UPMC Health Plan believes telehealth is an important care delivery option that helps members gain access to care. We are committed to offering industry-leading coverage to our members—subject to federal, state, and local regulations—and to support our network providers in delivering cost-effective, quality care.
Telehealth benefits are available to members of all lines of business. Services may be reimbursed to providers who adhere to the telehealth pay policy, MP.148, and provide treatment that is in line with their scope of practice.
Clicking some of the links provided will redirect you to landing pages outside the UPMC Health Plan website that provide content we do not monitor and for which we are not responsible.
While almost all of our individual and group plans include extensive telehealth benefits, some ASO/self-funded employer plans do not cover telehealth services.
Does UPMC Health Plan adhere to U.S. Department of Health and Human Services Office of Civil Rights (OCR) enforcement of HIPAA compliance?
Yes, UPMC Health Plan follows OCR guidelines regarding HIPAA-compliant platforms, as outlined in the technology requirements within UPMC Health Plan’s telehealth policy, MP.148.
Are audio-only visits covered for telehealth?
UPMC Health Plan mirrored the temporary Centers for Medicare & Medicaid Services (CMS) coverage list (including services approved for delivery via audio only) during the public health emergency (PHE) for Medicare and Commercial lines of business. CMS has indicated that the temporary telehealth codes will expire at the end of calendar year 2023. UPMC Health Plan will continue to follow the CMS temporary code list for Medicare and Commercial lines of business through the end of 2023.
For behavioral health telehealth services, CMS and the Pennsylvania Department of Human Services have indicated that behavioral health services can be delivered via telehealth, including via audio only. There are no geographic restrictions for the originating site for behavioral health telehealth services, and Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) can serve as distance site providers for these services. See OMHSAS-22 and CY2022 Telehealth Update Medicare Physician Fee Schedule.
Will video visits continue to be covered for telehealth?
In many cases, yes. UPMC Health Plan has an extensive telehealth policy that outlines which services are covered for each line of business.
UPMC Health Plan mirrored the temporary CMS coverage list during the PHE for the Medicare and Commercial lines of business. CMS has indicated that the temporary telehealth codes will expire at the end of calendar year 2023. UPMC Health Plan will continue to follow the CMS temporary code list for Medicare and Commercial lines of business through the end of 2023.
Will Appendix A be removed?
No. For now, Appendix A will continue to be available as a point of reference for expired benefits and direction to the UPMC Health Plan policy and procedure documents that establish coverage rules for benefits after the PHE ends. Some government programs have PHE benefits that will continue for a period of time after the PHE ends, so providers caring for members with coverage through government programs should continue to check Appendix A for relevant updates. Appendix A is available in our policies and procedures manual and at Appendix A – COVID-19 Special Coverage and Payment Policy
- Consider conducting a needs assessment
Before deciding to offer telehealth care from your practice, you should evaluate whether the model fits your patients’ needs and would work with the type of care you provide.
Consider the following questions:
- Do your patients want telehealth services?
- A recent survey showed that the demand for telehealth care is on the rise:
- Prior to the COVID-19 pandemic, 66 percent of people were open to having a telehealth visit prior to the pandemic and only 8 percent had used telehealth.1
- Since COVID-19, surveys have shown that 71 percent are now open to having a telehealth visit and over 50 percent had done so in the three months prior to the survey.1
- 83 percent of respondents said they plan to continue using telehealth even after the coronavirus threat is mitigated.
- If you’re not sure, try conducting a survey of your patients in your office or via email.
- Are the visit types you conduct conducive to a telehealth visit?
- Are other providers offering similar telemedicine services?
- If so, can you collaborate or share best practices?
- Map out the use case
If you’ve decided that offering telehealth services is right for you, consider how your process would work by following these steps:
- Map out what your current visit looks like for the visit types identified in section 1.
- Determine if any parts of that process currently use in-person services.
- Determine which of the above-identified aspects can be replaced with comparable care via telehealth and note what that replacement would look like.
