Telemedicine Billing Manual

• Program Overview
  • Early and Periodic Screening, Diagnosis and Treatment (EPSDT)
  • Telehealth Home Health Monitoring
  • eHealth Entity Provider Specialty Type
• When Should a Provider Choose Telemedicine?
  • Requirements for Telemedicine Services
  • Covered Services
  • Non-Covered Services
• Health First Colorado Reimbursement for Telemedicine
  • Telemedicine for Primary Care Providers
  • Telemedicine for Specialty Care Providers
  • Telemedicine for Federally Qualified Health Centers, Rural Health Clinics and Indian Health Services
  • Physical Therapy, Occupational Therapy, Home Health, Hospice and Pediatric Behavioral Health Providers
  • Allowable Locations for Telemedicine
• Telemedicine Confidentiality Requirements
• Waiving the Face-to-Face Requirement & Required Disclosure Statements
• General Billing Information
• Billing Providers
• Originating Site Billing
• Distant Providers
• Billing HCPCS Q3014
• Telemedicine Place of Service Codes
• Rendering Providers
  • Telemedicine Modifier GT
• CMS 1500 Paper Claim Reference Table
  • Telemedicine Originator Claim Example
  • Telemedicine Distant Claim Example
• Timely Filing
• Telemedicine Revision Log

Return to Billing Manuals Web Page

Program Overview

Additional flexibilities have been allowed for Telemedicine during the COVID-19 State of Emergency. Visit the Telemedicine - Provider Information web page for further information.

Providers must be enrolled as a Health First Colorado provider in order to:

• Treat a Health First Colorado member
• Submit claims for payment to the Health First Colorado

Health First Colorado reimburses providers for medically necessary medical and surgical services furnished to eligible members.

Telemedicine is not a unique service, but a means of providing services approved by Health First Colorado through live interactive audio and video telecommunications equipment. Telemedicine services may be provided under two arrangements.

1. The first arrangement is when a member receives services via a live audio/visual connection from a single provider. This is the predominant arrangement for telemedicine.
2. The second arrangement is when a member and a provider are physically in the same location and additional services are provided by a second (distant) provider via a live audio/visual connection. In this arrangement the provider who is present with the member is called the originating provider, and the provider located at a different site, acting as a consultant, is called the distant provider.

The member must be present during any Telemedicine visit.

Providers should refer to the Code of Colorado Regulations Program Rules (10 CCR 2505-10, Section 8.200.3.B), for specific information when providing telemedicine services.

When a Federally Qualified Health Center (FQHC) or a Rural Health Clinic (RHC) provides care through telemedicine, the claim must include the modifier GT on line(s) identifying the service(s). The claims must follow the other requirements of an FQHC or RHC claim as identified in the FQHC and RHC Billing Manual.

Back to Top

Early and Periodic Screening, Diagnostic and Treatment (EPSDT)

8.280.4.E Other EPSDT Benefits

Other health care services may include other EPSDT benefits if the need for such services is identified. The services are a benefit when they meet the following requirements:

1. All goods and services described in Section 1905(a) of the Social Security Act are a covered benefit under EPSDT when medically necessary as defined at 10 C.C.R. 2505-10, Section 8.076.1.8, regardless of whether such goods and services are covered under the Colorado Medicaid State Plan.
2. For the purposes of EPSDT, medical necessity includes a good or service that will, or is reasonably expected to, assist the client to achieve or maintain maximum functional capacity in performing one or more Activities of Daily Living; and meets the criteria set forth at Section 8.076.1.8.b - g.
3. The service provides a safe environment or situation for the child.
4. The service is not for the convenience of the caregiver.
5. The service is medically necessary.
6. The service is not experimental or investigational and is generally accepted by the medical community for the purpose stated.
7. The service is the least costly.

Back to Top

Telehealth Home Health Monitoring

Telehealth monitoring is available for members who are eligible through the Home Health benefit and should not be billed as telemedicine. Providers rendering telehealth monitoring should refer to the Home Health Billing Manual located on the Billing Manuals web page under the CMS 1500 drop-down menu. 

Back to Top

eHealth Entity Provider Specialty Type

As of October 30th, 2022, there is a provider specialty type for Clinic and Non-Physician Practitioner groups that meet the following definition:

An eHealth entity is defined as a group practice that delivers services exclusively through telemedicine and is enrolled in a provider type that has an eHealth specialty.

Refer to the Code of Colorado Regulations (1- CCR 2505-10, Section 8.095) for more information. Providers who meet this definition must update their enrollment to this provider specialty type. Guidance on how to enroll is located on the Provider Enrollment web page. Services are restricted to those currently allowed for telemedicine. This information is located under Covered Services.

Back to Top

When Should a Provider Choose Telemedicine?

The primary purpose of telemedicine is to allow a member to receive direct medical services from a health care provider without person-to-person contact with a provider. Telemedicine can also be used by a member's medical provider to receive medical consultation from another medical provider regarding the member that may be accomplished in real-time. Additionally, telemedicine brings providers to people living in rural or frontier communities, as well as members facing transportation difficulties. Providers should weigh these advantages against quality of care and member safety considerations. They should also consider potential liability issues. Members may choose which is more convenient for them when providers make telemedicine available.

However, telemedicine should not be selected when face-to-face services are medically necessary. Members should establish relationships with primary care providers, who are available on a face-to-face basis.

Back to Top

Covered Services

Visit the Telemedicine - Provider Information web page for a list of billing codes which may be used with Place of Service (POS) 02 or 10.

Services may be rendered via telemedicine when the service is:

• A covered Health First Colorado benefit,
• Within the scope and training of an enrolled provider's license, and
• Appropriate to be rendered via telemedicine.

All services provided through telemedicine shall meet the same standard of care as in-person care.

The availability of services through telemedicine in no way alters the scope of practice of any health care provider, nor does it authorize the delivery of health care services in a setting or manner not otherwise authorized by law. [C. R. S. 2018, 25.5-5-414 (7)(a) & (b)

Back to Top

Non-Covered Services

• Services not otherwise covered by Health First Colorado are not covered when delivered via telemedicine
• Telemedicine does not include provider-to-provider consultations provided by telephone (interactive audio), email or facsimile machines.
• Services appropriately billed to managed care should continue to be billed to managed care. All managed care requirements must be met for services billed to managed care. Managed care may or may not reimburse telemedicine costs.
• Health First Colorado does not pay for provider education via telemedicine.
• The use of telecommunications equipment for delivery of services does not change prior authorization requirements established for the services being provided.

Back to Top

Health First Colorado Reimbursement for Telemedicine

 

Telemedicine for Primary Care Providers

A primary care provider can be reimbursed as the "originating provider" for any eligible Telemedicine Services where the member is present with the provider at the "originating site." Please see the 'Originating Site Billing' section for further information on reimbursement requirements for providers at an originating site with a member.

In order for a primary care provider to be reimbursed for Telemedicine Services as the "distant provider" the primary care provider must be able to facilitate an in-person visit in the state of Colorado if necessary for treatment of the member's condition. Please see the 'Distant Provider Billing' section for further information.

Back to Top

Telemedicine for Specialty Care Providers

A medical specialist provider can be reimbursed as the "originating provider" for any Telemedicine Services where the member is present with the provider at the "originating site." Please see the 'Originating Site Billing' section for further information on reimbursement requirements for providers at an originating site with a member.

A medical specialist provider can be reimbursed as the "distant provider." Please see the 'Distant Provider Billing' section for further information.

Back to Top

Telemedicine for Federally Qualified Health Centers, Rural Health Clinics, and Indian Health Services

Health First Colorado allows telemedicine visits to qualify as billable encounters for Federally Qualified Health Centers (FQHCs), Rural Health Clinic (RHCs), and Indian Health Services (IHS). Services allowed under telemedicine may be provided via telephone, live chat, or interactive audiovisual modality for these provider types.

Back to Top

Physical Therapy, Occupational Therapy, Home Health, Hospice and Pediatric Behavioral Health Providers

Physical therapists, occupational therapists, hospice, home health providers and pediatric behavioral health providers are eligible to deliver telemedicine services.

1. Home Health Agency services and therapies, Hospice, and Pediatric Behavioral Treatment may be provided via telephone-only.
2. Outpatient Physical, Occupational, and Speech Therapy services must have an interactive audio/visual connection with the member to be provided via telemedicine.

Telemedicine is covered for behavioral health providers under the capitated behavioral health benefit administered by the Regional Accountable Entities (RAEs). Behavioral health providers should contact their RAE for guidance. Visit the Accountable Care Collaborative Phase II web page for more information.

Back to Top

Allowable Locations for Telemedicine

If no originating provider is present during a Telemedicine Services appointment, then the location of the originating site is at the member's discretion and can include the member's home. However, members can be required to choose a location suitable to delivery of telemedicine services that may include adequate lighting and environmental noise levels suitable for easy conversation with a provider.

Back to Top

Telemedicine Confidentiality Requirements

All Health First Colorado providers using telemedicine to deliver Health First Colorado services must employ existing quality-of-care protocols and member confidentiality guidelines when providing telemedicine services. Health benefits provided through telemedicine must meet the same standard of care as in-person care. Record-keeping should comply with Health First Colorado requirements in 10 CCR 2505-10, Section 8.130.2.

Transmissions must be performed on dedicated secure lines or must utilize an acceptable method of encryption adequate to protect the confidentiality and integrity of the transmission. Transmissions must employ acceptable authentication and identification procedures by both the sender and the receiver. Providers of telemedicine services must implement confidentiality procedures that include, but are not limited to:

• Specifying the individuals who have access to electronic records
• Using unique passwords or identifiers for each employee or other person with access to the member records
• Ensuring a system to routinely track and permanently record such electronic medical information
• Advising members of their right to privacy and that their selection of a location to receive telemedicine services in private or public environments is at the member's discretion

 

Back to Top

Waiving the Face-to-Face Requirement & Required Disclosure Statements

The Health First Colorado requirement for an initial face-to-face contact between provider and member may be waived when treating the member through telemedicine. In-person contact between a health care provider and a member is not required for services delivered through telemedicine that are otherwise eligible for reimbursement.

Prior to treating the member through telemedicine for the first time, the provider must furnish each member with all of the following written statements, which must be signed (electronic signatures will be accepted) by the member or the member's legal representative:

• The member retains the option to refuse the delivery of health care services via telemedicine at any time without affecting the member's right to future care or treatment and without risking the loss or withdrawal of any program benefits to which the member would otherwise be entitled.
• All applicable confidentiality protections shall apply to the services.
• The members shall have access to all medical information resulting from the telemedicine services as provided by applicable law for member access to his or her medical records. [C. R. S. 2018, 25.5-5-320 (4)].

These requirements do not apply in an emergency. [C. R. S. 2018, 25.5-5-320 (5)].

 

Back to Top

General Billing Information

Refer to the General Provider Information Manual located on the Billing Manuals web page under the General Provider Information drop-down menu for general billing information.

Specific coverage and billing information may exist for the benefit being provided via Telemedicine. Refer to the Billing Manuals web page for benefit-specific details.

The following list of CPT/HCPCS codes may be billed using Place of Service code 02 or 10:

Procedure Code	Date Allowed for Telemedicine	Allowed for FQHC, RHC, IHS Telemedicine Billing	Allowed for Outpatient Hospital Telemedicine Billing
76801	Prior to March 20, 2020	Yes	No
76802	Prior to March 20, 2020	Yes	No
76805	Prior to March 20, 2020	Yes	No
76811	Prior to March 20, 2020	Yes	No
76812	Prior to March 20, 2020	Yes	No
76813	Prior to March 20, 2020	Yes	No
76814	Prior to March 20, 2020	Yes	No
76815	Prior to March 20, 2020	Yes	No
76816	Prior to March 20, 2020	Yes	No
76817	Prior to March 20, 2020	Yes	No
90791	Prior to March 20, 2020	Yes	No
90792	Prior to March 20, 2020	Yes	No
90832	Prior to March 20, 2020	Yes	No
90833	Prior to March 20, 2020	Yes	No
90834	Prior to March 20, 2020	Yes	No
90836	Prior to March 20, 2020	Yes	No
90837	Prior to March 20, 2020	Yes	No
90838	Prior to March 20, 2020	Yes	No
90839	Prior to March 20, 2020	Yes	No
90840	Prior to March 20, 2020	Yes	No
90846	Prior to March 20, 2020	Yes	No
90847	Prior to March 20, 2020	Yes	No
90849	Prior to March 20, 2020	Yes	No
90853	Prior to March 20, 2020	Yes	No
90863	Prior to March 20, 2020	Yes	No
92507	Prior to March 20, 2020	Yes	Yes
92508	March 20, 2020	Yes	Yes
92521	March 20, 2020	Yes	Yes
92522	March 20, 2020	Yes	Yes
92523	March 20, 2020	Yes	Yes
92524	March 20, 2020	Yes	Yes
92526	March 20, 2020	Yes	Yes
92606	March 20, 2020	Yes	Yes
92607	March 20, 2020	Yes	Yes
92608	March 20, 2020	Yes	Yes
92609	March 20, 2020	Yes	Yes
92610	March 20, 2020	Yes	Yes
92630	March 20, 2020	Yes	No
92633	March 20, 2020	Yes	No
96040	March 20, 2020	Yes	No
96101	March 20, 2020	Yes	No
96102	March 20, 2020	Yes	No
96110	March 20, 2020	Yes	Yes
96111	March 20, 2020	Yes	Yes
96112	March 20, 2020	Yes	Yes
96113	March 20, 2020	Yes	Yes
96116	March 20, 2020	Yes	No
96118	March 20, 2020	Yes	No
96119	March 20, 2020	Yes	No
96121	March 20, 2020	Yes	No
96125	March 20, 2020	Yes	No
96130	March 20, 2020	Yes	No
96131	March 20, 2020	Yes	No
96132	March 20, 2020	Yes	No
96133	March 20, 2020	Yes	No
96136	March 20, 2020	Yes	No
96137	March 20, 2020	Yes	No
96138	March 20, 2020	Yes	No
96139	March 20, 2020	Yes	No
96146	March 20, 2020	Yes	No
97110	March 20, 2020	Yes	Yes
97112	March 20, 2020	Yes	Yes
97129	March 20, 2020	Yes	Yes
97130	March 20, 2020	Yes	Yes
97140	March 20, 2020	Yes	Yes
97150	March 20, 2020	Yes	Yes
97151	March 20, 2020	Yes	No
97153	March 20, 2020	Yes	No
97154	March 20, 2020	Yes	No
97155	March 20, 2020	Yes	No
97158	March 20, 2020	Yes	No
97161	March 20, 2020	Yes	Yes
97162	March 20, 2020	Yes	Yes
97163	March 20, 2020	Yes	Yes
97164	March 20, 2020	Yes	Yes
97165	March 20, 2020	Yes	Yes
97166	March 20, 2020	Yes	Yes
97167	March 20, 2020	Yes	Yes
97168	March 20, 2020	Yes	Yes
97530	March 20, 2020	Yes	Yes
97533	March 20, 2020	Yes	Yes
97535	March 20, 2020	Yes	Yes
97537	March 20, 2020	Yes	Yes
97542	March 20, 2020	Yes	Yes
97755	March 20, 2020	Yes	Yes
97760	March 20, 2020	Yes	Yes
97761	March 20, 2020	Yes	Yes
97763	March 20, 2020	Yes	Yes
97802	March 20, 2020	Yes	No
97803	March 20, 2020	Yes	No
97804	March 20, 2020	Yes	No
98966	March 20, 2020	Yes	No
98967	March 20, 2020	Yes	No
98968	March 20, 2020	Yes	No
99201	Prior to March 20, 2020	Yes	No
99202	Prior to March 20, 2020	Yes	No
99203	Prior to March 20, 2020	Yes	No
99204	Prior to March 20, 2020	Yes	No
99205	Prior to March 20, 2020	Yes	No
99211	Prior to March 20, 2020	Yes	No
99212	Prior to March 20, 2020	Yes	No
99213	Prior to March 20, 2020	Yes	No
99214	Prior to March 20, 2020	Yes	No
99215	Prior to March 20, 2020	Yes	No
99401	March 20, 2020	Yes	No
99402	March 20, 2020	Yes	No
99403	March 20, 2020	Yes	No
99404	March 20, 2020	Yes	No
99406	March 20, 2020	Yes	No
99407	March 20, 2020	Yes	No
99408	March 20, 2020	Yes	No
99409	March 20, 2020	Yes	No
99417	January 1, 2021	Yes	No
99441	March 20, 2020	Yes	No
99442	March 20, 2020	Yes	No
99443	March 20, 2020	Yes	No
G0108	March 20, 2020	Yes	No
G0109	March 20, 2020	Yes	No
G8431	March 20, 2020	Yes	No
G8510	March 20, 2020	Yes	No
G9006	March 20, 2020	Yes	No
H0001	March 20, 2020	Yes	No
H0002	March 20, 2020	Yes	No
H0004	March 20, 2020	Yes	No
H0006	March 20, 2020	Yes	No
H0025	March 20, 2020	Yes	No
H0031	March 20, 2020	Yes	No
H0032	March 20, 2020	Yes	No
H0049	March 20, 2020	Yes	No
H1005	March 20, 2020	Yes	No
H2000	March 20, 2020	Yes	No
H2011	March 20, 2020	Yes	No
H2015	March 20, 2020	Yes	No
H2016	March 20, 2020	Yes	No
S9445	March 20, 2020	Yes	No
S9485	March 20, 2020	Yes	No
T1017	March 20, 2020	Yes	No
V5011	March 20, 2020	Yes	No

Back to Top

Billing Providers

Telemedicine services will only be reimbursed for providers who are enrolled in Health First Colorado at the time of service.

The availability of services through telemedicine in no way alters the scope of practice of any health care provider, nor does it authorize the delivery of health care services in a setting or manner not otherwise authorized by law. [C. R. S. 2018, 25.5-5-414 (7)(a) & (b)].

Back to Top

Originating Site Billing

The originating site (originating provider) is where the member is located. For an allowable provider type to bill for the originating site facility fee, the member and provider must be physically present in the same location.

