Telehealth Services

Reimbursement Policy: NDRP-GC-015
Topic: Telehealth Services
Effective Date: July 1, 2018          
Last Reviewed:
June 18, 2019



This policy addresses BCBSND’s reimbursement and coding guidelines for telehealth services.


Telehealth services is defined as the use of interactive audio, video or other telecommunications technology delivered over a secure connection that complies with the requirements as determined by BCBSND. Telehealth Services are provided by a Health Care Provider at a Distant Site providing covered services to the member at an Originating Site. This includes the use of Store-and-Forward Technology. Telehealth Services do not include the use of audio-only telephone, electronic mail or facsimile transmissions.

The following definitions apply to Telehealth Services:

  • Distant Site – a site at which a Health Care Provider or health care facility is located while providing medical services by means of telehealth via interactive audio video telecommunications technology.
  • Originating Site – a site at which a patient is located at the time health services are provided to the patient by means of telehealth via interactive audio video telecommunications technology.
  • Store-and-Forward Technology – the electronic information, imaging and communication that is transferred, recorded or otherwise stored in order to be reviewed at a Distant Site at a later date by a Health Care Provider or health care facility without the patient present in real time. The term includes telehome monitoring and interactive audio, video and data communication.


This policy is based on the CMS Telehealth (telemedicine) guidelines, North Dakota State Rules and Regulations (NDSRR) around telehealth services, and specific BCBSND coverage guidelines.

Blue Cross provides reimbursement for certain telehealth visits. The service must be between a patient and practitioner. Provider to provider telehealth visits are not reimbursed.

Eligible telehealth services include codes allowed per the CMS guidelines, NDSRR and BCBSND benefit coverage. Eligible sites may be reimbursed for the originating site fee. Both the distant site physician/QHP and the eligible originating site will submit a claim for their services. The distant site physician/QHP will bill the appropriate eligible code for the telehealth service(s) provided. The eligible originating site will bill for the originating site facility fee only. The originating site fee is billable on either the professional or institutional claim form.

Coding Requirements:

Originating Site Billing Requirements UB-04 Claim Form:

  • HCPCS – Q3014 (Telehealth originating site facility fee)
  • Revenue Code  – 0780 (Telemedicine, General Classification)

 CMS-1500 Form:

  • HCPCS – Q3014 (Telehealth originating site facility fee)
Distant Site Physician/Practitioner Billing Requirements CMS-1500 Claim Form:


  • GT Modifier – Via interactive audio and video telecommunication systems.

           Note: Effective January 1, 2018, the GT modifier is no longer required.

  • G0 Modifier – Telehealth services for diagnosis, evaluation, or treatment of symptoms of an acute stroke.

POS Code –

  • 02 Telehealth  


Telehealth visits are subject to the terms of the member’s contract and may not be covered under the member’s health plan.

The following applies to all claim submissions.

All coding and reimbursement is subject to all terms of the Provider Group Participation Agreement and subject to changes, updates, or other requirements of coding rules and guidelines. All codes are subject to federal HIPAA rules, and in the case of medical code sets (HCPCS, CPT, ICD-10), only codes valid for the date(s) of service may be submitted or accepted. Reimbursement for all Health Services are subject to current Blue Cross Medical Policy criteria, policies found in Provider Policy and Procedure Manual sections, Reimbursement Policies and all other provisions of the Provider Service Agreement (Agreement).

All payment for codes based on Relative Value Units (RVU) will include a site of service differential and will be calculated, if appropriate, using the appropriate facility or non-facility components, based on the site of service identified, as submitted by Provider.

Cross Reference:

–  Medical Policy – Telehealth

– CMS Medicare Learning Network (MLN) Telehealth Booklet


Reimbursement policies are intended only to establish general guidelines for reimbursement under BCBSND plans. BCBSND retains the right to review and update its reimbursement policy guidelines at its sole discretion.