- Map out a new process that incorporates the new, telehealth-compatible replacements.
- Identify if any of your identified processes will change.
- Work with frontline staff on how the processes can be adjusted.
- Pick a platform
In order to conduct telehealth visits, you must use a platform that meets certain requirements. There may also be other, optional features you want to use:
- Be sure to confirm that the platform is HIPAA compliant.
- When using telehealth technologies and systems to render services, providers must consider security, patient confidentiality, and privacy. You are required to use a HIPAA-compliant, secured, platform for the purpose of telemedicine encounters. The electronic channel must include and support all of the following:
- Access controls
- Encryption and decryption
- Audit controls
- Transmission security
- Third-party storage considerations, including a business associate agreement
- HIPAA technical safeguards
- Payment card industry data security standard (PCI-DSS)
- Make considerations for your capability needs
- Do you want your patients to be able to self-schedule?
- Do you need your platform to integrate with your EMR?
- For example, do you want:
- Video feature built in to EMR?
- HL7 and MDM messaging?
- What data reporting capabilities does the vendor offer?
- Ensure broadband requirements are met
Please refer to the Overcoming barriers section below.
- Hardware considerations
What physical components will you need to incorporate telehealth into your practice? Consider the following:
- Do you prefer traditional computers or smart devices, such as tablets or smartphones?
- How many providers will be conducting telehealth visits?
- This will determine the number of hardware devices to make available.
- Will providers be conducting the video visit on one platform and documenting in another platform?
- This will determine if the provider needs two monitors.
- Do the preferred devices come with cameras or will you need to buy them separately?
- Video visit aesthetics considerations
Telehealth visits are not the same as a regular video chat. They must maintain a level of professionalism akin to that of an in-office visit. Consider:
- Visit privacy.
- Noise level.
- Visual distractions.
- The provider’s clothing.
- Lighting in the room.
- How to maintain eye contact.
- Consent documents
You can find more information about consent by visiting the Current State Laws & Reimbursement Policies website and selecting the state in which you practice.
- Consider costs
- What costs are incurred or reduced by changing the workflow? (Refer to section 2.)
- How much will hardware cost? (Refer to section 5.)
- What will reimbursement look like?
- This is different for every payer. Please refer to the telehealth policy section of this page for UPMC Health Plan’s policies.
- Understand coding and billing requirements. Please refer to the telehealth and billing section of this page for UPMC Health Plan’s policies.
- Review state and federal laws
Please check the federal and state laws that are applicable to your practice. The National Telehealth Policy Resource Center monitors telehealth legislation and may be a helpful resource on the laws that apply to your practice. Visit cchpca.org/telehealth-resource-centers to learn more.
1Heath S. 83% of patients predict long-term telehealth care access. Patient Engagement HIT. June 18, 2020. Accessed November 12, 2020. https://patientengagementhit.com/news/83-of-patients-predict-long-term-telehealth-care-access
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What is telehealth?
Telehealth is the use of electronic information and communication technologies to provide and support health care. It can include interactive communication between a patient and provider or an interprofessional consultation between two providers.
Telehealth can take place in real-time between two individuals, or it can be “asynchronous”—where secure messages are exchanged without real-time interaction an example would be confirming a diagnosis or establish a treatment plan, etc.
Benefits of telehealth
Using telehealth to care for your patients may offer many benefits, including:
- Patient satisfaction.
- Can help create better relationships with your patients
- Increases patient retention
- Convenience.
- Patients are more likely to show up and be on time for scheduled appointments
- Patients are less likely to cancel appointments due to inclement weather, lack of child/elder care, transportation issues, etc.
- Improved access.
- Captures more patients in remote locations
- Patients who have difficult work schedules can be seen on a break or lunch break
- Increased visit compliance for patients with chronic conditions
- Improved quality.
- Accommodates same-day appointments for urgent care issues
- Patients can recover and heal at home without having to attend an on-site office visit where they may be exposed to other illnesses
- Decreased provider fatigue/burnout.
- Allows you to see more patients in less time
- Better work-life balance through flexible scheduling
Types of technology
In order to provide telehealth services to your patients, you will need internet access and a device, such as a laptop with a webcam, smartphone, or tablet. Some services are also available via phone.
During the public health emergency, there may be some exceptions for use of technology that is not in compliance with HIPAA regulations. However, providers are strongly encouraged to use a secure technology that is HIPAA compliant whenever able to do so.
- Care delivery options
- Live (synchronous) videoconferencing
- Video visits in real-time with your patients
- Store-and-forward (asynchronous)
- The transmission of recorded health history to a care provider, usually a specialist. Typically, data is gathered from the patient and sent through a secure email or messaging service to a cloud-based platform. The data is analyzed, and a diagnosis and treatment plan are sent back to the patient or provider. It is sometimes referred to as an e-visit.
- Remote patient monitoring (RPM
- The use of connected electronic tools to record personal health and medical data in one location for review by a provider in another location, usually at a different time.
- Phone
Telehealth for all
Providers face a digital divide among patients. Below are suggestions to help:
- Prioritize the support.
- Listen to patients with access challenges and work with them to design interventions.
- Connect patients to resources.
- Advocate for better broadband.
- Simplify the technology or offer alternative options.
How to promote health equity:
- Develop patient-facing materials in multiple languages and formats, including materials for the hearing and visually impaired.
- Consider the reading level of materials—seek input from patient advocacy groups and marketing teams.
- Test out technology with patients prior to appointments.
- Provider support when patients are in person.
- Consider interpreter services and closed-captioning options.
Talking to patients about telehealth:
- Outline the value of telehealth for them: easier and faster access, shorter wait times, convenience.
- Identify the equipment they will need for a telehealth appointment and offer support for use.
- Explain that audio-only is an option at times.
- Discuss privacy, medical records security, confidentiality.
- Offer resources for funds to purchase equipment if needed.
- Recommend that patients talk with their insurance provider on coverage options for telehealth appointments.
Suggestions for talking to your staff about telehealth:
- Train staff on technology aspects of telehealth.
- Suggest staff practice the use of technology prior to appointments.
- Provide additional training sessions as needed, not everyone is sophisticated with technology.
- Educate staff on security and privacy of telehealth.
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- Inform your patients that you are offering telehealth via:
- Website updates.
- Email blasts.
- Letters/Postcards to their homes.
- Phone calls to patients with scheduled appointments.
- Inform your patients which conditions your office will treat via telehealth.
- Prepare your patients for their visit.
- Let them know:
- How you will connect (e.g., phone, video, messaging).
- If they will need to download an app (e.g., AmWell, MyUPMC).
- What to do if they need to troubleshoot.
- What to wear.
- If they need to take any vitals prior to their appointment.
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During the COVID-19 public health emergency we have made significant expansions to our telehealth coverage, including greater allowance for use of telephone-based visits, to make telehealth more accessible for both patients and providers.
Place of Service clarification
- What are the new/modified Place of Service definitions for telehealth?
The Centers for Medicare & Medicaid Services has added a new/modification to the POS codes 10 and 02 for Medicare effective 1/1/22. Read the CMS bulletin.
Place of Service 02: Telehealth Provided Other than in Patient’s Home Descriptor: The patient location when health services and health-related services are provided or received, through telecommunication technology. POS 02 should be used when the patient is not located in their home when receiving health services or health-related services through telecommunication technology.
Place of Service 10: Telehealth Provided in Patient’s Home Descriptor: The patient location when health services and health-related services are provided or received through telecommunication technology. POS 10 should be used when the 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.
Medicaid Providers: This does not affect billing for Medicaid. Medicaid requirements, per Pennsylvania DHS Medicaid Bulletin 99-21-06, state that all telehealth billed for Medicaid services should be billed under the Place of Service 02: telemedicine. Please reference this bulletin for more details.
- Why is UPMC Health Plan requesting this for all lines of businesses when the bulletin notes it is for Medicare?
UPMC Health Plan’s claims system has been updated to accept POS 10 and the updated definition of POS 02 for relevant lines of business. Providers have patients with numerous types of insurance coverage and UPMC Health Plan wants to ensure the usage of the POS codes remains as streamlined and consistent as possible. The provider of care is ultimately responsible for providing accurate and compliant information on all submission of claims and/or billing information.
- What is the definition of telecommunication technology?
Telehealth is the use of electronic and communication technologies to provide and support health care when distance separates the patient from the provider. It utilizes interactive telecommunications technology (e.g., audio and video equipment) to permit either two-way interactive communication between the patient and physician or allow the physician to review the medical case without the patient being present in order to confirm a diagnosis and/or establish a treatment plan.
Telehealth is practiced either in real-time or as store-and-forward. Real-time telehealth requires the simultaneous attendance of provider and patient, or of multiple providers to a communications link that allows real-time interaction. Store-and-forward telehealth involves the acquisition and transmission of medical data from the patient to a medical provider for review and later assessment—it does not require the simultaneous presence of both parties and a real-time communication link. To learn more, please visit our Telehealth ‒ MP.148 policy at upmchp.us/policiesandprocedures.
- What if the patient is in their car or another location—what place of service should be used?
Per the CMS bulletin, telehealth provided in location other than in a patient’s home should be documented with POS 02.
- Is POS 02 and 10 used for only physical health services?
POS 02 and 10 can be used for both physical and behavioral health services for all relevant lines of business except Medicaid. Medicaid Behavioral Health is advising that Medicaid providers should continue to use POS 02. Therefore, providers should follow the billing guidance that affects their patients based on their insurance coverage. Review Pennsylvania DHS Medicaid Bulletin 99-21-06 for details on Medicaid billing expectations.
- What is Modifier 93?
Modifier 93 is a new audio-only modifier created by the American Medical Association effective 1/1/22. As defined by the AMA, modifier 93 is “specific to telephone/audio-only synchronous telehealth services. It includes a synchronous telemedicine service rendered via telephone or other real-time interactive audio-only telecommunications system. Synchronous telemedicine service is defined as a real-time interaction between a physician or other qualified health care professional and a patient who is located away at a distant site from the physician or other qualified health care professional. The totality of the communication of information exchanged between the physician or other qualified health care professional and the patient during the course of the synchronous telemedicine service must be of an amount and nature that is sufficient to meet the key components and/or requirements of the same service when rendered via a face-to-face interaction.”
- Effective 1/1/22 and through the duration of the Public Health Emergency (PHE), providers are able to use modifier 93 to indicate that a telehealth service was delivered via audio-only/telephonic modality; see Provider COVID-19 FAQ, Question, “How should I bill for care for my patients that only have a telephone available to them?” for audio-only telehealth services that UPMC Health Plan covers.
- Providers should use the appropriate Place of Service (POS 02/10) and/or modifier (95/93) on telehealth claims for all lines of business except Medicaid. Medicaid Providers: Pennsylvania DHS Medicaid Bulletin 99-21-06, state that all telehealth billed for Medicaid services should be billed under the Place of Service 02: telemedicine. Please reference this bulletin for more details.
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Policy/Billing and coding/reimbursement
- UPMC Health Plan pay policy, MP.148
- Reimbursement: Currently, UPMC Health Plan reimburses virtual services at the same contracted rate as in-person services.
- COVID-19 – Appendix A
Provider is responsible for the appropriate billing of services
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Learn more about telehealth well-child visits:
Provider is responsible for all clinical decisions and appropriate billing of services.
