1. CareFirst Telemedicine Policy August 18, 2011

2. Defines Telemedicine as a combination of interactive audio, video, or other electronic media for the purpose of - Diagnosis - Consultation, or - Treatment CareFirst does not consider the following to meet the definition of telemedicine services - Audio-only telephone discussions - Electronic mail messaging (e-mail) - Facsimile transmissions (FAX) These definitions are consistent with legislation approved by the Virginia General Assembly in 2010, which became effective January 1, 2011. Current CareFirst Medical Policy

3. Diagnosis, consultation and/or treatment services provided via telemedicine means, must meet all the requirements of a traditional in office face-to-face interaction between the practitioner and a patient. We recommend that the practitioner has an established relationship with the patient receiving the service, however, consultations between the attending and consulting practitioner with the patient present, and not previously known to the consultant, may be warranted. Requirements and Recommendations

4. (continued) All medical record documentation must support the appropriateness of the telemedicine service. Utilization review may be performed periodically. Services are reported using the standard evaluation and management CPT ® codes with HCPCS modifier - GT appended, which indicates that the service was provided “via interactive audio & video telecommunication systems.”

5. Requirements and Recommendations (continued) Standard CareFirst fee schedule allowances are reimbursed. Patient cost-sharing (e.g., copayments) apply to telemedicine services the same as any other face-to-face interaction with the practitioner. There are no restrictions on the type of practitioner that can be reimbursed for telemedicine services as long as they are credentialed by CareFirst. We do not pay for any technical fees or costs associated with the provision of telemedicine services.