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Anthem Blue CrossTelehealth Program
Provider Manual
Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 2
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Table of Contents Provider Manual
Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 3
Chapter 1: Introduction to Telehealth ....................................................................... 7
Overview ........................................................................................................................................... 7
Telehealth Program Objectives ........................................................................................................ 8
Telehealth Consultations .................................................................................................................. 8
Open Access Network Model............................................................................................................ 9
Readiness Disclosure Statement .................................................................................................... 10
Misrouted Protected Health Information ...................................................................................... 10
Chapter 2: Telehealth Contacts ................................................................................ 11
Telehealth Department Contacts .................................................................................................... 11
Technical Support for Systems and Software ................................................................................. 11
Provider/Member Services ............................................................................................................ 12
Utilization Management Services ...................................................................................................13
Vision Service Plan ..........................................................................................................................13
Chapter 3: Frequently Asked Questions ...................................................................14
What is Telehealth? ........................................................................................................................ 14
Why Use Telehealth? ...................................................................................................................... 14
What is Anthem Blue Cross’ Telehealth Program? ......................................................................... 15
What Types of Specialists Are Available? ....................................................................................... 15
How Does It Work? ......................................................................................................................... 15
For Live Video Telehealth: ........................................................................................................... 15
For Store and Forward Telehealth: ............................................................................................. 16
What Documentation is Required? ................................................................................................ 16
Whom Do I Call with Questions? ................................................................................................... 16
Chapter 4: Site Locations ......................................................................................... 17
Step‐By‐Step Instructions ............................................................................................................... 17
Chapter 5: Roles and Responsibilities ......................................................................19
Anthem Blue Cross ......................................................................................................................... 19
Presentation Sites ........................................................................................................................... 19
Table of Contents Provider Manual
Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 4
Specialty Centers ............................................................................................................................ 20
Chapter 6: When to Choose Telehealth .................................................................... 21
Assessing Telehealth Services ........................................................................................................ 21
Evaluating Telehealth Opportunities.......................................................................................... 21
Assessment for Appropriate Type of Telehealth Consultation .................................................. 23
Chapter 7: How to… ................................................................................................ 24
Refer a Patient for Telehealth Services .......................................................................................... 24
Assess the Patient’s Appropriateness for Telehealth Services ................................................... 24
Request Patient’s Verbal Consent for a Telehealth Consult ....................................................... 24
Request a Consultation ............................................................................................................... 25
Determine Appropriate Consultant Type ................................................................................... 25
Prepare and Schedule a Telehealth Encounter .............................................................................. 26
After Sending the Store and Forward Consultation Request ..................................................... 26
Schedule the Telehealth Consultation ........................................................................................ 27
Finalize Details ‐ One Day Prior to the Scheduled Appointment ............................................... 27
Finalize Details ‐ Immediately Before the Scheduled Appointment .......................................... 28
Conduct a Telehealth Consultation ................................................................................................ 28
During the Patient’s Appointment .............................................................................................. 28
Post Consultation ........................................................................................................................... 30
Evaluate and Implement the Recommended Treatment Plan from the Telehealth Specialist .... 30
Chapter 8: Claims and Billing ................................................................................. 32
Overview ......................................................................................................................................... 32
Electronic Professional Billing ....................................................................................................... 33
Anthem Blue Cross Utilization Controls and Procedures ............................................................. 33
Telehealth Billing for California Programs .................................................................................... 34
Fee Schedule ................................................................................................................................ 34
Modifiers ..................................................................................................................................... 34
Billable Codes for Telehealth ...................................................................................................... 35
Table of Contents Provider Manual
Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 5
Telecommunication Charges ...................................................................................................... 35
Billable CPT Codes for Live Video Telehealth Encounters ........................................................ 36
Site Fees for Live Video ............................................................................................................... 36
Billable Codes for Store and Forward Telehealth Encounters ...................................................... 37
Telecommunication Charges ...................................................................................................... 37
Specialists .................................................................................................................................... 37
Site Fees for Store and Forward ................................................................................................. 37
Submitting Telehealth Claims .................................................................................................... 38
Chapter 9: Developing Telehealth Medical Record Documentation ......................... 47
Introduction.................................................................................................................................... 47
Monitoring Usage and Reporting to Anthem Blue Cross .............................................................. 48
What Anthem Blue Cross Monitors ............................................................................................ 48
What You Should Report ............................................................................................................ 49
When You Should Report ........................................................................................................... 49
Telehealth Information Forms ....................................................................................................... 50
Telehealth Consultation Summary Form ................................................................................... 50
Telehealth Utilization Log ........................................................................................................... 50
Instructions for Completing the Utilization Log ........................................................................ 50
Patient Satisfaction Survey .......................................................................................................... 51
Chapter 11: Telehealth Program Glossary ............................................................... 52
Telehealth Information Forms ....................................................................................................... 54
Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 6
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Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 7
Chapter 1: Introduction to Telehealth
Provider Manual
Overview Anthem Blue Cross develops, manages, and comprehensively supports a statewide Telehealth
program in California to improve access to care
for rural populations. Anthem Blue Cross
facilitates access to Telehealth services, facilities
and technology through this program. These
Telehealth services are currently available to the
following member populations:
• CalPERS Basic Plan members residing in rural ZIP codes. Anthem Blue Cross administers
the CalPERS Basic Plan on behalf of Anthem Blue Cross Life and Health Insurance
Company. Anthem Blue Cross administers claims on behalf of Anthem Blue Cross Life
and Health Insurance Company but is not financially liable for benefits payable.
• Prudent Buyer PPO members residing in rural ZIP codes. Anthem Blue Cross administers
Prudent Buyer plans on behalf of Anthem Blue Cross Life and Health Insurance
Company. Anthem Blue Cross administers claims on behalf of Anthem Blue Cross Life
and Health Insurance Company but is not financially liable for benefits payable. The
following Prudent Buyer groups are eligible for the Telehealth benefit:
Blue Cross’ PPO Butte Schools Self-funded Program
Blue Cross’ PPO California’s Valued Trust (CVT)
Blue Cross’ PPO Self-Insured Schools of California (SISC)
Blue Cross’ PPO University of California (UC)
• County Medical Services Program (CMSP) with claims administered by Anthem Blue Cross Life and Health Insurance Company
• Anthem Blue Cross Medi-Cal Managed Care Plans
• Access for Infants and Mothers (AIM) program
Please note: the specific terms, conditions and limitations of Telehealth benefits are
dependent on the terms of the member’s particular coverage. Review your Service
Agreement Amendment Exhibit A to check the status of Anthem Blue Cross members
participating in the Telehealth benefit or call the Customer Service Center to check
benefit eligibility.
Chapter 1: Introduction to Telehealth
Provider Manual
Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 8
Telehealth Program Objectives
The objectives of Anthem Blue Cross’ Telehealth program are to:
• Increase access to care in rural areas
• Improve timeliness to diagnosis and treatment planning
• Improve quality of care
• Support the continued education and retention of rural providers
Telehealth is a health care delivery method that applies high-speed telecommunication
systems, computer technology and specialized medical cameras to examine, diagnose, treat and
educate patients at a distance. For example, through a Telehealth encounter, a patient in the
Sierra Mountains may seek medical treatment from a provider or specialist in Los Angeles or
San Francisco without incurring the expense of traveling to such distant locations.
Telehealth Consultations
While the application of Telehealth varies based on the specialty consultation needed, the two
methods of Telehealth encounters used in Anthem Blue Cross’ Telehealth program are:
Live Video (simultaneous) consultation: Connects the patient, primary care provider
(PCP) and specialist at the same time with video conferencing equipment to discuss
the patient’s medical condition
Store and Forward (asynchronous) consultation: Uses software to store and encrypt
the pertinent medical data and images. The presentation site then transmits the
secured data electronically to the specialist for review and consultation.
Chapter 1: Introduction to Telehealth
Provider Manual
Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 9
Open Access Network Model
Unlike the traditional Telehealth structure of one specialty location working with multiple
sites, Anthem Blue Cross’ Telehealth Program is based on an innovative Open Access Network
Model. This Open Access Network creates a web of access points throughout the state based on
a combination of strategic alliances with successful existing Telehealth programs and the
creation of new Telehealth locations.
The primary care sites, or presentation sites, are strategically located in areas with high rural
Prudent Buyer PPO, CalPERS Basic Plan, CMSP, AIM and Medi-Cal Managed Care
membership; locations with existing Telehealth programs; and areas with significant barriers
to access. Sites are equipped with computers, video monitors, telephone lines and cameras
needed to present a member’s exam, symptoms and condition to a provider or specialist with
video conference or special software and/or a secure Internet site. The Open Access Network
includes alliances with provider and specialist resources such as large academic medical
centers, tertiary care centers and private practices with high-quality clinical capability, specific
Telehealth technology and the enthusiasm to provide care through this innovative delivery
method. The Open Access Network offers unprecedented health care flexibility:
It enables presentation sites to connect to each other – primary care to primary care for
peer review, collaboration and educational opportunities
It connects presentation sites directly to any one of the specialty locations for diagnosis,
consultations and reviews
If services are not readily available at one specialty location, another location can be
contacted for a Telehealth consultation, essentially creating more support for Prudent
Buyer PPO, CalPERS Basic Plan, CMSP, AIM and Medi-Cal Managed Care rural
members
It enables the addition of new locations or specialty resources as the need arises
Chapter 1: Introduction to Telehealth
Provider Manual
Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 10
Open Network Model Diagram
Readiness Disclosure Statement
Anthem Blue Cross' latest Health Insurance Portability and Accountability Act of 1996
(HIPAA)-compliant privacy and security statements can be found on our website at
www.anthem.com/ca> Providers > Under Learn More select State Sponsored Plans
> Under Standards and Policies choose HIPAA Readiness Disclosure Statement.