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Environment
- Ensure privacy (HIPAA)
- Clinically appropriate exam room location, size, and layout
- Avoid background noise
- Adequate lighting for clinical assessment
Equipment
- Desktop computer vs. tablet
- High-speed internet
- Web camera
- Microphone
- Dual screens for EHR documentation note-taking
- RPM dashboard (if using)
- Headphones
Dress
- The same level of professional attire as in-person care
Communication
- Turn off other web applications and all notifications
- Review patient complaints and records before beginning call
- Adjust webcam to eye level to ensure contact
- Narrate actions with patient (If you need to turn away, look down to take notes, etc.)
- Verbalize and clarify next steps, such as follow-up appointments, care plan, prescription orders
- Pause to allow transmission delay
- Speak clearly and deliberately
- Choose empathetic language
- Use nonverbal language to signal that you are listening
Additional things to consider during a visit
- Skin tone of the patient
- Eye redness
- Work of breathing
- Ask your patient to point to "where it hurts"
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- Cultural sensitivity is significant when administering telehealth similar to in-person visits because it allows us to effectively function in other cultures, allows us to respect and value other cultures, and can reduce barriers between professionals and their patients.
- Telemedicine communication must be respectful of the patient’s language, cultural beliefs, and health literacy level.
- Telehealth increases access to care in underserved communities and can bridge cultural gaps.
- See patients in their relaxed, natural state and how they live.
- Things to consider:
- Not all patients may have Wi-Fi access.
- There may only be one, shared device in the home.
- Patients may have prepaid minutes or no mobile coverage.
- Space and/or quiet rooms may not be a possibility for all patients.
Considerations for Various Populations
UPMC providers work with patients who present a varying level of technical abilities as well as those that who have a preferred language other than English. Below are suggestions for how to manage these situations. For more information on telehealth equity and access, please visit the HHS telehealth website at telehealth.hhs.gov.
People with Disabilities
Telehealth technology can be challenging for patients, especially those with a disability. UPMC Health Plan wants to be inclusive of all patients.
Per CMS, Section 504 of the Rehabilitation Act and the Americans with Disabilities Act protects qualified individuals with disabilities from discrimination on the basis of disability in the provision of benefits and services.
Providers should talk with their patients about specific needs and what services would work best to ensure affective communication.
Examples of aids and services your patient may need:
- For blind/vision-loss/deaf-blind patients — Providing a qualified reader; information in large print, Braille, or electronically for use with a computer screen-reading program; or an audio recording of printed information.
- For deaf/hearing-loss/deaf-blind patients — Providing a qualified notetaker, qualified sign language interpreter, oral interpreter, cued-speech interpreter, tactile interpreter, real-time captioning, written materials, or a printed script of a stock speech.
- For patients with speech disabilities — Providing a qualified speech-to-speech translator, or suggesting the patient use paper/pencil to write out words; staff should listen attentively and not be afraid to ask the patient to repeat a word or phrase they don’t understand.
- UPMC AnywhereCare offers accessibility mode for images, other assistive technologies, and ASL interpreters as needed.
- MyUPMC offers ASL and interpreters as needed.
- More information can be found on UPMC Infonet* by searching “American Sign Language (ASL) Interpreter for their upcoming telemedicine visit” AND “Foreign (Non-English Speaking) Language Interpreter - MyUPMC Video Visit.”
- *Valid UPMC Network ID required for access to UPMC Infonet.
- Per HHS Office for Civil Rights (OCR) Guidance, Guidance and Resources for Electronic Information Technology: Ensuring Equal Access to All Health Services and Benefits Provided Through Electronic Means (hhs.gov) failure to ensure that services provided through Electronic and Information Technology (EIT) are accessible to people with disabilities may constitute discrimination under federal civil rights laws.
Patients with a preferred language other than English:
Patients with a preferred language other than English can face challenges when using telehealth and are less likely to use portals due to the language barriers.
- Consider ways to connect with them outside of the portal such as audio-only appointments.
- Think about a qualified medical interpreter for the telehealth appointment.
