PURPOSE: This rule establishes coverage of the Telehealth spoke site facility fee and to 13 CSR 70-3

define services considered appropriate for this form of interactive technology from a hub site to a participant at a spoke site.

PUBLISHER’S NOTE: The secretary of state has determined that the publication of the entire text of the material which is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material. The entire text of the rule is printed here.

1. (1) Administration.

   1. (A) This rule is established pursuant to the authority granted to the Missouri Department of Social Services, MO HealthNet Division, to promulgate rules governing the practice of Telehealth in the MO HealthNet Program.

   2. (B) Definitions.

      1. 1. Community Mental Health Center

(CMHC) means a legal entity through which comprehensive mental health services are provided to individuals residing in a certain service area.

1. 2. Consultation means a type of evalua-

tion and management service as defined by the most recent edition of the Current Procedural Terminology published annually by the American Medical Association.

1. 3. Consulting provider means a provider

who evaluates the patient and appropriate medical data or images through a Telehealth mode of delivery, upon recommendation of the referring provider.

1. 4. CPT code means a code used for

reporting procedures and services performed by physicians or other licensed medical professionals which is published annually by the American Medical Association in Current Procedural Terminology.

1. 5. Department means the Department of

Social Services.

1. 6. Division means the MO HealthNet

Division, within the Department of Social Services.

1. 7. GT modifier means a modifier that

identifies a Telehealth service which is approved by the Healthcare Common Procedure Coding System (HCPCS).

1. 8. Health care provider means a:

   1. A. Missouri licensed physician;
   2. B. Missouri licensed advanced regis-

tered nurse practitioner;

1. C. Missouri licensed dentist or oral

surgeon;

1. D. Missouri community mental health

center;

1. E. Missouri licensed psychologist;
2. F. Missouri licensed pharmacist; or
3. G. Missouri licensed speech, occupa-

tional, or physical therapist.

1. 9. Hub site (originating site) means a

Telehealth site where the health care provider providing the Telehealth service is physically located at the time of the Telehealth service and is considered the place of service.

1. 10. MTN means the Missouri Telehealth

Network.

1. 11. Participant means an individual eli-

gible for medical assistance benefits on behalf of needy persons through MO Health- Net, under section 208.151, RSMo.

1. 12. Presenting provider means a provider

who:

1. A. Introduces a patient to a consulting

provider for examination, observation, or consideration of medical information; and

1. B. May assist in the telemedicine con-

sultation.

1. 13. Telepresenter means a person with

the patient during the time of the encounter who aids in the examination by following the orders of the consulting clinician, including the manipulation of cameras and appropriate placement of other peripheral devices used to conduct the patient examination.

1. 14. Referring provider means a provider

who evaluates a patient, determines the need for a consultation, and arranges the services of a consulting provider for the purpose of diagnosis or treatment.

1. 15. Spoke site (distant site) means a

Telehealth site where the MO HealthNet participant receiving the Telehealth service is located for the encounter. A spoke site must be one of the following locations:

1. A. Office of a physician or health care

provider;

1. B. Hospital;
2. C. Critical access hospital;
3. D. Rural health clinic;
4. E. Federally Qualified Health Center;
5. F. Nursing home;
6. G. Dialysis center;
7. H. Missouri State Habilitation Center

or Regional Center;

1. I. Community Mental Health Center;
2. J. Missouri state mental health facili-

ty; or

1. K. Missouri state facility.
2. 16. Telehealth means the use of medical

information exchanged from one (1) site to another via electronic communications to improve the health status of a patient. Telehealth means the practice of health care delivery, evaluation, diagnosis, consultation, or treatment using the transfer of medical data, audio visual, or data communications that are performed over two (2) or more locations between providers who are physically separated from the patient or from each other.

1. 17. Telehealth service means a medical

service provided through advanced telecommunications technology from a hub site to a participant at a spoke site.

1. 18. Two (2)-way interactive video means

a type of advanced telecommunications technology that permits a real time service to take place between a participant and a presenting provider or a Telepresenter at the spoke site and a health care provider at the hub site.

1. (2) Covered Services.

   1. (A) A Telehealth service shall be covered only if it is medically necessary.
   2. (B) A Telehealth service shall require use of two (2)-way interactive video and shall not include store and forward services. The participant must be able to see and interact with the off-site provider at the time services are provided via Telehealth.

   3. (C) The hub site (originating site) is the location where the physician or practitioner is physically located at the time of the Telehealth service. Coverage of services rendered through Telehealth at the hub site is limited to:

      1. 1. Consultations made to confirm a

diagnosis; or

1. 2. Evaluation and management services;

or

1. 3. A diagnosis, therapeutic, or interpre-

tive service; or

1. 4. Individual psychiatric or substance

abuse assessment diagnostic interview examinations; or

1. 5. Individual psychotherapy; or
2. 6. Pharmacologic management.
3. (D) The participant must be present for the encounter.

1. (3) Eligible Providers.

