RE: eConsults

TO: ALL PROVIDERS

Effective June 1, 2024, MetroPlusHealth will begin coverage for eConsults also known as electronic consultations between a treating/requesting provider and a consultative provider (physicians [including psychiatrists], physician assistants [PAs], nurse practitioners [NPs], midwives [MWs]).

eConsults are intended for patient-specific treatment questions to be answered by a consultative provider without an in-person visit.

The consultative provider should respond to the eConsult request within three business days.

Limitations:

• eConsults cannot be used to arrange a referral or an in-person visit.
• eConsults may not be appropriate for cases that involve complex decision-making and urgent medical decision-making.
• eConsults must be performed through electronic communication between the treating/requesting provider and the consultative provider.

Member Rights and Consent
The treating/requesting provider is required to provide information about the eConsult and obtain written or verbal consent from the member prior to each eConsult. Member has the right to refuse an eConsult and see a consultative provider in-person if they wish to do so.

Documentation Requirements
The following information must be documented in the medical record by the treating/requesting provider:

• the written or verbal consent made by the member for the eConsult
• the request made by the treating/requesting provider, and
• the recommendation and rationale from the consultative provider

Billing Guidelines
Both the treating/requesting provider and the consultative provider must be enrolled in the NYS Medicaid program to receive reimbursement for eConsults.

For dates of service June 1, 2024, onwards, please submit claims for eConsults with the correct CPT codes to prevent future denials.

• 99451 Consultative Provider
  • Interprofessional telephone/internet/electronic health record assessment and management service provided by a consultative physician or other qualified health care professional, including a written report to the patient’s treating/requesting physician or other qualified health care professional, 5
    minutes or more of medical consultative time.
• 99452 Treating/Requesting Provider
  • Interprofessional telephone/internet/electronic health record referral service(s) provided by a treating/requesting physician or other qualified health care professional, 30 minutes.

If you have any questions regarding this memo, please contact MetroPlusHealth at: [email protected].

Thank you.

MetroPlusHealth

> Download the PDF