Billing for telephone and e-visits

As part of our initiative to support primary care providers in becoming patient-centered medical homes, Priority Health will reimburse, fee for service:

• 98966, 98967, 98968, 99441, 99442, 99443 (telephone visits, or phone assessments)
• 99444 (e-mail, or e-visits)

Read more about these reimbursement changes.

Requirements for telephone visits

The CPT manual defines billing and coding requirements for both the physician and the non-physician Qualified Health care Provider (QHP) telephone visit.

Read the PCMH policy on reimbursement for QHP phone visits (55KB PDF)

• Bill the non-physician QHP telephone visit under the participating PCP using codes 98966-98968.
• Priority Health defines QHPs as RNs, certified nurse practitioners, physician assistants, licensed Master's-level social workers (LMSWs), psychologists (both LLPs and PHDs), certified diabetes educators, registered dieticians and Master of Science-level trained nutritionists, clinical pharmacists and respiratory therapists.
• A participating PCP needs to be available to the QHP at the time of the telephone visit. "Available" can mean face-to-face, by phone, or by fax.
• QHPs may only assess patients within the scope of their licensure.
• When the patient initiates the call and the PCP or QHP returns the patient's call, it should be documented that way in the medical record.
• Copayments will not apply. 

Requirements for online medical evaluation visits ("e-visits")

"E-visits" are defined in the CPT manual, and their billing and coding requirements can be found there. In addition, Priority Health has created a medical policy on the use of e-visits (65KB PDF).

• You must use encrypted or authenticated e-mail for online medical evaluation visits. Standard e-mail is not acceptable, since it is not secure, has no "terms of use" or legal disclaimers in place to protect the provider, and can easily expose patient PHI including e-mail addresses to unintended third parties.
• Copayments will apply.
  

Requirements for reimbursement for phone and e-visits

• Payment will be made for all members of fully funded HMO, POS and PPO plans, with the exception of members with health savings accounts (HSAs).
• No modifier is necessary to bill these codes.
  
• These codes are not payable for members of self-funded or shared-funded plans.
• These codes are not payable for members of Medicare, Medicaid or MiChild plans.

Reimbursement rates

The reimbursement rates for these codes already exist in our standard fee schedules, based on your geographical region.
Call the Provider Help Line or your provider representative to request your region's fee schedule.


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