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Provider Manual

Telehealth Documentation Requirements

Last Updated on June 30, 2020

In order to ensure that medical records support telehealth services, Security Health Plan requires the following, at a minimum, be documented in the medical record:

  • Method of telehealth (e.g., secure two-way interactive video connection, phone call, etc.)
  • Provider location (e.g., clinic [city/name], home, other)
  • Listing all clinical participants, roles and actions (e.g., applicable when member presents at a clinic with MD at another location)
  • Member location (e.g., clinic [city/name], home, etc.)
  • Time spent in medical discussion must be explicitly documented to support the procedure code billed, including start/stop times, if required for the service (e.g., psychotherapy)
  • Patient consent
    • Providers must document confirmation that a member agrees to receive services via telehealth, verbal consent to receiving telehealth is an acceptable method but must be documented in the medical record
  • Other documentation requirements are the same as a face-to-face encounter