Processing update for telehealth, acute hospital care at home claims
After issuing and lifting a claims processing hold for certain services during the government shutdown, CMS recently provided another processing update for telehealth and acute hospital care at home claims.
CMS previously instructed Medicare Administrative Contractors to pay telehealth claims with dates of service on or after October 1, 2025, identified as permissible to pay under current law. This includes behavioral and mental health services with specific Healthcare Common Procedure Coding System codes, telehealth claims with place of service code 10 and diagnosis codes F01.A0-F99 if the services were not performed by certain healthcare providers, and more.
CMS has not been able to identify all telehealth claims payable under current law due to system limitations and coding variabilities, which has caused a subset of claims to be held to this day. The agency will return telehealth claims that are currently being held, were submitted on or before November 10, 2025, and with dates of service on or after October 1, 2025, to providers. Professional claims will be returned with claim adjustment reason code 16 and remittance advice remark code M77 messages.
This move is designed to resolve this subset of claims and improve cash flow for practitioners, according to CMS. It added that organizations may resubmit returned claims that meet the statutory requirements.
CMS provided additional instructions for fee-for-service providers on submitting telehealth claims here. The agency noted that some organizations may choose to hold currently unpayable claims in anticipation of potential Congressional action that restores a broader range of Medicare telehealth services. These organizations should evaluate providing beneficiaries with an Advance Beneficiary Notice of Non-Coverage. Practitioners who do not want to hold these claims should submit them with modifier -GY and monitor for further instructions from CMS if/when Congress takes action to expand Medicare telehealth payments.