All telemedicine services are billed on the CMS 1500 paper claim form or as an 837P transaction regardless of provider type.

The originating provider may bill for other Health First Colorado-covered services that were provided during the same visit as the Telemedicine visit.

In some cases, the originating provider site will not be providing clinical services, but only providing a site and telecommunications equipment. In this situation, the telemedicine originating site facility fee is billed using procedure code Q3014.

Originating providers bill as follows:

• If the originating provider is making a room and telecommunications equipment available but is not providing clinical services, the originating provider bills Q3014 (the procedure code for the telemedicine originating site facility fee).
• If the originating provider also provides clinical services to the member, the provider bills the rendering provider's appropriate procedure code and bills Q3014.
• The originating provider may also bill, as appropriate, on the UB-04 paper claim form or as an 837I transaction for any clinical services provided on-site on the same day that a telemedicine originating site claim is made. The originating provider must submit two separate claims for the member's two separate services.

Back to Top

Distant Providers

All distant providers should bill the appropriate procedure code and Place of Service 02 or 10 and FQ or FR modifiers if appropriate on the CMS 1500 paper claim form or as an 837P transaction.

When the patient is located in a hospital, please use the appropriate place of service code for where the patient is located.

Back to Top

Billing HCPCS Q3014

The following provider types may bill procedure code Q3014 (telemedicine originating site facility fee):

Physician	05
Clinic	16
Osteopath	26
FQHC	32
Doctorate Psychologist	37
MA Psychologist	38
Physician Assistant	39
Nurse Practitioner	41
RHC	45

Provider types not listed above may facilitate Telemedicine Services with a distant provider but may not bill procedure code Q3014. Examples include Nursing Facilities, Intermediate Care Facilities, Assisted Living Facilities, etc.

If practitioners at both the originating site and the distant site provide the same service to the member, both providers submit claims using the same procedure code with modifier 77 (Repeat procedure by another physician).

The originating site may not bill for assisting the distant site provider with an examination.

Back to Top

Telemedicine Place of Service Codes

All rendering providers must bill the appropriate procedure code using Place of Service code 02 or 10 and the appropriate modifiers FQ or FR on the CMS 1500 paper claim form or as an 837P transaction.

When the patient is located in a hospital, please use the appropriate place of service code for where the patient is located.

Place of Services codes 02 and 10 can be used during telehealth encounters:

• POS 02: Telehealth provided other than in the patient’s home. The location where health services and health related services are provided or received, through telecommunication technology. Patient is not located in their home when receiving health services or health related services through telecommunication technology.
• POS 10: Telehealth Provided in Patient’s Home. The location where health services and health related services are provided or received through telecommunication technology. Patient is located in their home (which is a location other than a hospital or other facility where the patient receives care in a private residence) when receiving health services or health related services through telecommunication technology. 

Additionally, modifiers FQ, FR, 93, and 95 can be added to POS 2 and 10:

• FQ: The service was furnished using audio-only communication technology.
• FR: The supervising practitioner was present through two-way, audio/video communication technology.
• 93: Synchronous Telemedicine Service Rendered Via Telephone or Other Real-Time Interactive Audio-Only Telecommunications System
• 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System
   

The following provider types may bill using modifier GT:

Physician	05
Clinic	16
Osteopath	26
FQHC	32
Doctorate Psychologist	37
MA Psychologist	38
Physician Assistant	39
Nurse Practitioner	41
RHC	45

Procedure codes listed below under Telemedicine Modifier GT" will receive an additional $5.00 to the fee listed on the most recent Health First Colorado Fee Schedule when billed using modifier GT.

Back to Top

Rendering Providers

If a rendering provider's number is required on the claim for a face-to-face visit, it is required on the claim for a telemedicine visit.

Clinics and the other provider types are required to enter the rendering provider's Health First Colorado provider number in field 19D.

When an originating site bills Q3014 (telemedicine originating site facility fee), there is generally no rendering provider actually involved in the service at the originating site.

However, a rendering provider number is still required and must be affiliated with the billing provider. The facility may enter either the member's usual provider's number, or another provider number affiliated with that site as the rendering provider.

When the member sees a rendering provider at the originating site and also uses the site as the telemedicine originating site, the facility bills the rendered service procedure code and Q3014 for the use of the telemedicine facility. The same rendering provider number is entered in field 19D.

Back to Top

Telemedicine Modifier GT

When used by an FQHC or RHC, the modifier GT identifies the services as being delivered through telemedicine modality. There is no enhanced payment to FQHCs and RHCs when using the modifier GT.