Misrouted Protected Health Information
Protected Health Information (PHI) can be misrouted to Providers and facilities by mail, fax, e-
mail, or electronic Remittance Advice. Providers and facilities are required to destroy
immediately any misrouted PHI or safeguard the PHI for as long as it is retained.
Important Note: You are not permitted to use or disclose Protected Health Information about
individuals that you are not currently treating or have enrolled to your practice. This applies to
Protected Health Information accessible in any Anthem Blue Cross online tool, or sent in any
medium including mail, email, fax or other electronic transmission.
Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 11
Chapter 2: Telehealth Contacts
Provider Manual
Telehealth Department Contacts
The following are contacts for the Telehealth department:
Phone: ..................................................................................... 1-866-855-2271
Fax: .......................................................................................... 1-805-987-0736
Email: ............................................................ca.telemedicine@anthem.com
Website: ....................................................... anthem.com/ca/telemedicine
Mail: ......................................................................................................................
Attn: Telehealth Department
Anthem Blue Cross
One WellPoint Way, CAT201-M002
Thousand Oaks, CA 91361
Contact us when:
You have any questions regarding the Telehealth Program
You need a revised monthly schedule of appointments available by specialty location
Technical Support for Systems and Software
Please contact the Telehealth department if:
You have technical difficulties
You have questions about equipment, such as hardware, software, medical devices or
telephone lines
Chapter 2: Telehealth Contacts
Provider Manual
Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 12
Provider/Member Services
Use the following telephone numbers to contact provider and member services:
CalPERS:………………………………………..………………………………………………….……. 1-877-737-7776
Prudent Buyer PPO: …………………………….………………………………………..………… 1-800-627-5342
California Valued Trust (CVT): ……………………………………….….. 1-800-677-6669 (Providers)
1-800-234-4333 (Members)
Self-Insured Schools of California (SISC):
Kern County……………………………………………………………………………………. 1-800-322-5709
Tulare and Kings Counties ……………………………………………………….……….. 1-559-734-1321
Coastal Healthcare Administrators……………………………………………….……. 1-800-564-7475
Rancho Cordova……………………………………………………………………….………. 1-800-365-0020
Los Angeles ……………………………………………………………………………..………. 1-800-825-5541
University of California (UC) ……………………………………………………….……. 1-888-209-7975
County Medical Services Program (CMSP)……………………………………….………… 1-800-670-6133
Medi-Cal (outside Los Angeles County) ………………………………………………………. 1-800-407-4627
Medi-Cal (inside Los Angeles County) ………………………………………………..……… 1-888-285-7801
AIM Program: …………………………………………………………………………………..…….. 1-800-433-2611
Call the appropriate program’s number when:
You need to verify eligibility
You need customer service related to Prudent Buyer PPO, California Public Employees’ Retirement System (CalPERS) Basic Plan, County Medical Services Program (CMSP), AIM Program or Medi-Cal Managed Care plans
You have questions regarding Prudent Buyer PPO, CalPERS Basic Plan, and CMSP, AIM Program or Medi-Cal Managed Care benefits
You have questions or issues regarding billing and claims
Chapter 2: Telehealth Contacts
Provider Manual
Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 13
Utilization Management Services
Use the following telephone numbers to contact utilization management services:
County Medical Services Program (CMSP)……………………………………….………… 1-800-273-4193
AIM Program and Medi-Cal Managed Care: ………………………………………………. 1-888-831-2246
CalPERS…………………………………………………………………………………………..……… 1-877-737-7776
Prudent Buyer PPO: …………………………………………………………………………..…….. 1-800-274-7767
Call these numbers when:
You need utilization management
You need preservice review (prior authorization)
Vision Service Plan
Use the following telephone number to contact:
Vision Service Plan (VSP) Customer Care: …………………………………………..……… 1-800-877-7195
Call these numbers when you have questions or issues regarding:
Optometry services
Billing or claims
Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 14
Chapter 3: Frequently Asked Questions
Provider Manual
What is Telehealth?
“Telehealth” means the mode of delivering health care services and public health utilizing the
combination of HIPAA compliant information and communication technologies to enable the
diagnosis, consultation, treatment, education, care management and self-management of
patient at a distance from health care providers. Telehealth does not include the use of audio-
only telephone, facsimile machine or e-mail pursuant to the provider and/or the member
contract.
A Telehealth consultation can be done in one of two ways:
Live Video: The primary care provider (PCP), the patient and a specialist meet at the same time using video and telephone equipment
Store and Forward/Secure website: An image of the patient’s condition is taken and sent electronically to the specialist for review
Why Use Telehealth?
Telehealth gives a rural patient better access to specialty care. Patients in rural areas often have a difficult time seeing a specialist because:
There are no specialists in the area
They have to travel a great distance to see a specialist
They have to take time off from work or school
They have to wait a long time to schedule an appointment
They are uncomfortable with seeing someone other than their regular doctor
Telehealth helps to address these challenges by connecting the specialist and the patient using technology.
Chapter 3: Frequently Asked Questions Provider Manual
Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 15
What is Anthem Blue Cross’ Telehealth Program?
Since 1998, Anthem Blue Cross has sponsored a Telehealth network throughout California. The Telehealth program has:
Over 60 presentation sites (clinics, doctor’s offices and other locations)
Over 18 specialty locations (university hospitals, leading medical centers, specialist offices)
Based on how it was developed, any presentation site can meet with any specialist regardless of
where the specialist is located. It is an open network.
What Types of Specialists Are Available?
More than 25 specialties are available for Telehealth appointments. The top five most common
specialties used for Telehealth are optometry, psychiatry, dermatology, endocrinology and
pediatric neurology.
How Does It Work?
There are two main types of Telehealth consultations. We describe both briefly, below.
For Live Video Telehealth:
The following are reasons why PCP’s use Live Video Telehealth consultations:
The patient’s primary care physician decides that a specialist is needed and that it may
be best to use Telehealth equipment
The patient agrees to a Telehealth appointment rather than going to the specialist in person
The presentation site schedules the Telehealth appointment and provides all of the information to the specialist
During the appointment, the patient and his/her medical case are “presented” by the presentation site provider or staff to the specialist using the video camera
The specialist makes recommendations to help the patient
Chapter 3: Frequently Asked Questions Provider Manual
Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 16
For Store and Forward Telehealth:
The following are reasons why primary care physicians use Store and Forward Telehealth
consultations:
The patient’s primary care physician decides that a specialist should know about the
patient’s condition
The patient agrees to have an electronic image taken of his/her medical condition
The presentation site forwards the patient’s information and images to the specialist for review
The specialist makes recommendations about the patient’s condition to the primary care physician
What Documentation is Required?
The following documentation is required to participate in a Telehealth session:
The patient must give verbal authorization for his/her doctor to use Telehealth, which the doctor then documents in the patient’s medical record
The presentation site submits forms to Anthem Blue Cross to describe what Telehealth events have been done
The presentation site and specialty location submit claim forms to Anthem Blue Cross for payment of the Telehealth consultation
Whom Do I Call with Questions?
Telehealth department toll free number ………………………………………….…… 1-866-855-2271
Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 17
Chapter 4: Site Locations
Provider Manual
For a list of all Site Locations, click here.
Step‐By‐Step Instructions
To navigate Anthem Blue Cross’ website manually to see specialty and presentation sites, and sites by county, enter anthem.com/ca/telemedicine into your Internet browser, or follow these instructions:
1. Enter anthem.com/ca into your Internet browser.
2. Click Providers.
3. Under the heading Learn More, select the Telehealth Services link.
4. From this page, click the Telemedicine Site Locator link.
5. This opens the Telemedicine Site Locator page. Choose from the following
selections:
Specialty Sites
Presentation Sites
Sites by County
Chapter 5: Roles and Responsibilities Provider Manual
Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 18
Covering California – Telehealth Network Site Locations
Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 19
Chapter 5: Roles and Responsibilities
Provider Manual
Anthem Blue Cross
Anthem Blue Cross’ Telehealth program provides and facilitates:
Training for Telehealth services
Technical support services (one year warranty) for Telehealth systems purchased by
Anthem Blue Cross
Access to discounted high-speed telephone rates
Assistance in identifying appropriate use of Telehealth applications
Assistance in accessing specialty services through Anthem Blue Cross’ Telehealth
Network
Reimbursement
Monitoring of Telehealth services for access and quality
Presentation Sites
The presentation site:
Provides at least one Telehealth site coordinator
Ensures that the Telehealth site coordinator is trained in the use and application of
Telehealth services
Identifies patients who would benefit from the use of Telehealth services
Uses Telehealth services as appropriate for patient care
Discusses use of Telehealth with patients to obtain verbal consent
Clearly identifies the goal of the Telehealth encounter with the patient and specialty care
provider
Organizes the presentation of clinical information with core elements of patient
information including demographics, history of present illness, applicable past
medical/social history, current treatments, reason for the consultation and any other
information needed to meet the goals of the consultation
Facilitates Live Video Telehealth encounters as clinically appropriate
Develops effective Store and Forward Telehealth encounters by capturing and gathering
images and providing complete data that will be needed by the specialist
Coordinates treatments and management of patient care and follow-up as indicated
Maintains electronic medical record files consistent with state and federal standards
Educates staff in the appropriate use, application and processes of Telehealth
Assumes a leadership role in guiding development of administrative support functions
for Telehealth applications in your facility
Chapter 5: Roles and Responsibilities Provider Manual
Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 20
Specialty Centers
The specialty center:
Ensures that all specialists are trained in
the use and application of Telehealth
Utilizes Telehealth services as
appropriate for patient care (diagnosis
and treatment)
Establishes protocols to accomplish
either a Live Video or Store and Forward
Telehealth encounter
Facilitates Live Video Telehealth
encounters by guiding physical exam
activities with the presentation site in a
manner that supports meeting the diagnostic and treatment goals for the patient
Evaluates Store and Forward Telehealth encounter requests and provides timely
response to the presentation site
Maintains respect for the presentation site primary care physician, presenter and
patient at all times
Informs the presentation site of the appropriate use, application and processes of
Telehealth for your specific specialty’s needs for the consultation
Adheres to strict confidentiality standards for all electronic medical records and
consultations
Maintains electronic medical record files consistent with state and federal standards
Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 21
Chapter 6: When to Choose Telehealth
Provider Manual
Assessing Telehealth Services
Assessing the appropriateness for Telehealth services for a patient is a professional role and the
responsibility of the primary care physician, or mid-level and above medical provider (such as
physician, nurse practitioner or physician’s assistant).
Assessment consists of identifying a clinical problem or symptom that a specialist can examine
using Telehealth technology. Clinical problems amenable to Telehealth consist of those where
data, images and a Live Video Telehealth encounter with a specialist provides a solution (such
as a treatment plan) or meets the medical need for on-going management of a non-acute
condition.
Evaluating Telehealth Opportunities
The following list helps in the selection of conditions suitable for Live Video and Store
and Forward Telehealth (see the following table):
Identify clinical conditions suited for visual presentation
Identify conditions suited for audio presentation
Identify conditions where use of the Telehealth technology will lead to a definitive
diagnosis or management decision
Ensure that conditions to be presented are within the technical capabilities and the
scope of Telehealth training for the presenter. A presenter can be a physician, nurse
practitioner, physician’s assistant or in some cases, a staff member assisting the
presentation site in the consultation
Ensure that technical capabilities of the Telehealth system supports a diagnosis and on-
going treatment management
Examples of disease states within a specialty that may be applicable to Telehealth are given in
the following table; however, these are not inclusive of all specialty applications nor should
these supersede the determination of the primary care provider regarding the appropriateness
for Telehealth services. In general, acute conditions evidencing emergent symptoms should be
seen in an emergency room.
Telehealth services may not be provided to CMSP members who have not yet met their
share of cost.
Chapter 6: When to Choose Telehealth
Provider Manual
Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 22
Conditions Generally Suitable for Telehealth Consultations
Specialty Conditions
Dermatology Most dermatology patients can be evaluated with Telehealth.
Store and Forward Telehealth – works well for patients with clinically apparent skin lesions (rashes, wounds, lesions)
Follow-up of non-apparent lesions
Ear, Nose, and Throat (ENT)
Post-operative follow-up
Follow up of a chronic or on-going condition
Monitoring a diagnosed condition
New patients who probably will not require immediate surgical intervention
Gastroenterology Dysphasia
Non-acute gastrointestinal symptomology
Chronic hepatitis
Encopresis
Chronic abdominal pain
Malabsorption
Pre-and post-procedural evaluations
Post-surgical follow-up
Internal Medicine / Pediatrics
Ongoing treatment and management of most chronic conditions (hypertension, liver disease, diabetes, heart disease and others)
Post-hospital follow-up
Infectious diseases
Hematology / Oncology
Allergy
Pre-surgical evaluation Neurology
Back and neck pain
Arm and leg pain
Pre-surgical evaluation
On-going treatment of chronic conditions
Clinic follow-up of a prior diagnostic evaluation
Seizure control issues
Attention Deficit Hyperactivity Disorder (ADHD) / Developmental conditions
Chapter 6: When to Choose Telehealth
Provider Manual
Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 23
Specialty Conditions
Orthopedics Post-operative examination
Post-operative follow-up
Follow-up of a chronic or on-going condition
Monitoring a diagnosed condition
New Patients who probably will not require immediate surgical intervention
Psychiatry / Psychology Any psychiatric patient who is medically and mentally unstable
Pulmonology Chronic lung conditions – Chronic Obstructive Pulmonary
Disease (COPD), asthma, cystic fibrosis, interstitial disease, lung infections, sleep apnea
Follow-up of prior diagnostic evaluation
Post-operative and post-treatment follow-up
Non-acute pulmonary disease
Assessment for Appropriate Type of Telehealth Consultation
After determining that a patient’s medical condition is appropriate for Telehealth, the next
step is to determine which method of Telehealth (Live Video or Store and Forward) is
appropriate based on what is both medically appropriate and most convenient for the patient.
Some general evaluation questions to consider when determining the appropriate type of
consultation include the following:
If…. Thin it’s best suited for:
The specialist need to interact with the patient Live Video
The specialist need the presenter to manipulate the patient
Live Video
Sufficient information (such as images, data, dictated comments, lab results) about the patient’s condition can be assembled
Store and Forward
Contact Anthem Blue Cross’ Telehealth department at 1-866-855-2271 with any
questions about either the Live Video or Store and Forward methods.
Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 24
Chapter 7: How to…
Provider Manual
Refer a Patient for Telehealth Services
The following information in this chapter identifies primary care physician (PCP), presentation
site and specialty site responsibilities throughout the Telehealth encounter, depending on
whether the consultation is a Store and Forward or a Live Video.
Assess the Patient’s Appropriateness for Telehealth Services
This is a professional role performed by the PCP and consists of identifying the clinical
condition or symptom that a specialist can examine using Telehealth technology (such as
where data/image exchange or a Live Video consultation with a specialist may produce a
consultation or second opinion.)
Request Patient’s Verbal Consent for a Telehealth Consult
It is no longer necessary to obtain written patient consent prior to a Telehealth consultation;
however, verbal consent is required. It is recommended that the presenting site representative
document the verbal consent exchange in the patient’s medical record and include the
following information:
Patient Name
Date of Birth
Patient ID Number
Provider Name
Signature of Provider/Representative Obtaining Verbal Consent
The doctor or his/her representative has recommended the use of a Telehealth consultation for
the above named patient’s medical condition. I explained what will happen during the
consultation. I have also informed the patient of the following:
The risk and benefits of the consultation
The risk and benefits of other choices
The results of not having the consultation
A patient receiving a Store and Forward consultation has the right to receive interactive
communication with the specialist. If requested, interactive communication with the
specialist may occur at the time of the consultation or within 30 days of the patient’s
notification of the results of the consultation.
Chapter 7: How to…
Provider Manual
Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 25
The patient had a chance to ask questions about the consultation and received
satisfactory answers to those questions
The patient understands he/she may stop or take away their consent to the consultation
at any time for any reason; this will not change their right to future care or treatment;
this decision will not change their rights to benefits under their insurance program
He/she understands that all confidentiality protections apply to the Telehealth
consultation
The patient verbally consented did not consent to the Telehealth consultation
Request a Consultation
After determining the consultation is appropriate for Telehealth services, the PCP contacts the
selected Telehealth presentation site to request a consultation and determine the type of
consultation most appropriate for the patient.
Determine Appropriate Consultant Type
The presentation site helps to determine the most appropriate consultation type – Store and
Forward or Live Video.
Presentation sites can perform Store and Forward consultations for referrals that do not
require extensive specialist and patient interaction (for example, dermatology). Since Store and
Forward Telehealth encounters do not require the specialist, the presenter and the patient to
be present simultaneously, this technology removes the burden of coordinating schedules. The
availability of specialists accepting Store and Forward Telehealth encounters varies by specialty
center.
Telehealth encounters coordinated through Live Video conferencing require coordination of
three entities – the patient, the presenter and the specialist.
For presentation sites only: If the referred patient is assigned to another PCP, you must
get authorization from the independent physician association (IPA) responsible for
paying the claim before presenting the patient to a specialist.
For assistance in determining access to Store and Forward and Live Video presentation
site locations, and specialties location sites available, please contact Anthem Blue Cross’
Telehealth department at 1-866-855-2271.
Chapter 7: How to…
Provider Manual
Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 26
Once the appropriateness and consultation type is determined by the presentation site, the
PCP forwards all the requested patient information to the presentation site. A list of the
probable information requested is below.
Once the presentation site has been contacted, they are responsible for several duties to
prepare for the Telehealth encounter, from scheduling the appointment to performing the
consultation.
Prepare and Schedule a Telehealth Encounter
In preparing the Telehealth documentation for the specialist location site, the presentation site:
Requests patient information required to schedule the consultation with the specialty
center, including:
Medical history
Chief complaint
History of current condition
Specific questions to be answered
Coordinates scheduling the appointment between the patient and the specialty location
site, including confirmation of the appointment date and time, and the address of the
presentation site
Obtains a verbal consent to participate in a Telehealth consultation from the patient
prior to the consultation
The consultation request is then sent by encrypted e-mail by the presentation site to the
desired specialist. The specialist site reviews the consultation request and sends scheduling
recommendations back to the presentation site through the Telehealth software.
After Sending the Store and Forward Consultation Request
If the specialist has not replied within a reasonable period, follow-up with a courtesy phone
call to confirm receipt and discuss the response time line.
Chapter 7: How to…
Provider Manual
Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 27
Schedule the Telehealth Consultation
Follow these steps when scheduling a consultation:
Verify with the specialty center that the patient’s condition is appropriate for a Store and
Forward or Live Video Telehealth consultation
If a Store and Forward consultation, note this and that the case is being presented on
behalf of the referring provider
Coordinate and schedule the Telehealth consultation between the presentation site,
specialty center and the patient
Fax all required patient medical information and test results to the specialty center
Finalize Details ‐ One Day Prior to the Scheduled Appointment
Follow these steps the day before a scheduled appointment:
Confirm the appointment date and time with the patient at least one day prior to the
Telehealth consultation
Remind the patient of the importance to arrive early in order to prepare for the
Telehealth consultation, answer questions and complete required forms
Confirm that the specialty center has received the faxed patient medical information and
any additional information needed by the specialty center
Remember (if applicable): Include a copy of the patient’s Anthem Blue Cross ID card
(front and back) so the specialty center knows where to send claims. If the patient
cancels the appointment, immediately contact the specialty center and cancel the
appointment with the telehealth site coordinator. This courtesy ensures that the
specialist can accommodate as many appointments as possible.
For Live Video presentation appointment, the appointment time is the time when the
specialist will see the patient – such as when the video conference will be placed. It is
important that the patient, primary care physician and equipment are ready at that
time.
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Finalize Details ‐ Immediately Before the Scheduled Appointment
Follow these steps immediately before the scheduled appointment:
Confirm you have obtained verbal consent from the patient
Answer all questions that the patient may have about the Telehealth process
Gather the necessary Telehealth materials (for example, clinical data, patient
information and medical records)
Confirm that the Telehealth system and medical instruments are working properly
For Store and Forward consultations, confirm availability of Store and Forward services
with the specialty center
For Live Video consultation, confirm teleconference connection by calling the specialty
center a few minutes prior to the scheduled appointment time. Once you confirm the
connection, mute the audio and the video until the patient and PCP /presenter are
ready.
Situate the patient in the Telehealth room, being mindful of patient privacy and
confidentiality
Conduct a Telehealth Consultation
Store and Forward consultations transmit information and appropriate medical images by
secure e-mail from the presentation site to the specialist for review. Live Video consultations
are conducted in real-time.
During the Patient’s Appointment
During the consultation, be cognizant of the following:
Use the appropriate software, scopes and cameras to capture the pertinent images and
medical information
Maintain a professional environment that respects the patient’s privacy and
confidentiality
Introduce all persons participating in the consultation at both locations
Limit distraction by eliminating background noise as much as possible
Prevent unknown people from entering the room during the consultation
During a Store and Forward consultation, it is not necessary for the specialist to be
present during the PCP or presenter’s presentation. It also is not necessary during this
type of presentation for the PCP to be present during the specialist’s response.
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Identify the site as the presenting site only
Provide the specialist with the name, phone and fax number of the patient’s referring
physician
Provide the referring PCP with the name phone and number of the specialist
Introduce the patient to the specialist
If the patient has an assigned PCP outside of the presenting site, introduce the patient:
“This is _______________. I am presenting this patient for their PCP,
Dr. _______________.”
Present medical history, previous treatments and goals for the consultation (for
example, second opinion, diagnosis, medication recommendation)
If this is a Store and Forward consultation, the presentation site saves images and
information to be shared with the specialist as part of the patient’s medical record
Create the electronic patient Store and Forward consultation using the appropriate
software, scopes and cameras to capture the pertinent images and medical information
Remember: Thoroughly complete the Demographics Form in the Store and Forward
software to include:
The referring site information – name of the PCP, phone number and other
information
The patient information – identification, health plan; if necessary, fax a copy of
the patient’s ID card (front and back) to the specialty center
Thoroughly complete the Referral Form in the Store and Forward software to include:
Medical history
Chief complaint
History of current condition
Specific questions to be answered
During a Store and Forward consultation or a Live Video consultation, the telehealth
encounter should be treated with the same professional courtesy as a traditional office
visit.
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Send the Store and Forward consultation to the desired specialty care provider using
HIPAA compliant e-mail
Post Consultation
After you complete the consultation, perform the following:
Mute the audio and disconnect the phone call
Address any patient questions or concerns
If the patient has another PCP outside of the presenting site, explain that the specialist’s
recommendations will be sent to their PCP for treatment management and prescription
needs; the patient should be referred to this outside PCP for follow-up needs
Coordinate the communication of the patient’s treatment/management plan and follow-
up needs to the appropriate PCP
Maintain all images and information from the Telehealth consultation as part of the
patient’s medical record; back-up the files in accordance with clinic policies and
procedures
Evaluate and Implement the Recommended Treatment Plan from the Telehealth Specialist
Once the specialist has completed his or her evaluation of the Telehealth consultation, the
presentation site or the specialist directly sends the recommendations to the referring
physician.
Include the telephone number where the specialist can call to verify receipt of the Store
and Forward consultation, or to discuss the consultation with the PCP. If your site is a
presenting site only, please identify your site as presenting only and include the name of
the patient’s assigned PCP and the phone number.
If you are the presenting site only, please make a copy of the request for consultation
and the specialist’s consultation report. Send these reports to the patient’s assigned
PCP for implementation of the treatment / management plan.
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It remains the referring physician’s role to be responsible for the patient’s care and to
implement the recommended treatment plan for the patient, including the ordering of any
tests and prescriptions. The referring physician can contact the specialist directly for further
discussion or clarification of recommendations.
Document any final actions taken concerning the patient’s care; maintain the specialist
consultation as part of the patient’s medical record.
The presentation site provides a service to present patients for timely specialty assessments.
You know your patients best and can provide continuity of care needed to improve their health
outcomes. Together, through Anthem Blue Cross’ Telehealth program, we can improve access
to care throughout California.
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Chapter 8: Claims and Billing
Provider Manual
Overview
The following is designed to give providers information regarding the submission of claims for
Telehealth office visits/consultation services that are rendered to members of Prudent Buyer
PPO eligible groups, CalPERS Basic Plan, County Medical Services Program (CMSP), AIM
Program or Medi-Cal Managed Care1. For detailed information regarding member benefits,
benefit limitations, share of cost, eligibility and billing instructions, please refer to the
appropriate Anthem Blue Cross Prudent Buyer PPO, CalPERS Basic Plan, County Medical
Services Program (CMSP), AIM Program and Medi-Cal Managed Care Provider Manuals.
In order to facilitate timely claims processing and payment, Anthem Blue Cross requires that
standardized billing procedures be followed when submitting claims.
The provider bills using the appropriate forms and in a manner acceptable to Anthem Blue
Cross within the filing limit specified in the provider’s contract. Claims are processed within 30
working days of receipt of the claim, provided the claim is complete containing all of the
required elements outlined for submission of the CMS-1500 or CMS-UB-04/1450, or Anthem
Blue Cross will send a written explanation to the provider stating the reason for the delay.
1Anthem Blue Cross facilitates access to Telehealth services, facilities and technology through this program. The benefits available, if any, for
Telehealth services, and the terms, conditions and limitations on those benefits will depend on the terms of the member’s particular coverage.
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Electronic Professional Billing
Submit claims electronically through your current electronic billing system. If you are not
currently submitting your claims electronically and want to do so, please call the Electronic
Data Interchange (EDI) at Anthem Blue Cross at 1-800-227-3983.
Anthem Blue Cross Utilization Controls and Procedures
All benefits are subject to the member’s contract benefits and limitations at the time services
are rendered. To be eligible for reimbursement, Telehealth services must be medically
appropriate covered services that are suitable in a Telehealth setting when the Member’s Plan
includes Telehealth benefits. Telehealth includes any HIPAA compliant technology that can
facilitate the diagnosis, consultation, treatment, education, care management and self-
management of a patient’s health care, including both synchronous (direct, real-time) and
asynchronous (medical information that is compiled and sent to the provider to review at a
later time) interaction.
In order for Telehealth services to be eligible for reimbursement, the provider’s services must
be rendered from one of the following locations:
Provider’s office
Hospital
Rural Health Clinic
Federally Qualified Health Center
Other location with prior plan approval
The following are examples of services not eligible for reimbursement as Telehealth services:
Non-direct patient services (e.g., coordination of care rendered before or after patient
interaction)
Services rendered by audio-only telephone communication; facsimile, e-mail or any
other non-secure electronic communication (provided these restrictions are specified in
the provider contract and/or the Evidence of Coverage document)
Any service that is not eligible for separate reimbursement when rendered to the patient
in person
Distant site facility fee (the County Medical Services Program does reimburse for this
benefit)
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Transmission cost (Access for Infants and Mothers (AIM) Program, Medi-Cal Managed
Care, and County Medical Services Program (CMSP) do reimburse for this benefit.
Asynchronous technology for other than teledermatology, teleopthalmology and
teleoptometry
Telehealth Billing for California Programs
Fee Schedule
Your rate of reimbursement or compensation for serving Anthem Blue Cross Prudent Buyer,
CalPERS, AIM, Medi-Cal, and CMSP members is dependent upon your professional or
participating medical group agreement (Agreement) reimbursement rates. Refer to your copy of
the Agreement and the fee schedules online. Fee schedules are proprietary and only available on
our secure website, Provider Access. You will need an ID and password to access this website
and these fee schedules.
Modifiers
Prepare the claim according to instructions in the Plan’s Provider Manual. Processing Telehealth
claims for Prudent Buyer PPO, CalPERS Basic Plan, Access for Infants and Mothers (AIM), Medi-
Cal Managed Care, and County Medical Services Program (CMSP) members is the same as
processing standard office visit claims except a Telehealth modifier must be added to the Current
Procedural Terminology (CPT®) code: GT for Live Video, GQ for Store and Forward. 2, 3
Do not offer Telehealth to CMSP members who have not met their share of cost.
Live Video Telehealth Encounter Modifier Service Type
GT Live Video Telehealth encounter for eligible members
Store and Forward Telehealth Encounter Modifier Service Type
GQ Store and Forward Telehealth encounter for eligible members
Refer to the Telehealth Sample Section from CMS-1500 (Bottom) and Telehealth
Sample Section from UB-04/CMS-1450.
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Billable Codes for Telehealth Please call the Customer Care Center identified on the back of the members’ insurance card or
refer to Important Contact Information if you have questions about covered benefits.
Telecommunication Charges Only the site that initiates the Live Video Telehealth encounter may bill for telecommunication
charges using code T1014-GT.
Prudent Buyer PPO and CalPERS Basic Plan do not reimburse telecommunication charges after
January 1, 2012. AIM, Medi-Cal, County Medical Services Program (CMSP) pay claims for
members’ Integrated Services Digital Network (ISDN) telecommunication charges for Live Video
Telehealth encounters only. A Live Video encounter may require using high-speed ISDN
telecommunications lines, which are more expensive than a regular, long-distance call. This
reimbursement only applies to Integrated Services Digital Network (ISDN) lines.
Only the site that initiates the Live Video Telehealth encounter may bill for telecommunication
charges, code T1014-GT. Prudent Buyer PPO and CalPERS Basic Plan do not reimburse
telecommunication charges. Indicate the start and stop time of each Live Video Telehealth
encounter on the claim.
Bill number of units
Each minute (or part thereof) is equal to one unit of occurrence
A maximum of 90 minutes of occurrence may be billed per Live Video Telehealth
encounter (1.5 hours billable maximum)
2 Administrative Services Only product offered by Anthem Blue Cross Life and Health Insurance Company. Anthem Blue Cross Life
and Health Insurance Company provides administrative services and does not assume any financial risk or obligation with respect
to claims. Anthem Blue Cross administers claims on behalf of Anthem Blue Cross Life and Health Insurance Company, but is not
financially liable for benefits payable. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are
Independent Licensees of the Blue Cross Association. Anthem Blue Cross, on behalf of Anthem Blue Cross Life and Health
Insurance Company, administers claims for the Prudent Buyer PPO, CalPERS Care Basic, PERS Choice Basic Plan and PERS
Select Plan members. Payment of CalPERS claims is issued by the California State Controller’s Office.
3 Anthem Blue Cross facilitates access to Telehealth services, facilities and technology through this program. The benefits
available, if any, for Telehealth services, and the terms, conditions and limitations on those benefits will depend on the terms of the
member’s particular coverage.
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Billable CPT Codes for Live Video Telehealth Encounters
Primary Care Physicians
99201-99205 New patient office visit
99211-99215 Established patient office visit
Specialists
99241-99245 Consultations
99211-99215 Follow-up visits
Psychiatry
90801-90809 Psychiatric diagnosis
90810-90815 Individual psychotherapy
90816-90819 Individual psychotherapy (inpatient)
90821-90829 Individual psychotherapy (inpatient)
90853 Medical psychoanalysis
90862 Pharmacological psychiatric mgmt.
99241-99245 Consultations
99211-99215 Established member office visit
Limitations may exist regarding billable CPT codes for Live Video Telehealth encounters. For
detailed information regarding member benefits, benefit limitations, share of cost, eligibility,
preservice review and billing instructions, refer to the appropriate Plan’s Provider Manual. You
may call the Customer Care Center identified on the back of the members’ insurance card or refer
to Important Contact Information if you have questions about covered benefits.
Site Fees for Live Video
Distant Site Fees Specialty Sites may not bill for a Telehealth site fee. Prudent Buyer PPO, CalPERS Basic Plan,
AIM, and Medi-Cal do not reimburse site fees for Specialty Sites.
County Medical Services Program (CMSP) does reimburse Distant Sites fees.
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Presenting Site Fees Billing entities serving eligible Anthem Blue Cross Prudent Buyer PPO and CalPERS Basic Plan
members will not be reimbursed for site fees. Billing entities serving eligible AIM, Medi-Cal,
County Medical Services Program (CMSP) members may bill for Presenting site fees.
Live Video Site Fee Billing Code
CMS-1500 CMS-1450
Presentation Site Q3014 Q3014
Specialty Location G9002 G9002
Billable Codes for Store and Forward Telehealth Encounters
Telecommunication Charges Store and Forward is accomplished using secured e-mail communication. As such, there are no
telecommunication charges applicable. Therefore, there is no telecommunication reimbursement.
Primary Care Physicians Bill the preparation of the Store and Forward consultation as part of the primary care physician’s
office visit. Use the appropriate CPT code based on total amount of time necessary to complete the
office visit and the Store and Forward consultation preparation.
Specialists Anthem Blue Cross pays claims for the review of patient files for a Store and Forward consultation
under codes 99241-99245 Consultations.
Site Fees for Store and Forward Specialty Sites may not bill a Telehealth site fee for Store and Forward consultations.
Presenting sites serving eligible Prudent Buyer PPO and CalPERS Basic Plan members will not be
reimbursed for site fees after January 1, 2012.
Presenting sites serving eligible AIM, Medi-Cal, and County Medical Services Program members
may bill site fees for Store and Forward consults.
Store and Forward Site Fee Billing Code
CMS-1500 CMS-1450
Presentation Site Q3014 Q3014
Specialty Location Not covered Not covered
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Submitting Telehealth Claims Submit claims electronically through your clearinghouse, or mail all hard copy claims to the
address listed on the member’s ID card.
CMS-1500 Claim Form All professional providers, including behavioral health practitioners and third party billing agents
(except Federally Qualified Health Centers, Rural Health Clinics and Tribal Health Clinics) should
bill using the most current version of the CMS-1500 claim form.
Fields to Complete f o r C M S - 1 5 0 0 Claim F o r m
The following guidelines will help in completing the CMS-1500 Claim form. The letter R indicates
a required field.
Field Number Title Explanation
Field 1 (R)
Medicare/Medicaid/TRICARE /CHAMPUS/CHAMPVA/Group Health Plan/FECA Blk Lung/Other ID
If claim is for Medicare, put an X in the Medicare box. If the member has both Medicare and Medicaid, put an X in both boxes. Attach a copy of the form submitted to Medicare to the claim.
Field 1a (R)
Insured’s ID Number
Use the member’s ID number from the Anthem
Blue Cross ID card.
Field 2 (R)
Patient’s Name
Enter the last name first, then the first name, then middle
initial (if known). Do not use nicknames or full middle
names.
Field 3 (R)
Patient’s Birth Date / Patient’s Sex
Enter date of birth as MM/DD/YY (Month/Day/Year). For example, enter September 1, 1993 as 09/01/1993. Check the appropriate box for the patient’s sex.
Field 4 (R) Insured’s Name “Same” is acceptable if the insured is the patient.
Field 5 (R)
Patient’s Address / Telephone
Enter complete address and telephone number. Include any unit or apartment number. Abbreviations for road, street, avenue, boulevard, place or other common ending to the street name are acceptable.
Field 6 (R) Patient Relationship to Insured Enter the relationship to the member or subscriber.
Field 7 (R) Insured’s Address “Same” is acceptable if the insured is the patient.
Field 8 (R)
Patient Status
Check Single, Married or Other for marital status. If
applicable, check Employed, Full-Time Student or Part-
Time Student.
Field 9 (R)
Other Insured’s Name
If there is other insurance coverage in addition to the
member’s Anthem Blue Cross coverage, enter the name
of the insured.
Field 9a (R)
Other Insured’s Policy or Group Number
Enter the name of the insurance with the group and
policy number.
Field 9b (R) Other Insured’s Date of Birth Use the date of birth format, MM/DD/YY.
Field 9c (R)
Employer’s or School Name Enter the name of other insured’s employer or school.
Field 9d (R) Insurance Plan Name or Program Name Enter the name of plan carrier.
Field 10 (R)
Patient’s Condition Related To
Describe the injury or accident, including whether or not
it occurred at work.
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Field Number Title Explanation
Field 10a (R)
Related to Employment?
Check Y or N. If insurance is related to workers’
compensation, check Y.
Field 10b (R)
Related to Auto Accident / Place?
Check Y or N. Enter the state abbreviation in which the
accident occurred.
Field 10c (R) Related to Other Accident? Check Y or N.
Field 10d Reserved for local use If applicable, use for member copay.
Field 11 (R)
Insured’s Policy Group or FECA Number
Insured’s group number. Complete information about
insured, even if same as patient.
Field 11a (R)
Insured’s Date of Birth / Sex
Use the date of birth format – MM/DD/YY. Check
M (male) or F (female).
Field 11b (R)
Employer’s Name or School Name
Enter the name of the organization from which the insured
obtained the policy.
Field 11c (R) Insurance Plan Name or Program Name Enter the name of the plan carrier.
Field 11d (R) Is There Another Health Benefit Plan? Check Y or N. If yes, complete items 9A-9D.
Field 12 (R) Patient’s or Authorized Person’s Signature
Sign and date the form. (“Signature on file” indicates that
the appropriate signature obtained by the provider is
acceptable for this field.)
Field 13 (R)
Insured’s or Authorized Person’s Signature
Sign and date the form. (“Signature on file” is acceptable
for this field.)
Field 14 (R)
Date of Current
Enter the date of the injury, illness or pregnancy (if
applicable). For professional emergency services
billing, enter the Injury Date.
Field 15 First Date Enter the date of the first consultation for the
patient’s condition. Date format is MM/DD/YY.
Field 16 Dates Patient Unable to Work in Current
Occupation (From - To) Date format is MM/DD/YY.
Field 17 (R) Name of Referring Physician or Other
Source
Enter the name of physician, clinic or facility referring the
patient to the provider.
Field 17a - This field is available to enter another identification number.
Field 17b (R)
NPI Enter the provider’s National Provider Identifier number.
Field 18 Hospitalization Dates Related to Current
Services (From - To) Date format is MM/DD/YY.
Field 19 (R) Reserved for Local Use
Enter rendering NPI of mid-level practitioners such as
nurse practitioners and physicians assistants here.
For multiple transfers, indicate that the claim is part of a multiple transfer and provide the other client’s complete name and Medicaid number. Provide information about the accident, including date occurred, how it happened, and whether it was self-inflicted or employment-related.
Field 20
Outside Lab? (Yes or No); $ Charge Check Yes if lab services were sent to an outside lab;
check No if not.
Field 21 (R) Diagnosis or Nature of Illness or Injury Enter the appropriate diagnosis code or nomenclature.
Check with a coding expert if you aren’t sure.
Field 22 Medicaid Resubmission
Under “Original Ref. No.” enter the 17-digit
transaction control number (TCN) associated with
any claim being resubmitted that is older than one
year (365 days). Use field 19 if you need
additional space.
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Field Number Title Explanation
Field 23 (R) Prior Authorization Number
Enter authorization information in this field, which can be a preservice review or reference number, or on-call
physician NPI - enter rendering physician NPI when
provider is not the PCP, but is “covering for,” on-call or has received permission from the PCP to provide services that day.
Field 24a (R) Date(s) of Service If dates of service cross over from one year to
another, submit two separate claims (example: one
claim for services in 2005, one claim for services in
2006). Itemize each date of service on the claim;
avoid spanning dates.
Field 24b (R) Place of Service This is a 2-digit code. Use current coding as indicated in
the CPT Manual.
Field 24c EMG Enter the appropriate EMG number.
Field 24d (R) Procedure, Services, or Supplies Enter the appropriate CPT codes or nomenclature.
Indicate appropriate modifier when applicable. Do not use NOC codes unless there is no specific CPT code available. If you use an NOC code, include a narrative description.
Field 24e (R)
Diagnosis Pointer
Use the most specific ICD-9 code available. After
October 1, 2013, use the most specific ICD-10 code
available.
Field 24f (R) $ Charges Charge for each single line item.
Field 24g (R)
Days or Units Enter the quantity of services for each itemized line.
Field 24h EPSDT Family Plan Indicate if the services were the result of Early
Periodic Screening, Diagnostic and Treatment
(EPSDT) Services checkup or a family planning referral.
Field 24i (R)
ID Qualifier / NPI
Enter the provider’s National Provider Identifier number.
Field 24j (R) Rendering Provider NPI. Entering the rendering provider NPI in the
unshaded field of Box 24J.
Field 25 (R) Federal tax identification number (TIN) This is the 9-digit number listed on your W-9.
Field 26 Patient’s Account Number This is for the provider’s use in identifying patients and
allows up to nine numbers or letters (no other characters
are allowed).
Field 27 (R)
Accept Assignment? All providers of Medicaid services are required to
check Y.
Field 28 (R) Total Charge Enter the total charge for each single line item.
Field 29 (R)
Amount Paid Enter any payment that you have received for this claim.
Field 30 Balance Due The balance due has to equal the amount in box 28 less
the amount in box 29.
Field 31 (R) Full Name and Title of Physician or
Supplier
Either the actual signature or typed / printed designation is
acceptable.
Field 32 (R) Service Facility Location Information Include suite or office number. Abbreviations for road,
street, avenue, boulevard, place or other common ending
to the street name are acceptable.
Field 32a (R)
NPI Enter the service facility’s National Provider
Identifier number, (if appropriate).
Field 32b This field is available for you to enter another identification
number.
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Field Number Title Explanation
Field 33 (R) Billing Provider Info and PH # Enter the provider name, street, city, state, ZIP code and
telephone number.
Field 33a (R)
NPI Enter the provider’s National Provider Identifier number.
Field 33b
This field is available for you to enter another identification
number.
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Enter appropriate procedure codes (Box 24 D) for:
Telecommunication charge (if applicable) *
Service
Presenting site fee (Live Video or Store and Forward) *
Specialist site fee (CMSP benefit/Live Video only) *
* CMSP - Additional form is required, bill site fees on a separate claim form. No reimbursement for telecommunication
or site fees for Prudent Buyer PPO/CalPERS eligible members.
Enter the appropriate Telehealth modifier (Box 24 D):
GT - Live Video Telehealth encounter
GQ - Store and Forward Telehealth encounter
UB-04 Claim Form
All facilities, including Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs)
and Tribal Health Clinics (THCs), should bill using the most current version of the UB-04
(CMS-1450) claim form. Refer to the table below for information to include on the UB-04.
Use the member’s ID number when billing, whether submitting electronically or by
paper.
Fields to Complete for the UB-04 The following guidelines will help you in completing the UB-04 (also known as the CMS-1450)
claim form. The letter R indicates a required field for all members; RI indicates a required field for
inpatient; RO indicates a required field for outpatient; and C indicates a conditional field).
Locator # Box Title Description
1 (R) Facility name and address Enter the facility name and address
2 **blank**
3 Patient Control No. Enter the member’s account number
4 (R) Type of Bill Type of bill (TOB) code
5 (R) Fed Tax No. The provider’s federal tax identification number (TIN)
6 (R)
Statement Covers Period
From/Through The FROM and THROUGH dates covered by the claim being
submitted
7 Cov D. Covered days
8 N-C D. Non-covered days
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Locator # Box Title Description
9 C-I D. Coinsurance days
10 L-R D. Lifetime reserve days
11 **blank**
12 (R)
Patient Name
Enter the member’s name as it appears on the member’s
ID card.
13
Patient Address Enter the member’s complete address (number, street, city, state
and ZIP code).
14 (R)
Birth Date Enter the member’s date of birth in MM/DD/YY format.
15 (R) Sex Enter the member’s gender (M or F).
16
MS
Enter the member’s marital status: Single Married Other
17 (R)
Admission Date
Enter the member’s admission date to the facility in
MM/DD/YY format.
18 (R)
Admission Hr
Enter the member’s admission hour to the facility in military time (00 to 23) format.
19 (R) Admission Type Enter the type of admission.
20 (R) Admission SRC Enter the source of admission.
21 (R)
D. Hr
Enter the member’s discharge hour from the facility in military time (00 to 23) format.
22 (R) Status Enter the patient’s status.
23 Medical Record No. Optional medical record number
24-30 (R) Condition Codes Condition code (81) X0 – X9
31 **blank**
32-35 (R) Occurrence Codes / Dates Occurrence codes (42), if applicable
36
Occurrence Span (Code, From
& Through Date)
Days in MM/DD/YY format
37 **blank**
38 **blank**
39-41 (R) Value Codes (Code / Amount) Value codes and amounts
42 (R) Rev CD Revenue Code (required for all institutional claims)
Locator # Box Title Description
43 (R) Description Description of services rendered
44 (R)
HCPCS/Rates
The accommodation rate per day for inpatient services or
HCPCS/CPT code for outpatient and FQHC services
45 (R) Serv Date Date of services rendered
46 (R)
Serv Units
Number/units of occurrence for each line or service being billed
47 (R) Total Charges Total charge for each line of service being billed
48 Non Covered Charges Enter non-covered charges
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Locator # Box Title Description
49 **blank**
50 Payor Payor Identification (third party payors)
51 (R)
Provider No
Medicare Provider ID number. Enter Medicaid qualifier
1D on electronic claims.
52 Rel Info. Release of information certification indicator
53 Asg Ben Assignment of benefits certification indicator
54 Prior Payments Prior payments
55 Est Amount Due Estimated Amount Due
56 (R) **blank** Enter facility NPI
57 Due from Patient
58 (R) Insured’s Name Member’s Name
59
P. Rel
Patient’s relationship to insured (N/A if member is the
insured)
60 (R)
CERT.-SSN-HIC.-ID NO.
Insured’s ID number. Be sure to Include XDI prefix for CMSP members.
61
Group Name
Insured Group Name (the name of any other health plan)
62
Insurance Group No.
Insurance Group Number (the policy number of any other
health plan)
63 Treatment Authorization Codes Authorization number or authorization information
64 ESC Employment status code
65
Employer Name
Name of organization from which the insured obtained the other policy
66 Employer Location Organization’s complete address
67 (R)
Prin. Diag. CD.
Principal ICD-9 diagnostic codes. After October 1, 2013, use the principal ICD-10 diagnostic codes.
68-75 (R)
Other Diag. Codes
ICD-9 diagnostic code. After October 1, 2013, use the
ICD-10 diagnostic codes.
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Locator # Box Title Description
67 (R)
Prin. Diag. CD.
Principal ICD-9 diagnostic codes. After October 1, 2013, use the principal ICD-10 diagnostic codes.
68-75 (R)
Other Diag. Codes
ICD-9 diagnostic code. After October 1, 2013, use the
ICD-10 diagnostic codes.
76 Attending Enter attending physician’s NPI.
77 E-Code External cause of injury code
78 **blank**
79 (R) P.C. Procedure coding method used
80 (R)
Principal Procedure (Code/Date)
ICD-9 principal procedure code and dates, if applicable After October 1, 2013, ICD-10 principal procedure code and dates, if applicable.
81 (R) Other Procedure (Code/Date) Enter taxonomy codes.
82 (R) Attending Phys. ID The attending physician’s ID number
83 (R) Other Phys. ID Other physician ID
84
Remarks
Use this field to explain special situations. For claims that include share of cost, include the EVS number in this field.
85 (R) Provider Representative Provider representative signature
86 (R) Date Signature date
Chapter 8: Claims and Billing Provider Manual
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Telehealth Sample Section CMS-1450/UB-04
Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 47
Chapter 9: Developing Telehealth Medical Record Documentation
Provider Manual
Introduction
Telehealth are patient encounters using special technology (such as Live Video Conference,
Store and Forward Software and secure Internet sites). As such, documenting Telehealth
encounters should be accomplished in the same manner as a patient office visit – through
medical records.
The medical record standard in some clinics is the traditional paper record. Most clinics have
an electronic medical record system. If you use electronic medical records, you should already
have policies and procedures in place to safeguard the electronic record. Clinics not currently
using an electronic record need to consider how they monitor and maintain the electronic
records created by Telehealth technology.
The principles of confidentiality and laws governing medical records remain the same for all
records whether created electronically or in paper form. Anthem Blue Cross’ Telehealth
program is a point-to-point system that preserves confidentiality through encryption. This
means that the presentation site controls the medical record and patient data. Only specialists
you choose, receive the medical files. Because Anthem Blue Cross’ Telehealth program builds
on existing systems of care and administrative processes, existing policies need only be
amended to include the additional dimension of electronic data and storage. A system of rights
and authorities to the computer software is built into the Telehealth software. It requires login
security for all users. Your policy should consider designating levels of access to the electronic
record as a safeguard.
All clinical encounters have a patient folder. Each encounter is identified and a date and time
stamp applied that cannot be changed. It is necessary to back up these electronic records on a
routine basis to prevent a loss of data. A regular routine, and well-defined procedures, easily
support this aspect of medical record keeping.
Label electronic patient folders similarly to how you label paper-based patient folders. Give
captured images unique names that identify the patient, date the image was captured, and a
number, such as “Smith, Josephine 131107_01”. This indicates that this is the first image taken
of Josephine Smith’s condition on November 7, 2013.
Chapter 9: Developing Telehealth Medical Record Documentation
Provider Manual
Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 48
All Telehealth encounters require that verbal informed consent be obtained and documented.
This documentation is part of the medical record and you should keep it with other
documentation. Consultation reports are sent from specialty centers to your facility as well as
audio clips of the dictated report. Maintain both for the medical record.
Complete the Telehealth Consultation Summary Form after a consultation in order to
document the consultation in the patient’s paper-based medical record or scan the document
into the electronic medical record.
Monitoring Usage and Reporting to Anthem Blue Cross
What Anthem Blue Cross Monitors
In order to meet the goals of this Telehealth program, Anthem Blue Cross monitors and
identifies barriers to care and attempts to identify solutions. Anthem Blue Cross evaluates
pertinent information as the Telehealth Program moves forward to identify areas where
Anthem Blue Cross can affect the success of the program by assisting with training, expanding
the network of specialists or addressing infrastructure requirements and other needs.
Adaptations and development of the Telehealth program occur based on monitoring and
evaluation by Anthem Blue Cross of the results of your program. The monitoring of Telehealth
services is an on-going process.
Anthem Blue Cross monitors the following items:
Telehealth accomplishments and problems
Telehealth encounters (number, type, referrals, specialties, sites)
Satisfaction of patients (voluntary)
Difficulties with referral process
Needs (instrumentation, specialties, providers)
Monitoring by Anthem Blue Cross occurs through the monthly utilization log submission by
the presentation sites. Additional monitoring may include completed Patient Satisfaction
Forms (voluntary), telephone calls and informal discussions and meetings.
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Provider Manual
Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 49
What You Should Report
Complete and submit the following to Anthem Blue Cross on a monthly basis.
Completed Telehealth Utilization Log (number and type of encounters, specialties and
sites)
Completed Patient Satisfaction Survey (voluntary)
Complete and submit the Telehealth Utilization Log for reporting consultations and the
Telehealth Patient Satisfaction Survey Form every month. Please feel free to submit a
narrative description of any Telehealth problem you have had during the month or any
achievements that you would like to share with us.
When You Should Report
Unless otherwise stipulated in Anthem Blue Cross’ Telehealth Agreement, complete reports
monthly and submit by the 10th day of the following month. Reporting continues in
accordance with the contract between Anthem Blue Cross and your organization. You may e-
mail, fax or mail us your reports.
E-mail: [email protected]
Fax: 1-805-987-0736, Attn: Telehealth Program
Mail:
Attn: Telehealth Department Anthem Blue Cross One WellPoint Way, CAT201-M002 Thousand Oaks, CA 91362
Please feel free to e-mail any comments, accomplishments or problems to
Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 50
Chapter 10: Forms and Logs Provider Manual
Telehealth Information Forms
Thank you for your participation in Anthem Blue Cross’ Telehealth Program.
Anthem Blue Cross monitors the Telehealth Program to meet regulatory and internal
commitments through regular data submissions found in the following reports, forms and
surveys. If you have any further input, please feel free to contact the Telehealth Program at
1-866-855-2271.
You will find all forms mentioned in this chapter at the end of this Manual.
Telehealth Consultation Summary Form
Complete the Telehealth Consultation Summary Form after a consultation in order to
document the consultation in the patient’s paper-based medical record or scan the document
into the electronic medical record.
Telehealth Utilization Log
The Telehealth Utilization Log tracks the Telehealth events, both clinical and non-clinical,
for each presentation site. This log provides general information regarding the application and
result of each event. Following are the instructions to complete the utilization log.
Site Name: Name of your facility
For the Month of: Month being reported (for example, May, 2012)
Name of the person completing the log
Signature of the person completing the log
Date log was sent to Anthem Blue Cross Telehealth Department
Instructions for Completing the Utilization Log
Complete one row per Telehealth event (clinical and non-clinical).
Field Instructions
Date For Live Video, enter the date of the consultation or non-clinical use. For Store and Forward, presentation sites should note the date that the information was forwarded to the specialist.
Patient ID Include the patient ID for Anthem Blue Cross members only; otherwise, note “non-Anthem Blue Cross for Patient ID. Do not provide any other patient identifying information.
Chapter 10: Forms and Logs Provider Manual
Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 51
Patient Satisfaction Survey
This is a voluntary Telehealth Patient Satisfaction Survey Form for each patient. We
provide this form in both English and Spanish.
Do not include the patient’s name unless the patient agrees to a personal follow-up.
Unless otherwise instructed, submit these forms to Anthem Blue Cross’ Telehealth
department every month.
You can choose one of the following ways to submit the forms:
E-mail reports to [email protected] (For Utilization Logs only)
Fax reports to 1-805-987-0736
Mail reports to:
Attn: Telehealth Department Anthem Blue Cross One WellPoint Way, CAT201-M002 Thousand Oaks, CA 91362
For questions or comments, call the Telehealth department at 1-866-855-2271.
Field Instructions
Live Video or Store and Forward Enter the Telehealth application code:
LV – Live Video
SF – Store and Forward
Specialty Center Enter the location to which you connected for this event (for example, XYZ Specialty Center)
Definitions
(A) Specialty Enter the appropriate choice from Section A. Specialty (for example, 3 – Dermatology). If the specialty is not listed, enter “39” for other and note the specific specialty on the line below.
(B) Payment Source Enter the appropriate choice from Section B, Payment Source (for example, 2-Grant Funded Consult.)
(C) Non-Clinical Usage Enter the appropriate choice from Section E, Non-Clinical Usage (for example, 3-Continuing Education / Clinical Conference)
Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 52
Chapter 11: Telehealth Program Glossary
Provider Manul
Term Definition
CalPERS California Public Employees Retirement System, which added Anthem Blue Cross’
Telehealth Program to the PERS Care Basic Plan and PERS Choice Basic Plan.
CMS‐1500 Center for Medicare and Medicaid Medical Claim Form
GQ HIPAA‐approved insurance claim modifier for Store and Forward consultations.
GT HIPAA‐approved insurance modifier for Live Video consultations.
HPSA Health Professional Shortage Area
ISDN Lines
High‐speed telecommunication lines installed by the telephone company that are plugged
into the Telehealth workstation at some Telehealth sites (presentation site and specialty
centers) to transmit and receive Live Video Telehealth consultations.
Live Video (Simultaneous) Connects the patient, primary care physician (PCP) and specialist at the
same time by video conferencing equipment to discuss the patient’s medical condition.
MSSA
Medical Service Study Area – Classified in three categories: Frontier, Rural and Urban:
• Frontier – an area with a population density equal to or less than 11 persons per square
mile.
• Rural – an area with a population density of 250 persons or less per square mile and
having no incorporated area greater than 50,000 persons.
• Urban – based on a series of exception definitions, an area not designated as
Frontier or Rural.
MUA Medically Underserved Area
MUP Medically Underserved Population
Open Access Network
The Open Access Network allows presentation sites to connect to each other, primary
care to primary care, for peer review, collaboration and educational purposes. It also
connects presentation sites directly to multiple specialty centers for diagnosis,
consultation and reviews.
Originating site
The location where the patient or patient’s condition is presented by Telehealth. Originating
sites are:
• Office of a physician or practitioner
• Hospital
• Critical Access Hospital
• Rural Health Clinic
• Federally Qualified Health Center
• Hospital‐based renal dialysis center
• Skilled nursing facility
• Community mental health centers
PCP Primary care physician
Presentation Site
A health care facility at which the patient is present and from which the patient, patient’s
history, medical case and particular referral questions are presented to a specialist through
Telehealth technologies.
Chapter 11: Telehealth Program Glossary Provider Manual
Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 53
Term Definition
Presenter Primary care physician, mid‐level or office staff member assisting the presentation site in
presenting the patient to the specialist.
Presentation Communication of patient’s history, demographic information, necessary images, and
data to facilitate diagnosis, treatment and education of the patient.
Specialty Calendar A monthly calendar of all specialists in the Telehealth Network, scheduled Telehealth clinics, and specialties they provide. Sent by e‐mail each month to all Telehealth sites in
the network.
Specialty Center
A health care facility with an independent specialist or group of specialists to whom a patient, patient’s history, medical case and particular referral questions are presented by Telehealth originating site staff seeking consultative services, diagnosis, treatment
recommendations and patient education.
Store and Forward (Asynchronous) Uses software to store and encrypt the pertinent medical data and images. The secured data is then transmitted electronically to the specialist for review
and consultation.
Telehealth A health care delivery method that applies high‐speed telecommunications systems, computer technology and specialized medical cameras to examine, diagnose, treat and
educate patients at a distance.
Telehealth Site Coordinator
The Telehealth site coordinator:
• Competently uses Telehealth equipment and software
• Coordinates and schedules referrals between the presentation site, specialist and the patient
• Manages the technical aspects of the presentation (patient positioning, introductions, camera, scopes)
• Coordinates completion of required forms
• Maintains a log of all Telehealth usage for Live Video and Store and Forward
• Provides monthly Utilization Log reports to Anthem Blue Cross
Utilization Log A report that tracks the Telehealth events, both clinical and non‐clinical for each
presentation site. The utilization log is submitted every month.
Telehealth Information Forms
Provider Manual
Anthem Blue Cross Revision Date: September 2014 Version 2.4 Telehealth Program Page 54
Telehealth Information Forms
As is discussed in Chapter 10 – Telehealth Forms and Logs – the following forms are available:
.
Telehealth Consultation Summary Form
Telehealth Utilization Log
Telehealth Patient Satisfaction Survey Form
Blue Cross of California, doing business as Anthem Blue Cross, is contracted with L.A. Care Health Plan to provide Medi-Cal managed care services in Los Angeles County. In all other areas, Medi-Cal managed care services are provided by Blue Cross of California Partnership Plan, doing business as Anthem Blue Cross Partnership Plan. Independent licensees of the Blue Cross Association. ® ANTHEM is a registered trademark. ® The Blue Cross name and symbol are registered marks of the Blue Cross Association. 0608 CAW2228 05012012
Telehealth Consultation
Summary Form
Patient Information
Patient Name: Patient ID Number:
Address:
City: State: ZIP Code:
Date of Birth:
Allergies:
Home Telephone Number: Work Telephone Number:
Primary Care Physician Information
Primary Care Physician:
Phone Number:
Specialist Information
Physician Name:
Specialty:
Phone Number: Location:
Telehealth Consultation Summary
Date of Service:
Chief Complaint:
Pertinent Past Medical History:
Current Medications:
Summary Report with Recommendations:
Follow-up:
Signature Date
Anthem Blue Cross is the trade name of Blue Cross of California and Anthem Blue Cross Partnership Plan is the trade name of Blue Cross of California Partnership Plan, Inc. Independent licensees of the Blue Cross Association. ®ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association. Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County. CAW2234S 082014
Presentation Site: _____________________________________________ For the month of: ___________________________________________
Name of person completing log: ____________________________Signature:__________________________________ Date: ________________
Fax reports to Anthem Blue Cross’ Telehealth department at 1-805-987-0736 or e-mail to [email protected].
Date Patient ID Number (Anthem Members Only) Otherwise enter “Non-Anthem”
Live Video or
Store and Forward
Specialty Center Consulted
(A) Specialty
(B) Payment Source
(C) Non-Clinical Usage
1.
2.
3.
4.
5.
6.
7.
8.
9.
Definitions
(A) Specialty (B) Payment Source (C) Non-Clinical Usage
1. Behavioral Health 14. Nutrition Services 29. Hematology 1. Blue Cross Medi-Cal 1. Admin. Conference Meeting
2. Cardiology 15. Oncology 30. Neurology Peds. 2. Other Medi-Cal/Fee-for-Service 2. Community Use
3. Dermatology 16. OB/GYN 31. Optometry 3. CalPERS 3. Continuing Education/Clinical Conference
4. DDS Service 17. Ophthalmology 32. Pallative Care 4. Blue Cross PPO 4. College Courses/Nursing Classes
5. Dentistry 18. Orthopedics 33. Social Services 5. Blue Cross CMSP 5. Other Training
6. Gastroenterology (GI) 19. Pain Management 34. Substance Abuse 6. Other CMSP 6. Patient Education
7. General Surgery 20. Pediatrics 35. Therapies (PT, OT, ST) 7. Medicare 7. Professional Committees
8. Hepatology 21. Plastic Surgery 36. Diabetic Retinopathy Screening 8. Other Private Insurance 8. Supervision Staff/Students
9. HIV/AIDs 22. Psychiatry 37. Other 9. Patient Self-Pay 9. Support Groups
10. Infectious Disease 23. Pulmonology 38. Diabetes Education 10. Uninsured 10. Test Calls
11. Internal Medicine 24. Rheumatology 39. Pediatric Psychiatry 11. Veterans Administration (VA) 11. Distance Education
12. Nephrology 25. Urology 12 Other CalPERS 12. Test Calls
12. Neurology 28. Genetics 13. Other
Telehealth Utilization Log
Telehealth Patient Satisfaction Survey
Blue Cross of California, doing business as Anthem Blue Cross, is contracted with L.A. Care Health Plan to provide Medi-Cal managed care services in Los Angeles County. In all other areas, Medi-Cal managed care services are provided by Blue Cross of California Partnership Plan doing business as Anthem Blue Cross Partnership Plan. Independent licensees of the Blue Cross Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. ® The Blue Cross name and symbol are registered marks of the Blue Cross Association. 0608 CAW2233 082014
Please check or circle the most appropriate response and answer all questions.
Please respond to the following statements if you had a Live Video Telehealth encounter.
Other comments:
This survey is voluntary and confidential. If you have any questions, please call Anthem Blue Cross’
Telehealth Program at 1-866-855-2271. Completed survey’s may be se submitted to Anthem Blue Cross by
faxing to 805-987-0736, emailing to [email protected] or mailed directly to Anthem Blue Cross
at 1 WellPoint Way, Thousand Oaks, CA 91363 Attn: Telehealth Department. Thank you for your time.
Date: ____________________ Telehealth Site: ____________________________________________
Method of Telehealth encounter (please check one) Store and Forward Live Video
For Which Specialty: ___________________________________________________________________
1a. I would have had to wait to see a
specialist doctor:
1 to 14 days 15 to 30 days 31 to 60 days
61 to 90 days more than 90 days N/A
1b. The wait time for my Telehealth
appointment was:
1 to 14 days 15 to 30 days 31 to 60 days
61 to 90 days more than 90 days N/A
Disagree Neutral Agree N/A
2. The care I received using Telehealth
was as good as seeing the specialty
doctor in person.
3. It was not difficult scheduling a
Telehealth appointment.
4. I would use Telehealth again.
5. My questions about Telehealth were
answered by the doctor or nurse at my
clinic.
Disagree Neutral Agree N/A
1. I was introduced to all the
doctors/nurses in both locations.
2. The specialty doctor told me what was
wrong with me or what to do to
improve my condition.
3. The picture was clear, I could see the
doctor.
4. I could hear the doctor.
Telehealth is a collaborative project to improve access to care.
Anthem Blue Cross is the trade name of Blue Cross of California. Independent licensee of the Blue Cross Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association. Anthem Blue Cross facilitates access to Telehealth services, facilities and technolo-gy through this program. The benefits available, if any, for Telehealth services, and the terms, conditions and limitations on those benefits will depend on the terms of the member’s particular coverage.
ACA-PM-0006-14 08.14