Running Down a Payer's OB Telehealth Policy

Why this is per-payer work

There is no universal telehealth rulebook. Medicare publishes one set of rules, each state Medicaid program another, and every commercial plan writes its own policy, often differing between product lines under the same brand. The same virtual prenatal problem visit can be a clean 99214 95 10 claim on one plan and a rejection on the next, purely on configuration. Denials are the expensive way to learn a policy; the grid below is the cheap way.

Where policies actually live

In rough order of authority:

• The provider manual and payer policy bulletins, usually under “telehealth” or “telemedicine” on the payer’s provider portal. This is the citable source; save the PDF and the date.
• CMS, for Medicare: the annual Physician Fee Schedule rule and the telehealth services list.
• State Medicaid fee schedules and provider notices, plus state telehealth parity laws, which constrain what commercial plans in that state can do.
• Your contracts. Parity and covered-service language sometimes lives in the fee agreement, not the public policy.
• Provider relations, in writing. When the published policy is ambiguous, ask by portal message or email so the answer is documented. A phone answer is not a source.

The five questions to answer per payer

1. Eligible codes. Is it the 99202–99215 series, the 98000-series, or both? Are consult codes, NST interpretation, and RPM codes on the list?
2. Modifier. 95, legacy GT, or none required? What does the plan want for audio-only, 93 or something plan-specific?
3. POS. Does the plan follow the 02/10 split, and does POS 10 price at the non-facility rate? See POS 02 vs 10.
4. Parity. Is a video visit paid at the in-person allowable, a percentage of it, or a separate telehealth fee schedule?
5. Audio-only. Covered at all, and under which code family and conditions? See audio-only rules.

Building the payer grid

One row per plan, one column per question, plus a source link and a verified date. Something like:

Keep it wherever the billing team already lives, a shared sheet is fine. What makes it work is discipline, not tooling: every cell has a source, every row has a date, and a claim rule never changes based on memory.

Keeping it alive

Telehealth policy has stabilized since the PHE years but it has not stopped moving. Medicare adjusts the telehealth list annually and commercial plans revise mid-year. A quarterly re-verification pass, plus an update whenever a telehealth denial contradicts the grid, keeps the grid trustworthy. A stale grid fails exactly like having no grid, just more confidently.

FAQ

Where do I find a payer’s telehealth policy? Start with the provider portal’s medical policy or reimbursement policy section, searching “telehealth” and “telemedicine”. If the published policy does not answer one of the five questions, ask provider relations in writing.

Do commercial payers have to pay the same as in-person visits? Only where a state parity law or the contract says so. Many states mandate coverage parity but not payment parity, which is why the parity column belongs on the grid rather than being assumed.

How often should we re-verify telehealth policies? Quarterly is the practical floor in 2026, plus immediately when a denial pattern contradicts your grid. Annual is not enough while CMS and plans are still adjusting post-PHE rules.

Which payer rules apply to a Medicaid managed care plan? Generally the state Medicaid telehealth rules set the floor and the managed care plan’s own policy sits on top. Check both, and treat the plan’s provider manual as the operative document for claim mechanics.