State and School Employees' Health Insurance Plan - Telehealth: Participant-Initiated to Provider Online Evaluation and Management Services

POLICY NUMBER

L.2.04.441

DESCRIPTION

Online medical evaluations and management services are not in-person but are evaluation and management services by an Advanced Health System, Inc. (AHS) Network Provider in response to a Participant’s online inquiry accessed through a secured internet site.

AHS Network Providers have a limited ability to interact with Participants through a secured electronic audio visual online communication resource, which resource is established by the AHS Network Provider and made available to the Participant. It is a low complexity clinician interactive visit to address urgent but not emergent clinical conditions. The AHS Network Provider consults with the patient regarding their symptoms and advises treatment, including but not limited to; prescriptions, medical advice and/or medical referral. Examples of an online visit would include, but are not limited to: upper respiratory infections such as colds, sore throat runny nose, sinus congestion and seasonal allergies.

POLICY

Participant-Initiated to Provider Online Evaluation and Management Services

An online medical evaluation and management visit is considered medically necessary if all of the following criteria are met:

1. The visit is performed by AmWell, OR

2. The visit is performed by an AHS Network Provider with electronic audio visual online communication resource visit capabilities, AND

3. The patient initiates the medical encounter through the AHS Network Provider’s electronic audio visual online communication resource resource, AND

4. The visit is a low complexity, straight forward decision making encounter which addresses an urgent but not emergent clinical condition.

POLICY EXCEPTIONS

None

POLICY GUIDELINES

Medical Policy Manual coverage guidelines should not be used in lieu of the Participant's specific benefit plan language outlined in the Mississippi's State and School Employees’ Life and Health Insurance Plan.

Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Participant's illness, injury or Mental Health Disorders, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:

A. consistent with the symptoms or diagnosis and treatment of the Participant’s condition, illness, or injury; and

B. appropriate with regard to standards of good medical practice; and

C. not solely for the convenience of the Participant, his or her Provider; and

D. the most appropriate supply or level of care which can safely be provided to the Participant. When applied to the care of an Inpatient, it further means that services for the Participant’s medical symptoms or conditions require that the services cannot be safely provided to the Participant as an Outpatient.

For the definition of Medically Necessary, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.

POLICY HISTORY

01/22/2018: New policy added.

05/17/2018: Medical policy link updated in policy description.

07/03/2018: Added medical policy link in policy description.

09/25/2018: Policy links updated.

12/21/2018: Code Reference section updated to add new HCPCS codes G0071 and G2012, effective 01/01/2019.

12/19/2019: Code Reference section updated to add CPT codes 99421, 99422, and 99423 effective 01/01/2020.

03/26/2025: Policy reviewed. Policy statements unchanged. Policy Guidelines updated. Code Reference section updated to remove deleted CPT code 99444.

01/01/2026: Code Reference section updated to note deletion of G0071 effective 12/31/2025.

SOURCE(S)

1. Miss. Code Ann. §83-9-351

2. Mississippi Administrative Code, Title 30, Part 2635, Chapter 5

3. Centers for Medicare & Medicaid Services Medicare Learning Network Telehealth Services Fact sheet

CODE REFERENCE

This may not be a comprehensive list of procedure codes applicable to this policy.

The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.

Covered Code

CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.