   1. (A) A health care provider utilizing Telehealth at either a hub site or a spoke site shall be enrolled as a MO HealthNet provider pursuant to 13 CSR 70-3.020 and licensed for practice in Missouri. A health care provider utilizing Telehealth must do so in a manner that is consistent with the provisions of all laws governing the practice of the provider’s profession.
   2. (B) A provider agrees to conform to MO HealthNet program policies and instructions as specified in the provider manuals, which are incorporated by reference and made a part of this rule as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, at its website www.dss.mo.gov/mhd, February 1, 2008. This rule does not incorporate any subsequent amendments or additions.

2. (4) Prior Authorization and Utilization Review. All services are subject to utilization review for medical necessity and program compliance. Reviews can be performed before services are furnished, before payment is made, or after payment is made.

   1. (A) Prior Authorization. Certain procedures or services can require prior authorization from the MO HealthNet Division or its authorized agents. Services for which prior authorization was obtained remain subject to utilization review at any point in the payment process. A service provided through Telehealth is subject to the same prior authorization and utilization review requirement which exist for the service when not provided through Telehealth.
   2. (B) Eligibility Determination. Prior authorization of services does not guarantee an individual is eligible for a MO HealthNet service. Providers must verify that an individual is eligible for a specific program at the time services are furnished and must determine if the participant has other health insurance.

3. (5) Reimbursement.

   1. (A) Reimbursement to the health care provider delivering the medical service at the originating site and the distant site are made at the same amount as the current fee schedule amount for the service provided without the use of a telecommunication system.
   2. (B) The claim for service will use the appropriate evaluation and management CPT code and the GT modifier indicating interactive communication was used.
   3. (C) The spoke site is eligible to receive a facility fee.
   4. (D) Services provided by practitioners must be within their scope(s) of practice and according to MO HealthNet policy.
   5. (E) Reimbursement for services furnished by interns or residents in hospitals with approved teaching program or services furnished in other hospitals that participate in teaching programs is made through institutional reimbursement. The division cannot be billed directly by interns or residents for Telehealth services.

4. (6) Documentation for the Encounter. Patient records at the hub and spoke sites are to document the Telehealth encounter consistent with the service documentation described in MO HealthNet provider manuals.

   1. (A) A request for a Telehealth service from a referring provider and the medical necessity and Procedure of General Applicability

for the Telehealth service shall be documented in the participant’s medical record.

1. (B) A health care provider shall keep a complete medical record of a Telehealth service provided to a participant and follow applicable state and federal statutes and regulations for medical record keeping and confidentiality in accordance with 13 CSR 70- 3.020.

2. (C) Documentation of a Telehealth service by the health care provider shall be included in the participant’s medical record maintained at the participant’s location and shall include:

   1. 1. The diagnosis and treatment plan

resulting from the Telehealth service and progress note by the health care provider;

1. 2. The location of the hub site and spoke

site;

1. 3. A copy of the signed informed con-

sent form; and

1. 4. Documentation supporting the medi-

cal necessity of the Telehealth service.

1. (7) Confidentiality and Data Integrity. All Telehealth activities must comply with the requirements of the Health Insurance Portability and Accountability Act of 1996 and all other applicable state and federal laws and regulations.

   1. (A) A Telehealth service shall be performed on a secure telecommunications line or utilize a method of encryption adequate to protect the confidentiality and integrity of the Telehealth service information.
   2. (B) Both a hub site and a spoke site shall use authentication and identification to ensure the confidentiality of a Telehealth service.

   3. (C) A provider of a Telehealth service shall implement confidentiality protocols that include:

      1. 1. Identifying personnel who have

access to a Telehealth transmission; and

1. 2. Preventing unauthorized access to a

Telehealth transmission.

1. (D) A provider’s protocols and guidelines shall be available for inspection by the department upon request.

1. (8) Informed Consent.

   1. (A) Before providing a Telehealth service to a participant, a health care provider shall document written informed consent from the participant and shall ensure that the following written information is provided to the participant in a format and manner that the participant is able to understand:

      1. 1. The participant shall have the option

to refuse the Telehealth service at anytime without affecting the right to future care or treatment and without risking the loss or 13 CSR 70-3

withdrawal of a MO HealthNet benefit to which the participant is entitled;

1. 2. The participant shall be informed of

alternatives to the Telehealth service that are available to the participant;

1. 3. The participant shall have access to

medical information resulting from the Telehealth service as provided by law;

1. 4. The dissemination, storage, or reten-

tion of an identifiable participant image or other information from the Telehealth service shall not occur without the written informed consent of the participant or the participant’s legally authorized representative;

1. 5. The participant shall have the right to

be informed of the parties who will be present at the spoke site and the hub site during the Telehealth service and shall have the right to exclude anyone from either site; and

1. 6. The participant shall have the right to

object to the videotaping or other recording of a Telehealth service.

1. (B) A copy of the signed informed consent shall be retained in the participant’s medical record and provided to the participant or the participant’s legally authorized representative upon request.
2. (C) The requirement to obtain informed consent before providing a service shall not apply to an emergency situation if the participant is unable to provide informed consent and the participant’s legally authorized representative is unavailable.

AUTHORITY: section 208.201, RSMo Supp. 2007.* Original rule filed Jan. 2, 2008, effective Aug. 30, 2008.

*Original authority: 208.201, RSMo 1987, amended 2007.