/telephonic services. Refer to the current prioritized list and guidelines at https://www.oregon.gov/oha/HPA/DSI-HERC/Pages/Prioritized-List.aspx;
(e) Maintain clinical and financial documentation related to telemedicine services as required in OAR 410-120-1360.
(7) Performing / Rendering Providers of covered physical health telemedicine services shall:
(a) Hold a current and valid license without restriction from a state licensing board where the provider is located;
(b) Have authority to provide physical health telemedicine services for eligible Oregon Medicaid beneficiaries;
(c) Comply with correct coding standards using the most appropriate Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes.
STATUTORY/OTHER AUTHORITY: ORS 413.042
STATUTES/OTHER IMPLEMENTED: ORS 414.025, 414.065