COVID-19 Payer Information

UPDATE - The Centers for Medicare & Medicaid Services (CMS) have released guidance for implementing several provisions included in the Coronavirus Aid, Relief, and Economic Security (CARES) Act. READ MORE 
Allwell from Absolute Total Care will be following this guidance as we adjudicate Medicare claims for applicable COVID-19 inpatient treatment services. The CARES Act provides for a 20% increase to the inpatient prospective payment system (IPPS) Diagnosis Related Group (DRG) rate for COVID-19 patients for the duration of the public health emergency.

>>>Click here to read past updates

UPDATE - COVID-19 Update 12/29/20 - Medicare Advantage. READ MORE 
Question - Will Aetna continue to follow the CARES Act legislation and the recent extension to reinstate Sequestration on April 1, 2021?
Answer - Yes. Aetna will follow the new extension for the CARES Act legislation. Beginning with claims dates of service on or after April 1, 2021, the Medicare 2% sequestration reduction will be applied to provider claim reimbursements.

Question - If the suspension of the sequestration adjustment is extended by legislation beyond the 4/1/2021, will Aetna continue to not apply the 2% reduction?
Answer - We will evaluate any new legislation and make related policy decisions at the time it occurs.

12/23/2020 - COVID-19 Vaccine FAQs 12/23/20. READ MORE 
Question - Which COVID-19 vaccinations will Aetna cover?
Answer - Aetna will cover any COVID-19 vaccine that has received FDA authorization, at no added cost to members. To date, the FDA has issued Emergency Use Authorizations for the Pfizer-BioNTech and Moderna COVID-19 vaccines.

12/14/2020 - Aetna helps members access COVID-19-related care through new and extended waivers. Aetna, a CVS Health company, announced that it is waiving member cost-sharing related to the COVID-19 vaccination for Commercial and Medicaid members. READ MORE  
For Medicare, CMS has indicated it will cover the full cost of the vaccine for all Medicare beneficiaries, including those in a Medicare Advantage plan, in 2020 and 2021. In addition, Aetna extended a series of cost-share waivers as part of its continued steps to help members access the care they need during the COVID-19 pandemic.

Extended waivers include:

^^ Waiving member cost-sharing for inpatient admissions for treatment of COVID-19 or health complications associated with COVID-19 for Commercial insured and Medicare Advantage plan members, through January 31, 2021.
^^ Waiving member cost-sharing for covered in-network telemedicine visits for outpatient behavioral and mental health counseling services for Commercial insured plan members, through January 31, 2021.
^^ Waiving member cost-sharing for covered in-network telemedicine visits for medical and behavioral health services for Aetna Student Health plan members through January 31, 2021.
^^ Waiving member cost-sharing for in-network telemedicine visits for Medicare Advantage members for specialist visits, which includes mental and behavioral health providers, through January 31, 2021.
^^ Waiving Medicare Advantage member cost-sharing for all in-network primary care visits, whether done in-office and via telehealth, for any reason, through January 31, 2021.
^^ Aetna continues to waive member cost-sharing for diagnostic testing related to COVID-19 for Commercial, Medicare and Medicaid members.

We are closely monitoring the progress of the pandemic, federal and state policies and the associated impact on our members, customers and providers. We’ll continue to adjust our policies, as appropriate, to ensure access to care.

>>>Click here to read past updates

AHA, Others Urge Congress to Pass Legislation to Provide Relief from Medicare Sequestration in 2021. READ MORE 
America’s front line health providers continue to battle the COVID-19 pandemic as it spikes in different communities across the country. We are concerned that persistent high COVID-19 rates will continue to stress the entire health care system. Our members provide health care to the more than 62 million Medicare beneficiaries. We urge you to pass legislation that would extend the congressionally-enacted moratorium on the application of the Medicare sequester cuts into 2021 and through the duration of the public health emergency (PHE).

UPDATE - High-Level Overview of Select Provisions in the Consolidated 2020 Omnibus Legislation. READ MORE 

High points are:
> The suspension of the Medicare Sequestration cut of 2 percent is continued. Originally set to end on December 31, 2020, the Medicare sequestration cut is pushed out and is now scheduled to end on March 31, 2021. This means, the 2 percent cut to Medicare payments is avoided for 3 months, which will provide a temporary but additional reprieve from a Medicare cut.

