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Special Contracting Requirements

Provider Assurance Requirements for Telemedicine


Telemedicine or Telehealth is the delivery of health care services or consultations through electronic communication while the patient is at one site (an originating site) and the licensed health care provider is at a distant site.

  • For Minnesota Health Care Programs (MHCP): Effective January 1, 2016, to be eligible for reimbursement of telemedicine under MHCP, providers must attest to criteria established by the Minnesota Department of Human Services to demonstrate the safety or efficacy of delivering a particular service via telemedicine.  The provider assurance requirements set forth below include those criteria and are incorporated by reference, as administrative requirements, into the Medica provider participation agreements.  These requirements pertain to services rendered by Medica participating providers to Medica Health Plans (“Medica”) members covered under MHCP. 
  • For Commercial, Medica Health Plan Solutions, and IFB Members: Effective January 1, 2017, to be eligible for reimbursement of telemedicine for all other Medica members enrolled for coverage under Medica benefit plans,  the provider assurance requirements set forth below will apply.  

Refer to Medica’s reimbursement policy on telemedicine for additional information including specific billing and coding requirements, such as the use of modifiers.

Provider Assurance Statement

As a provider billing for telemedicine services in accordance with Medica’s policy for services rendered to Medica members, you attest to compliance with the following requirements and acknowledge that you will maintain documentation proving compliance with the requirements:

  • Maintenance of written policies and procedures specific to telemedicine services that are reviewed and updated regularly;
  • Maintenance of policies and procedures that adequately address patient safety before, during and after the telemedicine service is rendered;
  • Establishment of protocols addressing how and when to discontinue telemedicine services;
  • Establishment of a quality assurance process related to telemedicine services which includes, without limitation, all applicable Health Insurance Portability and Accountability Act and regulations promulgated thereunder, as amended (“HIPAA”) requirements; and
  • Documentation of each occurrence of a health care service provided by telemedicine that includes all of the following-
    • The type of service provided,
    • The time the service began and the time the service ended,
    • A description of the provider’s basis for determining that telemedicine is an appropriate and effective means for delivering service to the recipient,
    • The mode of transmission of the telemedicine service, and
    • The location of the originating and the distant site.
Date: 8/18/2019 2:46:33 PM Version: 4.0.30319.42000 Machine Name: PWIVE-CMSWEB01