California Telemedicine & Telehealth Reimbursement Overview

Provider Reimbursement Eligibility
Consent for Telemedicine Live Video Reimbursement Store & Forward Reimbursement Originating Site & Transmission Fees Eligible Practitioners
State Law

California law states that the provider at the originating site must obtain and document oral or written consent before performing any telemedicine services.

See California Health & Safety Code Sec. 2290.5.

Private payers may reimburse for live video and Medi-Cal will reimburse for services provided via live video.
See California Health & Safety Code Sec. 1374.13

 

In-person contact between a health care provider and a patient shall not be required under the Medi-Cal program for services appropriately provided through telehealth, subject to reimbursement policies adopted by the department to compensate a licensed health care provider who provides health care services through telehealth that are otherwise reimbursed pursuant to the Medi-Cal program.

ARTICLE 4. The Medi-Cal Benefits Program [14131 – 14138]

Store & forward is included under California’s definition of telemedicine, so it is reimbursed the same.

See California Business & Professions Code Sec. 2290.5

No health insurer shall limit the type of setting where services are provided for the patient or by the health care provider before payment is made for the covered services appropriately provided by telehealth, subject to the terms and conditions of the contract between the policyholder or contract holder and the insurer, and between the insurer and its participating providers or provider groups”.  This interpretation would include the home.

CA INSURANCE CODE – INS, Article 10123.85.  

No Reference Found

Medicaid

The provider is to obtain and document, at minimum, oral consent.

See Page 2 Medi-Cal Telehealth Manual.

Medi-Cal will reimburse for telemedicine services provided through means of live video.  Services must be billed with either a GT or 95 modifiers.

See Page 1 of the Medi-Cal Telehealth Manual.

Medi-Cal will reimburse store & forward when it is used for tele-dermatology, tele-dentistry and tele-ophthalmology.
See Page 6 of the Medi-Cal Telehealth Manual

The home is an eligible originating site.  “HSC Section 1374.13 states there is no limitation on the type of setting between a health care provider and a patient when providing covered services appropriately through a telehealth modality.”

The originating site facility fee is reimbursable when billed with code Q3014 (telehealth originating site facility fee).

Transmission costs incurred while providing telehealth services via
audio/video communication are reimbursable when billed with code T1014 (telehealth transmission, per minute, professional services bill separately).

See Page 1-3 of the Medi-Cal Telehealth Manual

To find out if your provider class is eligible for medicaid reimbursement reference the appropriate medicaid manual for your specialty.
(California Provider Manuals)

Medicare

See Telemedicine Reimbursement Guide – Medicare Section

See Telemedicine Reimbursement Guide – Medicare Section

See Telemedicine Reimbursement Guide – Medicare Section

See Telemedicine Reimbursement Guide – Medicare Section

See Telemedicine Reimbursement Guide – Medicare Section

Private Payors

Private payors are actively exploring telemedicine and telehealth, but each provider is different. If you are in network with a specific provider, call and request documentation of their policy related to telehealth.

Self Pay

There are no limitations for self pay patients/clients, and providing telehealth services is a great way to increase revenue with patients that are selfpay or value premium services.

Provider Reimbursement Eligibility
Consent for Telemedicine
State Law

California law states that the provider at the originating site must obtain and document oral or written consent before performing any telemedicine services.

See California Health & Safety Code Sec. 2290.5.

Medicaid

The provider is to obtain and document, at minimum, oral consent.

See Page 2 Medi-Cal Telehealth Manual.

Medicare

See Telemedicine Reimbursement Guide – Medicare Section

Live Video Reimbursement
State Law

Private payers may reimburse for live video and Medi-Cal will reimburse for services provided via live video.
See California Health & Safety Code Sec. 1374.13

 

In-person contact between a health care provider and a patient shall not be required under the Medi-Cal program for services appropriately provided through telehealth, subject to reimbursement policies adopted by the department to compensate a licensed health care provider who provides health care services through telehealth that are otherwise reimbursed pursuant to the Medi-Cal program.