> Additional Provider Relief:
- $3 billion and new distribution requirements for the Provider Relief Fund.
- $1 billion in direct funds to the Indian Health Service to carry out services.

11/10/2020 - AMA Announces Vaccine-Specific CPT Codes for COVID-19 Immunizations. READ MORE 
Working closely with the Centers for Disease Control and Prevention, the CPT Editorial Panel has approved a unique CPT code for each of two coronavirus vaccines as well as administration codes unique to each such vaccine. The new CPT codes clinically distinguish each coronavirus vaccine for better tracking, reporting and analysis that supports data-driven planning and allocation. Importantly, these CPT codes are available prior to the public availability of the vaccines to facilitate updating of health care electronic systems across the U.S.

For quick reference, the new Category I CPT codes and long descriptors for the vaccine products are:

• 91300 Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3mL dosage, diluent reconstituted, for intramuscular use.
• 91301 Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5mL dosage, for intramuscular use.
• 0001A Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3mL dosage, diluent reconstituted; first dose.
• 0002A Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3mL dosage, diluent reconstituted; second dose.
• 0011A Immunization administration by intramuscular injection of Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5mL dosage; first dose.
• 0012A Immunization administration by intramuscular injection of Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5mL dosage; second dose.

>>>Click here to read past updates

UPDATE - COVID-19 Update 12/24/20. READ MORE 
Amerigroup recognizes the intense demands facing doctors, hospitals and all health care providers in the face of the COVID-19 pandemic. Today, unless otherwise required under state and federal mandates, as detailed below, Amerigroup is making adjustments to assist providers in caring for members. These adjustments apply to members of all lines of business, except as noted below, and in-network and out-of-network providers, where permissible. Medicare adjustments and suspensions may have different timeframes or changes where required by federal law.

Inpatient and respiratory care - - Prior authorization requirements are suspended for patient transfers from acute IP hospitals to skilled nursing facilities effective December 21, 2020 through January 15, 2021. These adjustments apply for our Medicare and Medicaid plan members receiving care from in-network providers. While prior authorization is not required, we continue to require notification of the admission via the usual channels and clinical records on day two of admission to aid in our members' care coordination and management. Amerigroup reserves the right to audit patient transfers.

COVID-19 Update 12/24/20 for Medicare Advantage. READ MORE 
Amerigroup recognizes the intense demands facing doctors, hospitals and all health care providers in the face of the COVID-19 pandemic. Today, unless otherwise required under State and Federal mandates as detailed below, Amerigroup is making adjustments to assist providers in caring for members. These adjustments apply to members of all lines of business except as noted below, including self-insured plan members and in-network and out-of-network providers, where permissible. We encourage our self-funded customers to participate, although these plans may have an opportunity to opt out. Medicare adjustments and suspensions may have different timeframes or changes where required by federal law. Where permissible, these guidelines apply to Federal Employee Plan (FEP) members.

Inpatient and respiratory care - - Prior authorization requirements are suspended for patient transfers from acute IP hospitals to skilled nursing facilities effective December 21, 2020 through January 15, 2021. These adjustments apply for our fully-insured and self-funded employer, individual, Medicare and Medicaid plan members receiving care from in-network providers. While prior authorization is not required, we continue to require notification of the admission via the usual channels and clinical records on day two of admission to aid in our members’ care coordination and management. Amerigroup reserves the right to audit patient transfers.

6/5/2020 - Telehealth (video + audio): effective March 17, 2020 through September 30, 2020, Amerigroup will waive any normally required member cost shares for telehealth visits from in-network providers, including visits for mental health or substance use disorders, for our Medicaid, Medicare-Medicaid (MMP) and CHIP members, where permissible. For out-of-network providers, normally required cost shares will be waived through June 15, 2020. Cost sharing will be waived for members using our authorized telemedicine service, LiveHealth Online, and for care received for other providers delivering virtual care through internet video and audio services. READ MORE

Telephonic - only care: effective March 19, 2020 through September 30, 2020, Amerigroup will cover telephonic-only visits with in-network providers. Out-of-network coverage will be provided where required. This includes covered visits for mental health or substance use disorders and medical services. Any normally required cost shares will be waived for in-network providers only. Exceptions include chiropractic services and physical, occupational, and speech therapies, and any services which require physical contact with the patient. These services require face-to-face interaction and therefore are not appropriate for telephone-only consultations. READ MORE

