Will there be additional guidance regarding the delivery of Mental Health services via telehealth? 

• According to the Telehealth Services Supplement, PSR may be delivered via telehealth.  However, the Mental Health manual defines PSR as being provided " to groups of individuals in a community, non-residential setting...".  If telehealth is to be used for PSR, most likely the recipient of the service will be in their own home during service delivery.  Will there be a requirement of in person attendance at PSR combined with telehealth visits? 
• Re: Case Management services, can the 90 day face to face be delivered via telehealth or must it be an in person face to face?  Is there a required number of in person face to face services for Case Management?  
• The Mental Health Manual states that the Comprehensive Needs assessment for PSR, Partial Hosp, ICT and Crisis Intervention may be conducted via Telehealth.  There is no mention of including CM in a comprehensive needs assessment conducted via telehealth, yet CM is listed as a medicaid covered mental health an substance use disorder service authorized for delivery by telemedicine in the telehealth services supplemental manual. 

Will there be guidance regarding consent given by individuals served?  We have a number of individuals in our Outpatient and medical services who would prefer to only be seen via telehealth.  Will it be acceptable to simply mark a checkbox indicating that verbal consent has been obtained, or will it be required to attempt to obtain a "wet" signature?  We frequently do not receive mailed documentation back and many of the people we serve do not have the necessary electronic devices to access emailed forms for signature. 

Will their be guidance on the language that will need to be used for verbal consent moving forward after the PHE  has ended? 

Will there be guidance on the restrictions of the member (individual with Medicaid) temporarily being out of Virginia and still being able to receive telehealth services during their travel. This is more for the Early Intervention targeted case management piece. 

Will there be guidelines on determining when 'telehealth' is appropriate or not? Early Intervention services are to occur in the home and I wanted to find out what parameters will be put in place to make sure families give fully informed consent for the services to be held via telehealth?

Fairfax- Falls Church Community Board Services agrees and supports all the comments to date below:

1. Member Choice and Education, Page 6:

If a Provider, whether at the originating site or distant site, maintains a consent agreement that specifically mentions use of telehealth as an acceptable modality for delivery of services including the information noted above, this shall meet DMAS’s required documentation of patient consent.

• Requesting clarification on Member Choice and Education, Page 6:

Please provide clarity and additional information around when an in-person visit is deemed clinically appropriate. Clarification regarding when telehealth is deemed not clinically appropriate in addition is needed.

2. Reimbursement and Billing for Telehealth Services, Page 3-4:

Telemedicine

Distant site Providers must include the modifier GT on claims for services delivered via telemedicine. Place of Service (POS), the two-digit code placed on claims used to indicate the setting, should reflect the location in which a telehealth service would have normally been provided, had interactions occurred in person. For example, if the member would have come to a private office to receive the service outside of a telehealth modality, a POS 11 would be applied. Providers should not use POS 02 on telehealth claims, even though this POS is referred to as “telehealth” for other payers. Place of service codes can be found at https://www.cms.gov/Medicare/Coding/place-of-service-codes/ Place _of_Service_Code_Set.

Store-and-Forward

Distant site Providers must include the modifier GQ. Place of Service (POS), the two-digit code placed on claims used to indicate the setting, should reflect the location where the distant site provider is located at the time that the service is rendered.

Originating Site Fee

Telemedicine In the event it is medically necessary for a Provider to be present at the originating site at the time a synchronous telehealth service is delivered, said Provider may bill an originating site fee (via procedure code Q3014) when both of the following conditions are met:

· The Medicaid member is located at a provider office or other location where services can be received (this does not include the member’s residence); and                                                                     

· The Provider (or the Provider’s designee), is affiliated with the provider office or other location where the Medicaid member is located and attends the encounter with the member. The Provider or designee may be present to assist with initiation of the visit but the presence of the Provider or designee in the actual visit shall be determined by a balance of clinical need and member preference or desire for confidentiality.

• Comments/feedback: Please consider and allow the use of other modifiers for services provided via telemedicine and distance site providers, as opposed to limiting modifiers to GT and GQ. The proposed change will exclude all other telehealth modifiers that are currently being utilized.

• Requesting clarification-Reimbursement and Billing for Telehealth Services, Page 3-4: Additional clarity and distinction around Telemedicine Distant site Providers, Store-and-forward Distant site providers, and Originating site is needed.