ARTICLE 4. The Medi-Cal Benefits Program [14131 – 14138]

Medicaid

Medi-Cal will reimburse for telemedicine services provided through means of live video.  Services must be billed with either a GT or 95 modifiers.

See Page 1 of the Medi-Cal Telehealth Manual.

Medicare

See Telemedicine Reimbursement Guide – Medicare Section

Store & Forward Reimbursement
State Law

Store & forward is included under California’s definition of telemedicine, so it is reimbursed the same.

See California Business & Professions Code Sec. 2290.5

Medicaid

Medi-Cal will reimburse store & forward when it is used for tele-dermatology, tele-dentistry and tele-ophthalmology.
See Page 6 of the Medi-Cal Telehealth Manual

Medicare

See Telemedicine Reimbursement Guide – Medicare Section

Originating Site & Transmission Fees
State Law

No health insurer shall limit the type of setting where services are provided for the patient or by the health care provider before payment is made for the covered services appropriately provided by telehealth, subject to the terms and conditions of the contract between the policyholder or contract holder and the insurer, and between the insurer and its participating providers or provider groups”.  This interpretation would include the home.

CA INSURANCE CODE – INS, Article 10123.85.  

Medicaid

The home is an eligible originating site.  “HSC Section 1374.13 states there is no limitation on the type of setting between a health care provider and a patient when providing covered services appropriately through a telehealth modality.”

The originating site facility fee is reimbursable when billed with code Q3014 (telehealth originating site facility fee).

Transmission costs incurred while providing telehealth services via
audio/video communication are reimbursable when billed with code T1014 (telehealth transmission, per minute, professional services bill separately).

See Page 1-3 of the Medi-Cal Telehealth Manual

Medicare

See Telemedicine Reimbursement Guide – Medicare Section

Eligible Practitioners
State Law

No Reference Found

Medicaid

To find out if your provider class is eligible for medicaid reimbursement reference the appropriate medicaid manual for your specialty.
(California Provider Manuals)

Medicare

See Telemedicine Reimbursement Guide – Medicare Section

Private Payors

Private payors are actively exploring telemedicine and telehealth, but each provider is different. If you are in network with a specific provider, call and request documentation of their policy related to telehealth.

Self Pay

There are no limitations for self pay patients/clients, and providing telehealth services is a great way to increase revenue with patients that are selfpay or value premium services.

Telemedicine CPT Codes

Unique CPT codes do not exist specifically for telemedicine or telehealth. Instead a modifier is applied to existing codes.

  • For interactive audio and video sessions, place a GT modifier in front of the CPT codes you typically use for in person services.
  • For services provided via an asynchronous telecommunication system, simply add a GQ modifier in front of the CPT codes you typically use for in person services.

Telehealth Parity

California does have a parity law that recognizes telemedicine as a legitimate way for an individual to receive health care services. Therefore, telemedicine is treated the same as in-person services.

See California Parity Laws

Definitions

Telehealth Parity

Telehealth services are equal to in person services and reimbursed at the same rate.

Asynchronous Communication

The exchange of messages, such as among the hosts on a network or devices in a computer, by reading and responding as schedules permit rather than according to some clock that is synchronized for both the sender and receiver or in real time. Email, chat and text messaging are primary examples of asynchronous communication.

Distant or Hub Site

The location or site where the practitioner or provider is located while utilizing telemedicine services to meet with patients.

Originating Site

The location of the patient at the time services are provided. An originating site can be the client's home or a public facility like a rural hospital or physician's office. Many payors will reimburse for an originating site fee if it meets specific requirements. Rural use cases provide an applicable example for an eligible originating site fee where the patient will go to a local medical facility like a primary care physician's office and meet with a specialist located in distant urban health facility.

Additional Telemedicine Resources

Telehealth and telemedicine are fast growing and changing segments. Both state licensure and state legislation are changing rapidly along with federal legislation and for this reason the information provided cannot be considered legal advice. We make every attempt to keep state specific information up to date, but encourage you to validate this information through the following sites: