Washington Code 71.24.335 – Reimbursement for behavioral health services provided through telemedicine or store and forward technology — Coverage requirements — Audio-only telemedicine
Current as of: 2023 | Check for updates
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(1) Upon initiation or renewal of a contract with the authority, behavioral health administrative services organizations and managed care organizations shall reimburse a provider for a behavioral health service provided to a covered person through telemedicine or store and forward technology if:
Terms Used In Washington Code 71.24.335
- Authority: means the Washington state health care authority. See Washington Code 71.24.025
- Behavioral health administrative services organization: means an entity contracted with the authority to administer behavioral health services and programs under RCW 71. See Washington Code 71.24.025
- Behavioral health services: means mental health services, substance use disorder treatment services, and co-occurring disorder treatment services as described in this chapter and chapter 71. See Washington Code 71.24.025
- Contract: A legal written agreement that becomes binding when signed.
- Department: means the department of health. See Washington Code 71.24.025
- Managed care organization: means an organization, having a certificate of authority or certificate of registration from the office of the insurance commissioner, that contracts with the authority under a comprehensive risk contract to provide prepaid health care services to enrollees under the authority's managed care programs under chapter 74. See Washington Code 71.24.025
- person: may be construed to include the United States, this state, or any state or territory, or any public or private corporation or limited liability company, as well as an individual. See Washington Code 1.16.080
- Recovery: means a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential. See Washington Code 71.24.025
(a) The behavioral health administrative services organization or managed care organization in which the covered person is enrolled provides coverage of the behavioral health service when provided in person by the provider;
(b) The behavioral health service is medically necessary; and
(c) Beginning January 1, 2023, for audio-only telemedicine, the covered person has an established relationship with the provider.
(2)(a) If the service is provided through store and forward technology there must be an associated visit between the covered person and the referring provider. Nothing in this section prohibits the use of telemedicine for the associated office visit.
(b) For purposes of this section, reimbursement of store and forward technology is available only for those services specified in the negotiated agreement between the behavioral health administrative services organization, or managed care organization, and the provider.
(3) An originating site for a telemedicine behavioral health service subject to subsection (1) of this section means an originating site as defined in rule by the department or the health care authority.
(4) Any originating site, other than a home, under subsection (3) of this section may charge a facility fee for infrastructure and preparation of the patient. Reimbursement must be subject to a negotiated agreement between the originating site and the behavioral health administrative services organization, or managed care organization, as applicable. A distant site, a hospital that is an originating site for audio-only telemedicine, or any other site not identified in subsection (3) of this section may not charge a facility fee.
(5) Behavioral health administrative services organizations and managed care organizations may not distinguish between originating sites that are rural and urban in providing the coverage required in subsection (1) of this section.
(6) Behavioral health administrative services organizations and managed care organizations may subject coverage of a telemedicine or store and forward technology behavioral health service under subsection (1) of this section to all terms and conditions of the behavioral health administrative services organization or managed care organization in which the covered person is enrolled, including, but not limited to, utilization review, prior authorization, deductible, copayment, or coinsurance requirements that are applicable to coverage of a comparable behavioral health care service provided in person.
(7) This section does not require a behavioral health administrative services organization or a managed care organization to reimburse:
(a) An originating site for professional fees;
(b) A provider for a behavioral health service that is not a covered benefit; or
(c) An originating site or provider when the site or provider is not a contracted provider.
(8)(a) If a provider intends to bill a patient, a behavioral health administrative services organization, or a managed care organization for an audio-only telemedicine service, the provider must obtain patient consent for the billing in advance of the service being delivered.
(b) If the health care authority has cause to believe that a provider has engaged in a pattern of unresolved violations of this subsection (8), the health care authority may submit information to the appropriate disciplining authority, as defined in RCW 18.130.020, for action. Prior to submitting information to the appropriate disciplining authority, the health care authority may provide the provider with an opportunity to cure the alleged violations or explain why the actions in question did not violate this subsection (8).
(c) If the provider has engaged in a pattern of unresolved violations of this subsection (8), the appropriate disciplining authority may levy a fine or cost recovery upon the provider in an amount not to exceed the applicable statutory amount per violation and take other action as permitted under the authority of the disciplining authority. Upon completion of its review of any potential violation submitted by the health care authority or initiated directly by an enrollee, the disciplining authority shall notify the health care authority of the results of the review, including whether the violation was substantiated and any enforcement action taken as a result of a finding of a substantiated violation.
(9) For purposes of this section:
(a)(i) “Audio-only telemedicine” means the delivery of health care services through the use of audio-only technology, permitting real-time communication between the patient at the originating site and the provider, for the purpose of diagnosis, consultation, or treatment.
(ii) For purposes of this section only, “audio-only telemedicine” does not include:
(A) The use of facsimile or email; or
(B) The delivery of health care services that are customarily delivered by audio-only technology and customarily not billed as separate services by the provider, such as the sharing of laboratory results;
(b) “Disciplining authority” has the same meaning as in RCW 18.130.020;
(c) “Distant site” means the site at which a physician or other licensed provider, delivering a professional service, is physically located at the time the service is provided through telemedicine;
(d) “Established relationship” means the provider providing audio-only telemedicine has access to sufficient health records to ensure safe, effective, and appropriate care services and:
(i) The covered person has had, within the past three years, at least one in-person appointment, or at least one real-time interactive appointment using both audio and video technology, with the provider providing audio-only telemedicine or with a provider employed at the same medical group, at the same clinic, or by the same integrated delivery system operated by a carrier licensed under chapter 48.44 or 48.46 RCW as the provider providing audio-only telemedicine; or
(ii) The covered person was referred to the provider providing audio-only telemedicine by another provider who has had, within the past three years, at least one in-person appointment, or at least one real-time interactive appointment using both audio and video technology, with the covered person and has provided relevant medical information to the provider providing audio-only telemedicine;
(f) “Originating site” means the physical location of a patient receiving behavioral health services through telemedicine;
(g) “Provider” has the same meaning as in RCW 48.43.005;
(h) “Store and forward technology” means use of an asynchronous transmission of a covered person’s medical or behavioral health information from an originating site to the provider at a distant site which results in medical or behavioral health diagnosis and management of the covered person, and does not include the use of audio-only telephone, facsimile, or email; and
(i) “Telemedicine” means the delivery of health care or behavioral health services through the use of interactive audio and video technology, permitting real-time communication between the patient at the originating site and the provider, for the purpose of diagnosis, consultation, or treatment. For purposes of this section only, “telemedicine” includes audio-only telemedicine, but does not include facsimile or email.
(10) The authority must adopt rules as necessary to implement the provisions of this section.
NOTES:
Conflict with federal requirements—2022 c 213: See note following RCW 41.05.700.
Conflict with federal requirements—2021 c 157: See note following RCW 74.09.327.
Effective date—2019 c 325: See note following RCW 71.24.011.
Contingent effective date—2017 c 202 § 7: “Section 7 of this act takes effect January 1, 2018, but only if neither Substitute House Bill No. 1388 (including any later amendments or substitutes) nor Substitute Senate Bill No. 5259 (including any later amendments or substitutes) is signed into law by the governor by July 23, 2017.” [ 2017 c 202 § 10.] Neither Substitute House Bill No. 1388 nor Substitute Senate Bill No. 5259 was signed into law by July 23, 2017.
Findings—Intent—2017 c 202: See note following RCW 74.09.495.