Home Telemonitoring Benefits for Texas Medicaid Will Change

Date: September 9, 2024

Attention: Providers

Effective date: September 1, 2024

Call to action: Texas Children’s Health Plan (TCHP) would like to inform providers that effective for dates of service on or after September 1, 2024, home telemonitoring (also known as remote patient monitoring) benefits will change for Texas Medicaid.

Overview of Benefit Changes

• Major changes to this medical benefit include the following:
• Updates to some home telemonitoring guidelines
• The addition of federally qualified health centers (FQHCs) and rural health clinics (RHCs) as home telemonitoring providers
• Prior authorization updates

Home Telemonitoring Guidelines

• Home telemonitoring providers must establish a plan of care with outcome measures based on the physician’s or requesting provider’s order for each patient. 
• The plan of care and outcome measures must be reviewed by the patient’s physician or requesting provider.
• Scheduled periodic reporting of patient data to the physician or requesting provider is required in the event of a measurement outside the parameters established in the physician’s orders, or at least once per month when there have been no readings outside the established parameters.

Billing information: When submitting a claim for home telemonitoring services, home health agency providers must submit revenue code 780 with procedure code S9110.

FQHC and RHC information

FQHC and RHC providers may be reimbursed separately for the provision of home telemonitoring services if the services follow all requirements and guidelines outlined in this article and in the following subsections of the Texas Medicaid Provider Procedures Manual (TMPPM), Telecommunication Services Handbook:

• Subsection 3.6, “Telemonitoring Services”
• Subsection 3.7.1, “Prior Authorization of Telemonitoring Services”
• Subsection 3.8.1, “Documentation Requirements for Telemonitoring Providers”

Procedure code G0511

• Procedure code G0511 will be a benefit for home telemonitoring services provided by an FQHC or RHC provider.
• One provider must bill for Initial equipment setup, patient education on use of the equipment, monthly collection and transmission of physiologic data, and physician or requesting provider services under procedure code G0511.
  •  At least 16 days of data collection per month are required for procedure code G0511 to be considered for reimbursement.

Prior Authorization information

• Procedure code G0511 will require prior authorization and will be reimbursable once per month per patient when services are provided by FQHC and RHC providers. Prior authorization requests that are submitted by home health agency or hospital providers for procedure code G0511 will be denied.
• Physicians and providers who may request home telemonitoring and sign prior authorization forms will include nurse practitioners, clinical nurse specialists, and physician assistants.
• For patients of any age who have diabetes or hypertension, only one of the following risk factors will be required for approval of home telemonitoring services:
• Two or more hospitalizations in the previous 12-month period
  • Frequent or recurrent emergency department visits
  • A documented history of poor adherence to medication regimens
  • Documented risk of falls
  • A documented history of care access challenges
• The Home Telemonitoring Services Prior Authorization Request Texas Medicaid form and instructions will be revised to reflect the updated prior authorization criteria and provider information identified in this alert. The revised form and instructions will be available on the electronic prior authorization portal and as a fillable PDF on the Texas Medicaid & Healthcare Partnership (TMHP) website beginning September 1, 2024.
•  The previous version of the Home Telemonitoring Services Prior Authorization Request Texas Medicaid form (revised 08/20/2021) will no longer be accepted after November 30, 2024. If the discontinued form is submitted on or after December 1, 2024, TMHP will return the form to the provider with a request that the revised form be submitted

Next step for Providers: Providers are strongly advised to share this information with their staff and adhere to the guidelines outlined in this communication. 

If you have any questions, please email Provider Relations at: providerrelations@texaschildrens.org. 

For access to all provider alerts,log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.