The following procedure codes, when billed with modifier GT by appropriate providers, pay the telemedicine transmission fee (an additional $5.00 to the fee listed in the most recent Health First Colorado Fee Schedule). Any other procedure codes billed with modifier GT will not pay the telemedicine transmission fee. When providing Family Planning via Telemedicine, appropriate providers may use the combination modifier codes of FP/GT (in this order).

Procedure Codes	Comments
Outpatient Mental Health
90791	If interactive complexity then report with add on code 90785
90832	If interactive complexity then report with add on code 90785
90833	Use in conjunction with appropriate E/M code If interactive complexity then report with add on code 90785
90834	If interactive complexity then report with add on code 90785
90836	If interactive complexity then report with add on code 90785
90837	Medicare crossover only
90838	Medicare crossover only
90863	can be added to primary psychotherapy code
90846
90847
Evaluation & Management
99201
99202
99203
99204
99205
99211
99212
99213
99214
99215
Speech Therapy
92507
97532
Obstetrical Ultrasounds
76801
76802
76805
76810
76811
76812
76813
76814
76815
76816
76817
Other
96116

Back to Top

CMS 1500 Paper Claim Reference Table

The following paper form reference table shows required, optional, and conditional fields and detailed field completion instructions for the CMS 1500 claim form.

CMS Field Number & Label	Field is?	Instructions
1. Insurance Type	Required	Place an "X" in the box marked as Medicaid.
1a. Insured's ID Number	Required	Enter the member's Health First Colorado seven-digit Health First Colorado ID number as it appears on the Medicaid Identification card. Example: A123456.
2. Patient's Name	Required	Enter the member's last name, first name, and middle initial.
3. Patient's Date of Birth/Sex	Required	Enter the member's birth date using two digits for the month, two digits for the date, and two digits for the year. Example: 070114 for July 1, 2014. Place an "X" in the appropriate box to indicate the sex of the member.
4. Insured's Name	Conditional	Complete if the member is covered by a Medicare health insurance policy. Enter the insured's full last name, first name, and middle initial. If the insured used a last name suffix (e.g., Jr, Sr), enter it after the last name and before the first name.
5. Patient's Address	Not Required
6. Patient's Relationship to Insured	Conditional	Complete if the member is covered by a commercial health insurance policy. Place an "X" in the box that identifies the member's relationship to the policyholder.
7. Insured's Address	Not Required
8. Reserved for NUCC Use	Not Required
9. Other Insured's Name	Conditional	If field 11d is marked "YES", enter the insured's last name, first name and middle initial.
9a. Other Insured's Policy or Group Number	Conditional	If field 11d is marked "YES", enter the policy or group number.
9b. Reserved for NUCC Use
9c. Reserved for NUCC Use
9d. Insurance Plan or Program Name	Conditional	If field 11D is marked "YES", enter the insurance plan or program name.
10a-c. Is patient's condition related to?	Conditional	When appropriate, place an "X" in the correct box to indicate whether one or more of the services described in field 24 are for a condition or injury that occurred on the job, as a result of an auto accident or other.
10d. Reserved for Local Use
11. Insured's Policy, Group or FECA Number	Conditional	Complete if the member is covered by a Medicare health insurance policy. Enter the insured's policy number as it appears on the ID card. Only complete if field 4 is completed.
11a. Insured's Date of Birth, Sex	Conditional	Complete if the member is covered by a Medicare health insurance policy. Enter the insured's birth date using two digits for the month, two digits for the date and two digits for the year. Example: 070114 for July 1, 2014. Place an "X" in the appropriate box to indicate the sex of the insured.
11b. Other Claim ID	Not Required
11c. Insurance Plan Name or Program Name	Not Required
11d. Is there another Health Benefit Plan?	Conditional	When appropriate, place an "X" in the correct box. If marked "YES", complete 9, 9a and 9d.
12. Patient's or Authorized Person's signature	Required	Enter "Signature on File", "SOF", or legal signature. If there is no signature on file, leave blank or enter "No Signature on File". Enter the date the claim form was signed.
13. Insured's or Authorized Person's Signature	Not Required
14. Date of Current Illness Injury or Pregnancy	Conditional	Complete if information is known. Enter the date of illness, injury or pregnancy, (date of the last menstrual period) using two digits for the month, two digits for the date and two digits for the year. Example: 070114 for July 1, 2014. Enter the applicable qualifier to identify which date is being reported. 431 - Onset of Current Symptoms or Illness 484 - Last Menstrual Period
15. Other Date Not	Not Required
16. Date Patient Unable to Work in Current Occupation	Not Required
17. Name of Referring Physician	Conditional
17b. NPI of Referring Physician	Required	Required in accordance with Program Rule 8.125.8.A
18. Hospitalization Dates Related to Current Service	Not required
19. Additional Claim Information	Conditional
20. Outside Lab? $ Charges	Not Required
21. Diagnosis or Nature of Illness or Injury	Required	Enter at least one but no more than twelve diagnosis codes based on the member's diagnosis/condition. Enter applicable ICD-10 indicator.
22. Medicaid Resubmission Code	Conditional	List the original reference number for resubmitted claims. When resubmitting a claim, enter the appropriate bill frequency code in the left- hand side of the field. 7 - Replacement of prior claim 8 - Void/Cancel of prior claim This field is not intended for use for original claim submissions.
23. Prior Authorization	Conditional	Enter the six-character prior authorization number from the approved Prior Authorization Request (PAR). Do not combine services from more than one approved PAR on a single claim form. Do not attach a copy of the approved PAR unless advised to do so by the authorizing agent or the fiscal agent.
24. Claim Line Detail	Information	The paper claim form allows entry of up to six detailed billing lines. Fields 24A through 24J apply to each billed line. Do not enter more than six lines of information on the paper claim. If more than six lines of information are entered, the additional lines will not be entered for processing. Each claim form must be fully completed (totaled). Do not file continuation claims (e.g., Page 1 of 2).
