North Carolina

MASTER MEDICAID TELEHEALTH LAWS
WITH THE HELP FROM GD

Summary

“NC Medicaid reimburses live video telemedicine for medical and tele-psychiatry services as long as certain conditions are met. They do not provide reimbursement for store-and-forward, and make no reference to remote patient monitoring.

 

Definitions

“Telemedicine is the use of two-way real-time interactive audio and video between places of lesser and greater medical capability or expertise to provide and support health care, when distance separates participants who are in different geographical locations.”

Source: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telemedicine and Telepsychiatry, p. 1, March 15, 2019. (Accessed Apr. 2019).

Live Video

Policy

North Carolina Medicaid and NC Health Choice will reimburse for live video medical services and tele-psychiatry services. All of the following conditions must be met:
• The beneficiary must be present at the time of consultation;
• The medical examination must be under the control of the consulting provider;
• The distant site of the service must be of a sufficient distance from the originating site to provide services to a beneficiary who does not have readily available
access to such specialty services; and
• The consultation must take place by two-way real-time interactive audio and video
telecommunications system.

Source: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telemedicine and Telepsychiatry, p. 4, March 15, 2019 (Accessed Apr. 2019).
Eligible Services / Specialties

All services must be:
• Medically necessary;
• The procedure, product, or service is individualized, specific, and consistent with
symptoms or confirmed diagnosis of the illness or injury under treatment, and not
in excess of the recipient’s needs;
• The procedure, product, or service can be safely furnished, and no equally effective and more conservative or less costly treatment is available statewide;
• The procedure, product, or service is furnished in a manner not primarily intended
for the convenience of the recipient, the recipient’s caretaker, or the provider.
Distant site providers must obtain prior approval from NC Medicaid for services delivered via telemedicine and telepsychiatry when those services require prior approval based on service type or diagnosis. Providers must submit:
• Prior approval request
• All health records and any other records to document that the patient has met the
specific criteria for telemedicine services Special provisions apply for the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) program. See manual.

Source: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telemedicine and Telepsychiatry, p. 1-7, March 15, 2019 (Accessed Apr. 2019).

 

Teledentistry
Synchronous real-time dentistry is covered through D9995.

Source: NC Div. of Medcial Assistance. Medicaid Bulletin. p. 22, Jan. 2018. (Accessed Apr. 2019).
Eligible Providers

Eligible medical providers:
• Physicians;
• Nurse practitioners;
• Nurse midwives;
• Physician’s assistants.
Eligible tele-psychiatry providers:
• Physicians;
• Nurse Practitioners;
• Physicians Assistants;
• Advanced practice psychiatric nurse practitioners;
• Advanced practice psychiatric clinical nurse specialists;
• Licensed psychologists Ph.D. level;
• Licensed clinical social workers (LCSW);
• Community diagnostic assessment agencies.

Source: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telemedicine and Telepsychiatry, p. 6, March 15, 2019 (Accessed Apr. 2019).

 

System changes have been completed to allow non-psychiatric Nurse Practitioners (NPs) and Physician Assistants (PAs) to receive reimbursement for the following CPT codes.
• 90791 – Psychiatric diagnostic evaluation
• 90792 – Psychiatric diagnostic evaluation with medical services
NPs and PAs enrolled in the Medicaid or North Carolina Health Choice (NCHC) programs
may bill Medicaid or NCHC for these services.

Source: NC Div. of Medical Assistance, NC Medicaid Bulletin: July 2018. p. 10 (Accessed Apr. 2019).
Geographic Limits

“The distant site of the service must be of a sufficient distance from the originating site to provide services to a beneficiary who does not have readily available access to such specialty services.”
No reimbursement if:
• The recipient is located in a jail, detention center, or prison.
• The consulting provider is not a Medicaid-enrolled provider; the consulting provider does not follow established criteria for the service provided.
.

Source: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telemedicine and Telepsychiatry, p. 4-5, March 15, 2019 (Accessed Apr. 2019).
Facility/Transmission Fee

Originating-site provider facility fees paid to:
• Physicians;
• Nurse practitioners;
• Nurse midwives;
• Advanced practice psychiatric nurse practitioners;
• Advanced practice psychiatric clinical nurse specialists;
• Licensed psychologists (Ph.D. level);
• Licensed clinical social workers (LCSW);
• Physician’s assistants;
• Hospitals (inpatient or outpatient);
• Federally Qualified Health Centers;
• Rural Health Clinics;
• Local health departments;
• Local Management Entities.
No facility fees for distant-site providers.

