Back to Insights and Updates for ProvidersJuly 2023

MassHealth guidance on provider-to-provider e-consults

Tufts Health Plan Senior Care Options  |  Tufts Health Together - MassHealth MCO Plan and ACPPs  |  Tufts Health Unify

In response to the increased utilization of telehealth services, MassHealth released All Provider Bulletin 355 in October 2022 to announce their plan to implement a policy for coverage of provider-to-provider e-consults. More recently, MassHealth issued the March 2023 All Provider Bulletin 364 to provide additional information regarding the policy, including CPT codes available for billing e-consult services, as well as coverage and billing guidance.

Point32Health has updated our applicable Tufts Health Plan systems, as well as the Tufts Health Plan Evaluation and Management Professional Payment Policy, to reflect the guidance in this bulletin for dates of service on or after April 1, 2023, and Tufts Health Together claims are being reprocessed.

Changes include:

  • For an initial provider-to-provider e-consult, CPT code 99452 must be used (both to create the consult and respond to the member) for instances requiring at least 30 minutes of the requesting provider’s time. This code will only be paid one time per member in a 14-day period, even if billed multiple times during the period. Providers in a primary care setting or providing E/M services may bill 99452 when seeking specialty guidance from a specialist with whom the member doesn’t already have an established relationship, as outlined.
  • The following codes may be used to answer a provider-to-provider e-consult of five minutes or more medical consult time and/or acting in a specialty care and consultative function: 99451, 99446, 99447, 99448 or 99449. These codes will only be paid once per seven-day period per member, even if billed multiple times during the period. These codes will not pay if the member has already had an e-consult with another provider of the same type within 14 days; the provider rendering specialty guidance must be from a specialty type with whom the member doesn’t already have an established relationship.
  • Codes for e-consult must be billed on a professional claims form.
  • Telehealth modifiers are not required and will not be accepted for the following codes: 99446, 99447, 99448, 99449, 99451, or 99452.
  • E-consults may be billed for the same date of service as an office visit.

For more information, please refer to the updated Evaluation and Management Professional Payment Policy.

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