>>>Click here to read past updates

UPDATE - The payer is expanding its temporary suspension of prior authorization for acute in-network admissions from the emergency department to include all diagnoses (including COVID-19) and for in-network transfers and transportation between facilities. READ MORE

3/21/2020 - The payer will Cover and Waive Cost-Sharing for COVID-19 Testing (copays, deductibles, and coinsurance) when performed at a physician's office, urgent care, or ER. READ MORE

UPDATE - From March 17 through Dec. 31, 2020, Anthem will waive member cost shares for telehealth visits from in-network providers, including visits for mental health and substance use disorders, for our Medicare Advantage and Medicaid plans, where permissible. Effective from March 19 through December 31, 2020, Anthem’s affiliated health plans will cover telephonic-only visits with in-network providers. Out-of-network coverage will be provided where required. For out-of-network providers, Anthem is waiving cost shares from March 17 through June 14, 2020. Cost shares will be waived for in-network providers only. READ MORE 

5/1/2020 - Anthem has provided a repository of COVID-19 information including policies, webinar recordings, and Federal Resources available to Providers under the CARES Act. READ MORE

UPDATE - Information from Anthem for Care Providers About COVID-19 (Updated December 30, 2020). We’ve updated information about cost share waivers for COVID-19 treatment as well as cost share information for telehealth and telephonic-only care. READ MORE 
Will Anthem waive member cost shares related to COVID-19 including screening, testing, and treatment?  Yes, effective April 1, 2020, through January 31, 2021, Anthem and its delegated entities will waive cost shares for members undergoing treatment related to a COVID-19 diagnosis.

What member cost-shares will be waived by Anthem for virtual care through telehealth and telephone-only?

For in-network providers, effective March 17, through September 30, 2020, Anthem and its delegated entities will waive member cost share for telehealth (video + audio) and telephone-only visits from in-network providers, including visits for behavioral health, for our fully-insured employer, individual and Medicaid plans where permissible.

For Medicare plans, in-network providers, effective March 17, through December 31, 2020, Anthem and its delegated entities will waive member cost share for telehealth (video + audio) and telephone-only visits from in-network providers, including visits for behavioral health.

For out-of-network providers, Anthem is waiving cost shares for services received from March 17 through June 14, 2020. Cost sharing will be waived for members using Anthem’s telemedicine service, LiveHealth Online, as well as care received from other providers delivering virtual care through internet video + audio services. Self-insured plan sponsors may opt out of this program.

12/23/2020 - COVID-19 Update: We recently updated information regarding prior authorization requirements for patient transfers from acute inpatient hospitals to other levels of care. READ MORE 
Prior authorization requirements are suspended for patient transfers from acute IP hospitals to skilled nursing facilities, home health, acute rehabilitation, long-term acute care, swing beds, or any other lower level of care. These changes are effective December 22, 2020, and until further notice. These adjustments apply for our fully-insured and self- employer, individual, Medicare, and Medi-Cal plan members receiving care from in-network providers. While prior authorization is not required for facility transfers to lower levels of care, we continue to require notification of the admission via the usual channels and clinical records on day two of admission to aid in our members’ care coordination and management. Anthem reserves the right to audit patient transfers. Anthem encourages providers to continue to follow normal processes and obtain prior authorization and reminds providers that patient transfers should be to in-network facilities when possible.

10/16/2020 - We recently updated FAQs about telehealth and telephonic-only care.
READ MORE 
For in-network providers, effective March 17, through September 30, 2020, Anthem and its delegated entities will waive member cost share for telehealth (video + audio) and telephone-only visits from in-network providers, including visits for behavioral health, for our fully-insured employer, individual and Medicaid plans where permissible. For Medicare plans, in-network providers, effective March 17, through December 31, 2020, Anthem and its delegated entities will waive member cost share for telehealth (video + audio) and telephone-only visits from in-network providers, including visits for behavioral health.

For out-of-network providers, Anthem is waiving cost shares for services received from March 17 through June 14, 2020. Cost sharing will be waived for members using Anthem’s telemedicine service, LiveHealth Online, as well as care received from other providers delivering virtual care through internet video + audio services. Self-insured plan sponsors may opt out of this program.

>>>Click here to read past updates

UPDATE - Information from Anthem for Care Providers About COVID-19 (Updated December 30, 2020). We’ve updated information about cost share waivers for COVID-19 treatment as well as cost share information for telehealth and telephonic-only care. READ MORE 
Anthem’s affiliated health plans will waive cost shares for our fully-insured employer, individual, Medicare and Medicaid plan members—inclusive of copays, coinsurance and deductibles—for COVID-19 test and visits and services during the visit when the purpose of the visit is to be screened and/or tested for COVID-19, including telehealth visits. Anthem looks for the CS modifier to identify visits and services leading to COVID-19 testing. This modifier should be used for evaluation and testing services in any place of service including a doctor’s office, urgent care, ER or even drive-thru testing once available. Cost shares will be waived for emergency services related to COVID-19 testing or screening from either an in-network or out-of-network provider. If an in-network provider is not reasonably available, the cost share waivers will include testing or screening for COVID-19 when received from an out-of-network provider. While a test sample cannot be obtained through a telehealth visit, the telehealth provider can help you get to a provider who can do so. The waivers apply to members who have individual, employer-sponsored, Medicare and Medicaid plans.

Telehealth (video + audio) - For COVID-19 treatments via telehealth visits, Anthem’s affiliated health plans will cover telehealth and telephonic-only visits from in-network providers and will waive cost shares through January 31, 2021.

Effective from March 17 through September 30, 2020, Anthem’s affiliated health plans will waive member cost shares for telehealth visits from in-network providers, including visits for behavioral health, for insured health plans in Colorado under this guidance, including our fully-insured employer plans, individual plans and health savings account-qualified high deductible health plans (HSA-HDHPs). For out-of-network providers, Anthem is waiving cost shares from March 17 through June 14, 2020. Cost sharing will be waived for members using Anthem’s authorized telemedicine service, LiveHealth Online, as well as care received from other providers delivering virtual care through internet video + audio services. We encourage our self-funded customers to participate, and these plans will have an opportunity to opt in.

Telephonic-only care - Effective from March 19, 2020, through March 31, 2021, Anthem’s affiliated health plans will cover telephonic-only visits with in-network providers. Out-of-network coverage will be provided where required by law. This includes visits for behavioral health, for our fully insured employer plans, individual plans, Medicare plans and Medicaid plans, where permissible. This includes covered visits for mental health or substance use disorders and medical services, for our fully-insured employer plans, individual plans, Medicare plans and Medicaid plans, where permissible. Cost shares will be waived for in-network providers only. We encourage our self-funded customers to participate, and these plans will have an opportunity to opt in.

12/22/2020 - COVID-19 Update: We recently updated prior authorization requirements for patient transfers from acute inpatient hospitals to skilled nursing facilities. Prior authorization requirements are suspended for patient transfers from acute IP hospitals to skilled nursing facilities effective December 21, 2020 through January 15, 2021. READ MORE 

These adjustments apply for our fully-insured and self-funded employer, individual, Medicare and Medicaid plan members receiving care from in-network providers. While prior authorization is not required, we continue to require notification of the admission via the usual channels and clinical records on day two of admission to aid in our members’ care coordination and management. Anthem reserves the right to audit patient transfers.

12/2/2020 - COVID-19 Update - Prior Authorization and other policy adjustments.
READ MORE 
We’ve recently updated prior authorization requirements to be consistent with the Governor’s executive order regarding transfer and admission to another facility when the initial facility is determined by CDPHE to be at capacity. Consistent with the Colorado Governor’s Executive Order issued on November 23, 2020, if a Colorado facility is determined by CDPHE to be at capacity, a person transferred to another facility between now and December 23, 2020 under the terms of the executive order will be considered by Anthem has having an emergency medical condition.

This means the transfer and admission at the receiving facility are not subject to prior authorization requirements. It is important to remember that under the executive order, providers are required to follow the protections against balance billing and identify those patients that were transferred or received during this period. Any waiver of prior authorization is not a guarantee of payment. If the claim or patient is not properly identified, or if the claim is for a transfer outside the scope of the emergency order, the claim may deny for lack of benefit or lack of prior authorization. It is also important to remember that not all plans are subject to the order and if the patient’s identification card does not have “CO-DOI” on it, the patient’s plan may have different requirements.