 

Source: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telemedicine and Telepsychiatry, p. 4, 7, March 15, 2019 (Accessed Apr. 2019).

Store-and-Forward

Policy

North Carolina Medicaid will not reimburse for store-and-forward.

Source: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telemedicine and Telepsychiatry, p. 4-5, March 15, 2019 (Accessed Apr. 2019).
Email / Phone / Fax

No reimbursement for email.
No reimbursement for telephone.
No reimbursement for FAX.

Source: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telemedicine and Telepsychiatry, p. 4-5, March 15, 2019 (Accessed Apr. 2019).
Miscellaneous

Criteria for eligible beneficiaries:
• Must be enrolled in the NC Medicaid program or NC Health Choice
• Providers must verify each Medicaid or NCHC beneficiary’s eligibility each time a service is rendered
• The Medicaid beneficiary may have service restrictions due to their eligibility category that would make them ineligible for the NCHC Program
• Children must be between the ages of 6-18 (one of many restrictions in program)
Other Limitations:
• The referring provider must participate in the service as appropriate to meet the medical needs of the beneficiary
• Up to three different consulting providers may be reimbursed for a separately identifiable telemedicine or telepsychiatry service per date of service
• Only one facility fee is allowed per date of service per beneficiary
• There is no reimbursement to the referring provider at the originating site on the same date of service unless the referring provider is billing for a separately identifiable billable service.
• Health records must document that all the components of the service being billed were
provided
• These services are subject to the same restrictions as face-to-face contacts./p>

Source: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telemedicine and Telepsychiatry, p. 1-6, March 15, 2019 (Accessed Apr. 2019).

&nsbp;

The Office of Rural Health and Community Care shall oversee and monitor the establishment of a statewide telepsychiatry program.

Source: NC General Statutes Article 3, Ch. 143B, Sect. 12A.2B. (b). (Accessed Apr. 2019).

&nsbp;

Providers must comply with the following in effect at the time the service was rendered:
• All applicable agreements, federal, state and local laws and regulations including HIPAA and medical retention requirements.
• All Medicaid’s clinical coverage policies, guidelines, policies, provider manuals, implementation updates and bulletins published by CMS, DHHS, its divisions or its fiscal agent.

Source: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telemedicine and Telepsychiatry, p. 7, March 15, 2019 (Accessed Apr. 2019).

Professional Regulation /
Health & Safety

Definitions

Maternal and Child Health and Women’s Health
Telemedicine is the use of audio and video between places of lesser and greater medical capability or expertise to provide and support health care when distance separates participants who are in different geographical locations.

Source: NC General Statute 130A-125(b2)(1). (Accessed Apr. 2019).
Miscellaneous

Telemedicine may be utilized for neonatal or infant echocardiograms.

Source: 10A N.C.A.C. 43K.0102(c)(3). (Accessed Apr. 2019).

 

Telemedicine may be used to perform the initial examination required when an individual comes into custody of law enforcement.

Source: N.C. Gen. Stat. § 122C-263(c). (Accessed Apr. 2019).

 

Department of Health and Human Services required to study and recommend a telemedicine policy for consideration by the General Assembly & study the Psychology Interjurisdictional Compact. The study was submitted on October 1, 2017.

Source: HB 283 (Session Law 2017-133). (Accessed Apr. 2019).

 

The Commission is required to address follow-up protocols to ensure early treatment for newborn infants diagnosed with congenital heart defects, to include telemedicine (live video).

Source: NC General Statute 130A-125(b2)(1). (Accessed Apr. 2019).
Cross-State Licensing

Member of the Physical Therapy Compact

Source: PT Compact. Compact Map. HB 57 (2017). (Accessed Apr. 2019).

 

Member of the Nurses Licensure Compact.

Source: Current NLC States & Status. Nurse Licensure Compact. (Accessed Apr. 2019).

Contact us to discuss your telehealth initiatives in North Carolina


[recaptcha]

*Required