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Provider Manual

Telehealth Documentation Requirements

Last Updated on January 12, 2022

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); recommended but not required for Medicaid.
  • Listing all clinical participants, roles and actions (e.g., applicable when member presents at a clinic with MD at another location); recommended but not required for Medicaid.
  • Member location (e.g., clinic [city/name], home, etc.); recommended but not required for Medicaid.
  • 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 (required on an annual basis for Medicaid).
  • Other documentation requirements are the same as a face-to-face encounter