24A. Dates of Service	Required	The field accommodates the entry of two dates: a "From" date of services and a "To" date of service. Enter the date of service using two digits for the month, two digits for the date and two digits for the year. Example: 010119 for January 1, 2019. From To 01 01 19             or From To 01 01 19 01 01 19 Span dates of service From To 01 01 19 01 31 19 Practitioner claims must be consecutive days. Single Date of Service: Enter the six-digit date of service in the "From" field. Completion of the "To" field is not required. Do not spread the date entry across the two fields. Span billing: permissible if the same service (same procedure code) is provided on consecutive dates. Supplemental Qualifier To enter supplemental information, begin at 24A by entering the qualifier and then the information. ZZ - Narrative description of unspecified code N4 - National Drug Codes Enter NDC qualifier N4 (left-justified), immediately followed by the 11-digit NDC numeric code. Enter one space for separation. Enter the appropriate qualifier for the correct dispensing NDC unit of measure (UN - Units, ML - Milliliter, GR - Gram, or F2 - International Unit), immediately followed by the quantity (number of NDC units). VP - Vendor Product Number OZ - Product Number CTR - Contract Rate JP - Universal/National Tooth Designation JO - Dentistry Designation System for Tooth & Areas of Oral Cavity
24B. Place of Service	Required	Enter the Place of Service (POS) code 02 or 10 for services delivered using telemedicine modality.
24C. EMG	Not Required
24D. Procedures, Services, or Supplies	Required	Enter the procedure code that specifically describes the service for which payment is requested.
24D.	Required	Enter the HCPCS procedure code that specifically describes the service for which payment is requested. All procedures must be identified with codes in the current edition of Physicians Current Procedural Terminology (CPT). CPT is updated annually. HCPCS Level II Codes The current Medicare coding publication (for Medicare crossover claims only). Only approved codes from the current CPT or HCPCS publications will be accepted. Telemedicine For originating provider use procedure code Q3014. For distant provider use procedure code + modifier GT.
24D. Modifier	Conditional	Enter the appropriate procedure-related modifier that applies to the billed service. Up to four modifiers may be entered when using the paper claim form. GT Via Interact Audio/Video System/strong>,
24E. Diagnosis Pointer	Required	Enter the diagnosis code reference letter (A-L) that relates the date of service and the procedures performed to the primary diagnosis. At least one diagnosis code reference letter must be entered. When multiple services are performed, the primary reference letter for each service should be listed first, other applicable services should follow. This field allows for the entry of 4 characters in the unshaded area.
24F. $ Charges	Required	Enter the usual and customary charge for the service represented by the procedure code on the detail line. Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number. Some CPT procedure codes are grouped with other related CPT procedure codes. When more than one procedure from the same group is billed, special multiple pricing rules apply. The base procedure is the procedure with the highest allowable amount. The base code is used to determine the allowable amounts for additional CPT surgical procedures when more than one procedure from the same grouping is performed. Submitted charges cannot be more than charges made to non-Health First Colorado covered individuals for the same service. Do not deduct Health First Colorado co- payment or commercial insurance payments from the usual and customary charges.
24G. Days or Units	Required	Enter the number of services provided for each procedure code. Enter whole numbers only- do not enter fractions or decimals.
24H. EPSDT/Family Plan	Conditional	EPSDT (shaded area) For Early & Periodic Screening, Diagnosis, and Treatment related services, enter the response in the shaded portion of the field as follows: AV - Available- Not Used S2 - Under Treatment ST - New Service Requested NU - Not Used Family Planning (unshaded area) Not Required
24I. ID Qualifier	Not Required
24J. Rendering Provider ID #	Required	In the shaded portion of the field, enter the NPI of the Health First Colorado provider assigned to the individual who actually performed or rendered the billed service. This number cannot be assigned to a group or clinic.
25. Federal Tax ID Number	Not Required
26. Patient's Account Number	Optional	Enter information that identifies the member or claim in the provider's billing system. Submitted information appears on the Remittance Advice (RA).
27. Accept Assignment?	Required	The accept assignment indicates that the provider agrees to accept assignment under the terms of the payer's program.
28. Total Charge	Required	Enter the sum of all charges listed in field 24F. Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.
29. Amount Paid	Conditional	Enter the total amount paid by Medicare or any other commercial health insurance that has made payment on the billed services. Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.
30. Rsvd for NUCC Use
31. Signature of Physician or Supplier Including Degrees or Credentials	Required	Each claim must bear the signature of the enrolled provider or the signature of a registered authorized agent. Each claim must have the date the enrolled provider or registered authorized agent signed the claim form. Enter the date the claim was signed using two digits for the month, two digits for the date and two digits for the year. Example: 070116 for July 1, 2016. Unacceptable signature alternatives: Claim preparation personnel may not sign the enrolled provider's name. Initials are not acceptable as a signature. Typed or computer printed names are not acceptable as a signature. Signature on file notation is not acceptable in place of an authorized signature.
32. Service Facility Location Information 32a- NPI Number 32b- Other ID #	Required	Enter the name, address and ZIP code of the individual or business where the member was seen or service was performed in the following format: 1st Line Name 2nd Line Address 3rd Line City, State and ZIP Code If the Provider Type is not able to obtain an NPI, enter the eight-digit Health First Colorado provider number of the individual or organization.
33. Billing Provider Info & Ph #	Required	Enter the name of the individual or organization that will receive payment for the billed services in the following format: 1st Line Name 2nd Line Address 3rd Line City, State and ZIP Code
33a- NPI Number	Required
33b- Other ID #		If the Provider Type is not able to obtain an NPI, enter the eight-digit Health First Colorado provider number of the individual or organization.