Reimbursement and Billing for Telehealth Services, Page 3-4:

Telemedicine

Distant site Providers must include the modifier GT on claims for services delivered via telemedicine. Place of Service (POS), the two-digit code placed on claims used to indicate the setting, should reflect the location in which a telehealth service would have normally been provided, had interactions occurred in person. For example, if the member would have come to a private office to receive the service outside of a telehealth modality, a POS 11 would be applied. Providers should not use POS 02 on telehealth claims, even though this POS is referred to as “telehealth” for other payers. Place of service codes can be found at https://www.cms.gov/Medicare/Coding/place-of-service-codes/ Place _of_Service_Code_Set.

Comments/Feedback: All other Third Party Group Health Plans and Medicare require the place of service for Telehealth to be billed as POS 02. If DMAS requires that this be billed using the POS that the service would have normally been provided this will require a significant amount of additional system configuration and set up for Providers and Plans. This will be compounded with the multiple lines of business the MCO plans have that covered Members are enrolled in. They include DSNP, CCC Plus, MED4 and Third Party Group Health Plans. Please consider the allowance or flexibility to use the POS 02  to ensure continuity for all lines of business and plans. With the expanded services covered under the supplement I am not sure the magnitude of what this would entail is understood.

Please consider and allow the use of other modifiers, as opposed to limiting modifiers to GT and GQ. The proposed change will exclude all other telehealth modifiers that are currently being utilized. Third Party, other Group Health Plans and DNSP plans require the use of a different modifier other than GT and GQ.

Please provide clarity to the licensure requirement for unlicensed staff.

"Providers must meet state licensure, registration or certification requirements per their regulatory board with the Virginia Department of Health Professions to provide services residents via telemedicine. Providers shall contact DMAS Provider Enrollment (888-829-5373) or the Medicaid MCOs networks for more information."

LBAs/LABAs are licensed by the Board of Medicine, and that includes supervision of unlicensed staff. My question was specific to the ability of those unlicensed staff to provide telehealth services after the state of emergency is lifted. It was a question that came up early in the Covid flexibilities and were told that yes, they were – just want to be sure of the process going forward.

Many agencies are building its behavioral health work force by hiring license eligible staff and other staff working towards a certification. I see no mention of how billing should be done if a license eligible provider  working under the supervision of a licensed credential provider renders telehealth services.   I recommend a section be included in the telehealth manual  to explain the service delivery of supervisees, to include things such as,  would the license provider have to be on the telehealth visit with the supervisee? What modifiers would be used for reimbursement?  

Member Choice and Education section: Will consent be required for each telehealth appointment or could a provider have a consent form signed annually. Will providers be allowed to document verbal consent or will we need to obtain a “wet signature” from the client. 

According to Table 2, Psychosocial Rehabilitation would be authorized for delivery by telemedicine. The DMAS definition states that Psychosocial Rehabilitation shall be provided at least two or more hours per day to groups of individuals in a nonresidential setting. Please provide guidelines for telehealth delivery.

According to Table 2, Case Management services would be authorized for delivery by telemedicine. Could a telehealth appointment replace the 90-day face-to-face service? Please provide guidelines for telehealth delivery.

Telemedicine:

Telemedicine must not be used when face-to-face services are medically and/or clinically necessary. The distant Provider is responsible for determining that the service meets all requirements and standards of care. Certain types of services that would not be expected to be appropriately delivered via telemedicine include, but are not limited to, those that: are performed in an operating room or while the patient is under anesthesia; require direct visualization or instrumentation of bodily structures; involve sampling of tissue or insertion/removal of medical devices; and/or otherwise require the in-person presence of the patient for any reason.

Clarification:

Do you mean to include services that “require direct visualization or instrumentation of bodily structures” as a standalone statement? This suggests that needing to see edema, for example, might need to be completed in person because it requires visualization. It also suggests that if you want to see range of motion on a knee, for example, it also requires an in person visit. Please modify this language to clarify specifically what needs to be seen in person and consider that visualization is precisely what can be accomplished with video.

Originating Site Fee:

 In the event it is medically necessary for a Provider to be present at the originating site at the time a synchronous telehealth service is delivered, said Provider may bill an originating site fee (via procedure code Q3014) when both of the following conditions are met: · The Medicaid member is located at a provider office or other location where services can be received (this does not include the member’s residence); and · The Provider (or the Provider’s designee), is affiliated with the provider office or other location where the Medicaid member is located and attends the encounter with the member. The Provider or designee may be present to assist with initiation of the visit but the presence of the Provider or designee in the actual visit shall be determined by a balance of clinical need and member preference or desire for confidentiality.

Clarification:

Traditional telemedicine specifically allowed the rendering of clinical care between a patient and a remote provider. These visits are often facilitated by a nurse at the originating site (with the patient) using peripherals (stethoscope, for example, to transmit real-time heart and lung sounds). Will the need to operate a telemedicine cart and peripherals qualify as “clinical need?” There often is no clinical need for a MD/ACP to be available to provider care to the patient at the originating site; only the need for a nurse to operate the video cart and the peripherals.

Thank You:

We appreciate that you include language that will allow an RHC, FQHC, or IHC to serve as a provider site, not only as an originating site.

Documentation Requirements:

When billing for an originating site, the originating site and distant site Providers must maintain documentation at the originating Provider site and the distant Provider site respectively to substantiate the services provided by each. When the originating site is the member’s residence or other location that cannot bill for an originating site fee, this requirement only applies to documentation at the distant site.

Clarification:

If a single appointment, with a provider at a distant site and a patient at an originating site, is scheduled as a single “Joint Appointment” in an electronic health record, will the recording of that visit, including both the provider and patient site check in, intake, and visit documentation, suffice as documentation for both the provider site and the originating site? In other words, the originating site nurse will be documenting in the single Joint Appointment that is a distant provider’s visit and documentation of record? There is not a separate formal documentation of an interaction at the originating site; only the single visit with components from the distant and originating sites.

Authorized Services:

OTP/OBOT Specific Services *Initial prescriber assessment for … buprenorphine induction allowed via telehealth during the Public Health Emergency.

Clarification:

Strongly advocate that this be allowed beyond the Public Health Emergency. If an in person visit is required, this may prohibit patients seeking the care that is needed because of this requirement.

We would like to extend our appreciation for DMAS’ recognition that telehealth and telemedicine services are beneficial and may increase access to services, particularly through the allowance of various community locations as Originating Sites.  Unfortunately, Attachment A provides insufficient detail for providers to move forward with using telehealth to provide Mental Health and Substance Use Disorder services, particularly those that are more intensive than Outpatient therapy and medication management.  Specific questions along these lines include:

• Is there a limit to the number of hours per week that an individual may participate in billable telehealth services for programs such as Assertive Community Treatment, Intensive Outpatient, Partial Hospitalization, and Psychosocial Rehabilitation?  If so, is this connected to a maximum number of units/hours or to a percent of service hours that may be provided via telehealth?
• Assertive Community Treatment requirements specify fidelity to a specific model.  How does the use of telehealth impact the level of fidelity?
• Please confirm that this allows for Case Management face-to-face contacts to be provided via telehealth.
• Is the DBHDS Office of Licensing in agreement with these changes? 
• As written, Attachment A implies that a provider could run entire programs virtually, if only people for whom telehealth is an acceptable modality for delivery of services are accepted.  However, these services are licensed by DBHDS as “center-based”.  Will providers be sanctioned by DBHDS Office of Licensing if services are only available via telehealth?   
• If the provider maintains a consent agreement, but 100% of services are provided virtually, will documentation that the consent agreement was reviewed and the individual provided verbal consent to participate in telehealth services be acceptable?
• Will DMAS accept verbal approval of/agreement with individual services plans if the discussion occurs during a telehealth service?  Will DBHDS Offices of Licensing and Human Rights accept this?  What about for other documentation where a participant signature has been required historically? If the service is provided via telehealth and in-person contact does not take place for several days, weeks, or months, will signatures obtained at that time be accepted if there is documentation of verbal agreement?
• Will DMAS provide additional guidance and resources regarding best-practices for implementing services that have traditionally relied on the benefits of a clinical milieu and peer support in community, nonresidential settings (e.g., psychosocial rehabilitation, day treatment, partial hospitalization) in shifting to greater use of telehealth services?

On a more general level:

• Will services provided be billable to DMAS if the individual is located outside of Virginia?
• What actions will DMAS take to ensure standardization across the various contracted MCOs regarding expectations in the provision of telehealth and telemedicine?

• Appreciate telehealth supplement being added!!
• Recommend “Telemedicine” be replaced by “Telehealth”, or, specifically include audio only as an option for behavioral healthcare services. Lower income and rural clients do not often have reliable video or internet capabilities. Audio only for example could be allowable for some services if an effort to reduce barriers, increase access. Especially important early in treatment for crisis services and case management.