Inpatient and respiratory care -
** Extending the length of time a prior authorization issued on or before May 30, 2020, is in effect for elective inpatient and outpatient procedures to 180 days. This will help prevent the need for additional outreach to Anthem to adjust the date of service covered by the authorization.
** Concurrent review for discharge planning will continue unless required to change by federal or state directive.
** Prior authorization requirements are suspended for COVD-19 Durable Medical Equipment including oxygen supplies, respiratory devices, continuous positive airway pressure (CPAP) devices, non-invasive ventilators, and multi-function ventilators for patients who need these devices for COVID-19 treatment, along with the requirement for authorization to exceed quantity limits on gloves and masks.
** Respiratory services for acute treatment of COVID-19 will be covered. Prior authorization requirements are suspended where previously required.

UPDATE - Information from Anthem for Care Providers About COVID-19 (Updated December 30, 2020). We’ve updated information about cost share waivers for COVID-19 treatment as well as cost share information for telehealth and telephonic-only care. READ MORE 
Anthem’s affiliated health plans will waive cost shares for our fully-insured employer, individual, Medicare and Medicaid plan members—inclusive of copays, coinsurance and deductibles—for COVID-19 test and visits and services during the visit when the purpose of the visit is to be screened and/or tested for COVID-19, including telehealth visits. Anthem looks for the CS modifier to identify visits and services leading to COVID-19 testing. This modifier should be used for evaluation and testing services in any place of service including a doctor’s office, urgent care, ER or even drive-thru testing once available. Cost shares will be waived for emergency services related to COVID-19 testing or screening from either an in-network or out-of-network provider. If an in-network provider is not reasonably available, the cost share waivers will include testing or screening for COVID-19 when received from an out-of-network provider. While a test sample cannot be obtained through a telehealth visit, the telehealth provider can help you get to a provider who can do so. The waivers apply to members who have individual, employer-sponsored, Medicare and Medicaid plans.

Telehealth (video + audio) - For COVID-19 treatments via telehealth visits, Anthem’s affiliated health plans will cover telehealth and telephonic-only visits from in-network providers and will waive cost shares through January 31, 2021.

Effective from March 17 through September 30, 2020, Anthem’s affiliated health plans will waive member cost shares for telehealth visits from in-network providers, including visits for behavioral health, for insured health plans in Colorado under this guidance, including our fully-insured employer plans, individual plans and health savings account-qualified high deductible health plans (HSA-HDHPs). For out-of-network providers, Anthem is waiving cost shares from March 17 through June 14, 2020. Cost sharing will be waived for members using Anthem’s authorized telemedicine service, LiveHealth Online, as well as care received from other providers delivering virtual care through internet video + audio services. We encourage our self-funded customers to participate, and these plans will have an opportunity to opt in.

Telephonic-only care - Effective from March 19, 2020, through March 31, 2021, Anthem’s affiliated health plans will cover telephonic-only visits with in-network providers. Out-of-network coverage will be provided where required by law. This includes visits for behavioral health, for our fully insured employer plans, individual plans, Medicare plans and Medicaid plans, where permissible. This includes covered visits for mental health or substance use disorders and medical services, for our fully-insured employer plans, individual plans, Medicare plans and Medicaid plans, where permissible. Cost shares will be waived for in-network providers only. We encourage our self-funded customers to participate, and these plans will have an opportunity to opt in.

12/22/2020 -  COVID-19 Update: We recently updated prior authorization requirements for patient transfers from acute inpatient hospitals to skilled nursing facilities. Prior authorization requirements are suspended for patient transfers from acute IP hospitals to skilled nursing facilities effective December 21, 2020 through January 15, 2021. READ MORE 
These adjustments apply for our fully-insured and self-funded employer, individual, Medicare and Medicaid plan members receiving care from in-network providers. While prior authorization is not required, we continue to require notification of the admission via the usual channels and clinical records on day two of admission to aid in our members’ care coordination and management. Anthem reserves the right to audit patient transfers.

9/29/2020 - COVID-19 Update: Guidance for telehealth/telephonic care for Behavioral Health services. We are extending cost share waivers for telehealth and telephonic-only care. READ MORE 
Q: How is Anthem approaching the provision of mental health outpatient and substance abuse outpatient services via telephonic-only visits?

A: Anthem is making adjustments in our policy in the provision of these telephonic-only services to address the need for expanded access outside of telehealth (audio + video) to include telephonic only visits with in-network providers and out-of-network providers where required. We expect all mental health outpatient and substance abuse outpatient will still be provided within benefits limits, authorization limits, medical necessity criteria, and within state and federal regulatory requirements and licensure requirements, including HIPAA compliance and the regulations regarding how substance use information in handled. These changes for telephonic-only visits will be effective from March 19 through December 31, 2020. We will continue to actively monitor the rapidly evolving situation.

>>>Click here to read past updates

UPDATE - COVID-19 Update 12/14/20. We recently updated prior authorization requirements for patient transfers from acute inpatient hospitals to other settings. READ MORE 
Prior authorization requirements are suspended for patient transfers from acute IP hospitals to skilled nursing facilities, home health, acute rehabilitation, long term acute care and swing beds effective December 3, 2020 through February 1, 2021.These adjustments apply for our fully-insured and self-funded employer, individual, and Medicare plan members receiving care from in-network providers. While prior authorization is not required, we continue to require notification of the admission via the usual channels and clinical records on day two of admission to aid in our members’ care coordination and management. Anthem reserves the right to audit patient transfers. Anthem encourages providers to continue to follow normal process and obtain prior authorization and reminds providers that patient transfers should be to in network facilities when possible.

9/29/2020 - COVID-19 Update: Guidance for telehealth/telephonic care for Behavioral Health services. We are extending cost share waivers for telehealth and telephonic-only care. READ MORE 
Q: How is Anthem approaching the provision of mental health outpatient and substance abuse outpatient services via telephonic-only visits?

A: Anthem is making adjustments in our policy in the provision of these telephonic-only services to address the need for expanded access outside of telehealth (audio + video) to include telephonic only visits with in-network providers and out-of-network providers where required. We expect all mental health outpatient and substance abuse outpatient will still be provided within benefits limits, authorization limits, medical necessity criteria, and within state and federal regulatory requirements and licensure requirements, including HIPAA compliance and the regulations regarding how substance use information in handled. These changes for telephonic-only visits will be effective from March 19 through December 31, 2020. We will continue to actively monitor the rapidly evolving situation.

>>>Click here to read past updates

UPDATE - COVID-19 Update: We recently updated prior authorization requirements for patient transfers from acute inpatient hospitals to skilled nursing facilities. Prior authorization requirements are suspended for patient transfers from acute IP hospitals to skilled nursing facilities effective December 21, 2020 through January 15, 2021. READ MORE 
These adjustments apply for our fully-insured and self-funded employer, individual, Medicare and Medicaid plan members receiving care from in-network providers. While prior authorization is not required, we continue to require notification of the admission via the usual channels and clinical records on day two of admission to aid in our members’ care coordination and management. Anthem reserves the right to audit patient transfers.

UPDATE - COVID-19 Update: We recently updated prior authorization requirements for patient transfers from acute inpatient hospitals to skilled nursing facilities. Prior authorization requirements are suspended for patient transfers from acute IP hospitals to skilled nursing facilities effective December 21, 2020 through January 15, 2021. READ MORE 
These adjustments apply for our fully-insured and self-funded employer, individual, Medicare and Medicaid plan members receiving care from in-network providers. While prior authorization is not required, we continue to require notification of the admission via the usual channels and clinical records on day two of admission to aid in our members’ care coordination and management. Anthem reserves the right to audit patient transfers.

11/23/2020 - Information from Anthem for Care Providers about COVID-19.
READ MORE 
We recently updated FAQs about telephonic-only care. For COVID-19 treatments via telehealth visits, Anthem’s affiliated health plans will cover telehealth and telephonic-only visits from in-network providers and will waive cost shares through December 31, 2020. Effective from March 19 through December 31, 2020, Anthem’s affiliated health plans will cover telephonic-only visits with in-network providers. Out-of-network coverage will be provided where required by law. This includes covered visits for mental health or substance use disorders and medical services, for our fully-insured employer plans, individual, Medicare plans and Medicaid plans, where permissible. Cost shares will be waived for in-network providers only. We encourage our self-funded customers to participate, and these plans will have an opportunity to opt in.

>>>Click here to read past updates

UPDATE - COVID-19 Update: We recently updated prior authorization requirements for patient transfers from acute inpatient hospitals to skilled nursing facilities. Prior authorization requirements are suspended for patient transfers from acute IP hospitals to skilled nursing facilities effective December 21, 2020 through January 15, 2021. READ MORE 
These adjustments apply for our fully-insured and self-funded employer, individual, Medicare and Medicaid plan members receiving care from in-network providers. While prior authorization is not required, we continue to require notification of the admission via the usual channels and clinical records on day two of admission to aid in our members’ care coordination and management. Anthem reserves the right to audit patient transfers.