Back to Top

Telemedicine Originator Claim Example

Back to Top

Telemedicine Originator Claim Example

Back to Top

Timely Filing

For more information on timely filing policy, including the resubmission rules for denied claims, refer to the General Provider Information Manual located on the Billing Manuals web page under the General Provider Information drop-down menu.

Back to Top

Telemedicine Revisions Log

Revision Date	Addition/Changes	Made by
12/1/2016	Manual revised for interChange implementation. For manual revisions prior to 12/01/2016, please refer to Archive.	HPE
12/27/2016	Updates based on Colorado iC Stage II Provider Billing Manual Comment Log v0_2.xlsx	HPE
1/10/2017	Updates based on Colorado iC Stage Provider Billing Manual Comment Log v0_3.xlsx	HPE
1/19/2017	Updates based on Colorado iC Stage Provider Billing Manual Comment Log v0_4.xlsx	HPE
1/26/2017	Updates based on Department 1/20/2017 approval email	HPE
5/22/2017	Updates based on Fiscal Agent name change from HPE to DXC	DXC
2/20/2018	Updates based on Departments	DXC
2/23/2018	Removed NDC supplemental qualifier - not relevant for Telemedicine providers	DXC
6/15/2018	Updated timely filing information and removed references to LBOD, removed general billing information already available in the General Provider Information manual	DXC
6/7/2019	Language clarification. removed education-only services from the "Not Covered Services" section as these will now be covered. Not moving forward with requiring POS 02 for telemedicine claims so removed. POS was clarified to read "where the patient is located" as opposed to "where services were rendered."	HCPF
6/19/2019	Reformatted to correct page numbering issue	HCPF
01/03/2020	Converted to web page	HCPF
05/20/2020	Revised content through for clarity.	HCPF
9/14/2020	Added Line to Box 32 under the CMS 1500 Paper Claim Reference Table	HCPF
11/23/2020	Adding information specific to FQHC/RHC billing and distant site coverage	HCPF
4/6/2021	Adding information specific to Telemedicine Modifier GT	HCPF
2/1/2022	Editing POS to include 02 and 10. Adding info on modifier FQ and FR	HCPF
2/14/2022	Added information on EPSDT	HCPF
10/20/2022	Added information on eHealth Entity Provider Specialty Types	HCPF
5/9/2023	Added for end of PHE, added list of allowed procedure codes	HCPF
7/7/2023	Added clarifying language under non-Covered Services	HCPF