RCPA Shares Update on Medicare Telehealth Claims Hold

The Centers for Medicare and Medicaid Services (CMS) instructed all Medicare Administrative Contractors (MAC) to lift the claims hold and process claims with dates of service of October 1, 2025, or later for certain services impacted by select expired Medicare legislative payment provisions passed under the Full-Year Continuing Appropriations and Extensions Act, 2025 (Pub. L. 119-4, March 15, 2025).

This includes claims paid under the Medicare Physician Fee Schedule, ground ambulance transport claims, and Federally Qualified Health Center (FQHC) claims. This also includes telehealth claims that CMS can confirm are definitively for behavioral and mental health services. CMS has directed all MACs to continue to temporarily hold claims for other telehealth services (i.e. those that CMS cannot confirm are definitively for behavioral and mental health services) and for acute Hospital Care at Home claims.

Beginning October 1, 2025, many of the statutory limitations on payment for Medicare telehealth services that were lifted and subsequently extended in response to the COVID-19 Public Health Emergency through legislation again took effect for services that are not behavioral health services. These include prohibition of many services provided to beneficiaries in their homes and outside of rural areas, as well as hospice recertifications that require a face-to-face encounter. In the absence of Congressional action, practitioners who choose to perform telehealth services that are not payable by Medicare on or after October 1, 2025 may want to evaluate providing beneficiaries with an Advance Beneficiary Notice of Noncoverage (ABN). Further information on the use of an ABN, including ABN forms and form instructions, are available at CMS’ website. Practitioners should monitor Congressional action and may choose to hold claims associated with telehealth services that are currently not payable by Medicare in the absence of Congressional action. Visit here for more information.

CMS notes that the Bipartisan Budget Act of 2018 (Pub. L. 115-123, February 9, 2018), which added section 1899(l) to the Social Security Act, allows clinicians in applicable Medicare Shared Savings Program Accountable Care Organizations (ACO) to provide and receive payment for covered telehealth services to certain Medicare beneficiaries without geographic restrictions and in the beneficiary’s home. Separate from requirements to participate in the Medicare Shared Savings Program, there is no special application or approval process for applicable ACOs, their ACO participants, or ACO providers/suppliers to offer these covered telehealth services. Clinicians in applicable ACOs can furnish and receive payment for covered telehealth services under these special telehealth flexibilities. For clinicians in applicable ACOs, telehealth claims that CMS can confirm are definitively for behavioral and mental health services will be paid. At this time, claims for some telehealth services will continue to be held. View the fact sheet for information on to which ACOs these flexibilities apply.

If you have questions, please contact RCPA COO and Mental Health Policy Director Jim Sharp.