11/12/2020 - Information from Anthem for Care Providers about COVID-19 (updated 11/12/20). READ MORE 
We recently updated FAQs about COVID-19 testing and visits associated with COVID-19 testing. Anthem’s affiliated health plans will waive cost shares for our fully-insured employer, individual, Medicare and Medicaid plan members—inclusive of copays, coinsurance and deductibles—for COVID-19 test and visits and services during the visit when the purpose of the visit is to be screened and/or tested for COVID-19, including telehealth. Anthem looks for the CS modifier to identify visits and services leading to COVID-19 testing. This modifier should be used for evaluation and testing services in any place of service including a doctor’s office, urgent care, ER or even drive-thru testing once available. Cost shares will be waived for emergency services related to COVID-19 testing or screening from either an in-network or out-of-network provider in Nevada. While a test sample cannot be obtained through a telehealth visit, the telehealth provider can help you get to a provider who can do so. The waivers apply to members who have individual, employer-sponsored, Medicare and Medicaid plans.

>>>Click here to read past updates

UPDATE - COVID-19 Update: We recently updated prior authorization requirements for patient transfers from acute inpatient hospitals to skilled nursing facilities. Prior authorization requirements are suspended for patient transfers from acute IP hospitals to skilled nursing facilities effective December 21, 2020 through January 15, 2021. READ MORE 
These adjustments apply for our fully-insured and self-funded employer, individual, Medicare and Medicaid plan members receiving care from in-network providers. While prior authorization is not required, we continue to require notification of the admission via the usual channels and clinical records on day two of admission to aid in our members’ care coordination and management. Anthem reserves the right to audit patient transfers.

11/2/2020 - Information from Anthem for Care Providers about COVID-19. READ MORE 
We recently updated FAQs about telephonic-only care. For COVID-19 treatments via telehealth visits, Anthem’s affiliated health plans will cover telehealth and telephonic-only visits from in-network providers and will waive cost shares through December 31, 2020. Effective from March 19 through December 31, 2020, Anthem’s affiliated health plans will cover telephonic-only visits with in-network providers. Out-of-network coverage will be provided where required by law. This includes covered visits for mental health or substance use disorders and medical services, for our fully-insured employer plans, individual, Medicare plans and Medicaid plans, where permissible. Cost shares will be waived for in-network providers only. We encourage our self-funded customers to participate, and these plans will have an opportunity to opt in.

>>>Click here to read past updates

UPDATE - Information from Anthem for Care Providers About COVID-19 (Updated December 30, 2020). We’ve updated information about cost share waivers for COVID-19 treatment as well as cost share information for telehealth and telephonic-only care. READ MORE 
Empire is waiving cost shares for our fully-insured employer, individual, Medicare and Medicaid plan members—inclusive of copays, coinsurance and deductibles—for COVID-19 test and visits associated with the COVID-19 test, including visits to determine if testing is needed. Empire looks for the CS modifier to identify visits and services leading to COVID-19 testing. This modifier should be used for evaluation and testing services in any place of service including a doctor’s office, urgent care, ER or even drive-thru testing. While a test sample cannot be obtained through a telehealth visit, the telehealth provider can help you get to a provider who can do so.

IMPORTANT: In-network providers are reminded that they may not collect any deductible, copayment, or coinsurance for COVID-19 testing or visits to get the test.

Telemedicine (live video + audio via app) - For COVID-19 treatments via telemedicine visits, Empire will cover telehealth and telephonic-only visits from in-network providers and will waive cost shares through January 31, 2021.

For non-COVID 19 treatments via telemedicine including covered visits for mental health and substance use disorders Empire will waive cost shares for in-network visits through November 9, 2020 or any longer period required by state law. This applies to fully insured employer plans, Individual plans and Medicaid plans, where permissible.
For out-of-network providers, Empire waived cost shares for these services through June 14, 2020. This applied to use of our LiveHealth Online platform, as well as for care received from other providers delivering virtual care through internet video + audio services. We encourage our self-funded customers to participate, and these plans will have an opportunity to opt in.

Telehealth (telephonic with video capability) - For COVID-19 treatments via telehealth visits, Empire will cover telehealth and telephonic-only visits from in-network providers and will waive cost shares through January 31, 2021.