• Recommend adding Telehealth option for coverage for:
  
  • Mental Health Skill building- will allow for more client choice and access when short-term barriers arise
  • Outpatient Crisis Stabilization- will allow for more client choice, access to clients when short-term barriers arise
  • Mobile Crisis- Recommend adding this as Mobile Crisis Medicaid service option will begin December 1^st through project BRAVO

Reimbursement and Billing for Telehealth Services, Page 3-4: Telemedicine

Distant site Providers must include the modifier GT on claims for services delivered via telemedicine. Place of Service (POS), the two-digit code placed on claims used to indicate the setting, should reflect the location in which a telehealth service would have normally been provided, had interactions occurred in person:  Feedback-other Third Party Payers, Group Health Plans, and Medicare require the place of service for Telehealth to be billed as POS 02. If DMAS requires that this be billed using the POS that the service would “have normally been provided” it will be inconsistent with other payers and require a significant amount of additional system configuration and set up for Providers and Plans. This will be compounded with the multiple lines of business that the MCOs cover, including DSNP, CCC Plus, MED4 and Commercial Products. Please consider the allowance or flexibility to use the POS 02  to ensure continuity for all lines of business and plans.

First of all, the publication of a telehealth supplement is very much appreciated.  This is much better information than the limited information in the Provider Memo issued in 2014.

Would recommend that 'telemedicine' be replaced with 'telehealth' As this provides a more global and generic reference for these services.  Also, please consider including audio only as an option for behavioral health services.  There is a need for audio only services in several areas of the State where rural and lower income clients lack access to internet services.  these are needed se4rvices that would both reduce barriers and increase access to these needed services.  This is especially important for early intervention and crisis services as well as for the coordination of care.  This would also serve to reduce transportation barriers for needed services.    

The telehealth supplement and additional guidance is much appreciated. Thank you. 

• Suggest that language of 'telemedicine' be replaced with 'telehealth' as this provides a more accurate reflection of the larger scope of services that are now being provided via telehealth capabilities
• Please consider allowing for an audio only option for behavioral health services. Recommend language could be added to allow for audio-only with the reasons for audio-only clearly documented in record. The audio only option has expanded access to care for so many in rural and low-income communities across the state. Many of these communities need behavioral health services but do not have reliable Internet access and/or smart phone capabilities to meet video requirements. These communities also face additional barriers such as lack of public transportation that makes in-person services challenging; telehealth including audio-only would have a positive impact.
• Telehealth option should also be available for assessment purposes (when appropriate) to allow for more immediate access to care, positively impacting Same Day Access initiatives across the state.
• Please provide clarification on expectations for signature requirements for services being provided via telehealth. Should verbal consent be immediately documented and written signatures attempted to be obtained within a certain timeframe?
• Please provide clarification on consent for telehealth services. Is the consent service-specific where each service that expects to provide services via telehealth will need to obtain written consent? Or does the consent to telehealth services cover multiple services within the same agency (for example, medication management, case management, and outpatient therapy)?

• Recommend “Telemedicine” be replaced by “Telehealth”, or, specifically, include audio-only as an option for behavioral healthcare services. Lower-income and rural clients do not often have reliable video or internet capabilities. Audio only for example could be allowable for some services if an effort to reduce barriers, increase access. Especially important early in treatment for crisis services and case management and when technical issues prevent video.
• Recommend adding Telehealth option for coverage for:
  • Assessment-More specifically, Mental Health and Substance Use comprehensive behavioral health assessment. Will allow quicker access to care and reduce transportation barriers.
  • Outpatient Crisis Stabilization- will allow for more client choice, access to clients when short-term barriers arise
  • Mobile Crisis- Recommend adding this as Mobile Crisis Medicaid service option will begin December 1^st through project BRAVO

Page 11: Concern with the wording of two elements listed as requirements under Care Coordination Requirements of Mental Health Providers

• Actively collaborating with all internal and external service providers to achieve open communication and integration of all needed services; Concern as “open communication and integration of all needed services” is broad and not well defined. Additionally, if the provider has made attempts at collaboration, but the other provider won’t, the trying provider is not meeting expectations. It appears to remove individuals’ choice for what gets communicated.
• Coordinating all services and supports, including all active treating service providers and the individual’s family members and significant others involved in the individual’s life. The inclusion of the word all active services and supports and treating service providers is a concern.  This is very broad and implies a dependency on providers to coordinate activities, rather than assuring individual choice and promoting independence.

I recommend deleting "trained facilitator" from the list of options for persons present during Early Intervention services.  A "trained facilitator" is not part of the Part C Early Intervention cadre of personnel.

What actions will DMAS take to ensure standardization across the various contracted MCOs for the expectations in the provision of telehealth/telemedicine services?