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Top barriers to adoption:
Recommendations for overcoming above barriers:
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UPMC Health Plan members can search our provider directory for providers who offer some services via telehealth. Providers who offer telehealth are encouraged to sign up to be featured in this directory. Being included in the directory does not require providers to offer all services via telehealth or offer telehealth services to all patients; providers must determine what is medically appropriate. Please contact your physician account executive if you are interested in appearing as a telehealth provider in our searchable directory.
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As UPMC Health Plan members, your patients have 24/7 access to health care providers for non-emergent issues with the UPMC AnywhereCare app. This means you can feel comfortable knowing your patients are in good hands. Patients have the ability to have a visit summary sent to their PCP.
Conditions treated include:
- Bronchitis and cough.
- Cold and flu symptoms.
- Diarrhea.
- Pink eye.
- Rash.
- Seasonal allergies.
- Sinus infection.
- Tick bites.
- Urinary tract infection.
- Vaginal yeast infection.
- General medical advice.
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UPMC Health Plan is excited to announce a new, innovative product offered through the UPMC Health Plan Marketplace and Pennie™ for coverage starting Jan. 1, 2022. UPMC VirtualCare offers low-cost care options and choice to see providers virtually or in person.
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1. What home health services can providers offer via telehealth?*
Telehealth visits are for observation, training, or education in the following areas:
- Skilled nursing
- Medical social work
- Physical therapy
- Occupational therapy
- Speech therapy
- Home health aid
*A telehealth visit must contain both audio and video components.
2. What is the effective date for telehealth for home health agencies?
Telehealth services for home health are effective immediately. UPMC Health Plan has approved telehealth services since the beginning of the pandemic; however, UPMC Health Plan expanded telehealth services for home health as a permanent telehealth service. The updated telehealth policy is effective as of April 1, 2022. Please refer to question 3 for more information.
3. Is there a telehealth policy?
Please refer to the Telehealth Policy, MP.148, upmchp.us/telehealth. This updated policy is effective as of April 1, 2022, to add the home health telehealth coding.
4. What are the billing codes per service?
Medicare and Commercial and CHIP:
- UB Form
- Rev 0780 plus appropriate home health Healthcare Common Procedure Coding System (HCPCS) Code
- Telehealth modifier or Place of Service not required for the UB Form (Rev 0780 will indicate telehealth)
- Rate: $95 per visit has been added to the home health fee schedule
Medicaid and UPMC Community HealthChoices Primacy:
- 1500 Health Care Finance Administration (HCFA) Form with appropriate HCPCS home health code per services provided and the telehealth modifier (10 for services in the home and POS 2)
- Rate: Home health provider currently contracted rate
5. What are the recommended POS codes for home health telehealth?
Per telehealth policy Telehealth Policy, MP.148, upmchp.us/telehealth:
POS 02: Telehealth Provided Other than in Patient’s Home Descriptor: The patient location when health services and health-related services are provided or received, through telecommunication technology. POS 02 should be used when the patient is not located in their home when receiving health services or health-related services through telecommunication technology.
POS 10: Telehealth Provided in Patient’s Home Descriptor: The patient location when health services and health-related services are provided or received through telecommunication technology. POS 10 should be used when the 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.
POS 10 does not affect reimbursement rates: The addition of POS 10 is a recommendation per UPMC Health Plan; however, it is not mandatory.
6. Can remote monitoring be delivered through telehealth?
Remote monitoring can be used during a telehealth visit. However, remote monitoring is not a separate billable service and would be inclusive of a telehealth visit.
7. Can a start of care or recertification assessment be performed through telehealth?
The Outcome and Assessment Information Set, or OASIS, a group of data elements developed by the Centers for Medicare & Medicaid Services (CMS), represent core items of a comprehensive assessment for an adult home care patient, form the basis for measuring patient outcomes, and determine agency reimbursement. Per CMS regulations, OASIS assessments cannot be performed via telehealth.
Provider is responsible for appropriate billing of services.
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