Effective March 16, 2020, Empire began waiving member cost sharing for telehealth visits (by phone with video capability) with in-network, providers acting within the scope of their license. Out of network visits are also covered if the member’s benefit plan has out of network benefits. This includes covered visits for medical services as well as mental health and substance use disorders services, where medically appropriate if all other requirements for a covered health service are met. Self-insured plan sponsors may have opted out of this program. This waiver will remain in place from March 19 through December 31, 2020 or any longer period required by state law for our insured employer plans, individual plans and Medicaid plans, where permissible and from March 19 through September 30, 2020 for our Medicare members. Phone/video delivery must be HIPAA compliant.

12/22/2020 - COVID-19 Update: We recently updated prior authorization requirements for patient transfers from acute inpatient hospitals to skilled nursing facilities. Prior authorization requirements are suspended for patient transfers from acute IP hospitals to skilled nursing facilities effective December 21, 2020 through January 15, 2021. READ MORE 
These adjustments apply for our fully-insured and self-funded employer, individual, Medicare and Medicaid plan members receiving care from in-network providers. While prior authorization is not required, we continue to require notification of the admission via the usual channels and clinical records on day two of admission to aid in our members’ care coordination and management. Anthem reserves the right to audit patient transfers.

11/13/2020 - Information from Empire for Care Providers about COVID-19. We recently updated FAQs about cost shares for COVID-19 testing; COVID-19 testing and visits associated with COVID-19 testing. READ MORE 
Empire is waiving cost shares for our fully-insured employer, individual, Medicare and Medicaid plan members—inclusive of copays, coinsurance and deductibles—for COVID-19 test and visits associated with the COVID-19 test, including visits to determine if testing is needed. Empire looks for the CS modifier to identify visits and services leading to COVID-19 testing. This modifier should be used for evaluation and testing services in any place of service including a doctor’s office, urgent care, ER or even drive-thru testing. While a test sample cannot be obtained through a telehealth visit, the telehealth provider can help you get to a provider who can do so.

IMPORTANT: In-network providers are reminded that they may not collect any deductible, copayment, or coinsurance for COVID-19 testing or visits to get the test. 

>>>Click here to read past updates

UPDATE - COVID-19 Update 12/22/20. Prior authorization requirements are suspended for patient transfers from acute IP hospitals to skilled nursing facilities effective November 23, 2020 through January 15, 2021. READ MORE 
These adjustments apply for our fully-insured and self-funded employer, individual, Medicare and Medicaid plan members receiving care from in-network providers. While prior authorization is not required, we continue to require notification of the admission via the usual channels and clinical records on day two of admission to aid in our members’ care coordination and management. Anthem reserves the right to audit patient transfers.

11/25/2020 - Important COVID-19 update: Prior authorization and other policy adjustments (Updated November 25, 2020). READ MORE 
We’ve updated guidance about prior authorization requirements. These adjustments apply to members of all lines of business except as noted below, including self-insured plan members and in-network and out-of-network providers, where permissible. Medicare adjustments and suspensions may have different timeframes or changes where required by federal law.

Inpatient and respiratory care
** Prior authorization requirements are suspended for patient transfers from acute IP hospitals to skilled nursing facilities effective November 23 through December 31, 2020.These adjustments apply for our fully-insured and self-funded employer and individual plan members receiving care from in-network providers. While prior authorization is not required, we continue to require notification of the admission via the usual channels and clinical records on day two of admission to aid in our members’ care coordination and management. Anthem reserves the right to audit patient transfers.

** Prior authorization requirements suspended for patient transfers through May 30, 2020. Prior authorization will be waived for patient transfers from acute IP hospitals to skilled nursing facilities, rehabilitation hospitals, long-term acute care hospitals, and Behavioral Health residential/intensive outpatient/partial hospitalization programs, and to home health including ground transport in support of those transfers. Although prior authorization is not required, Anthem requests voluntary notification via the usual channels to aid in our members’ care coordination and management.

** Extending the length of time a prior authorization issued on or before May 30, 2020, is in effect for elective inpatient and outpatient procedures to 180 days. This will help prevent the need for additional outreach to Anthem to adjust the date of service covered by the authorization.

** Concurrent review for discharge planning will continue unless required to change by federal or state directive.

** Prior authorization requirements are suspended for COVD-19 Durable Medical Equipment including oxygen supplies, respiratory devices, continuous positive airway pressure (CPAP) devices, non-invasive ventilators, and multi-function ventilators for patients who need these devices for COVID-19 treatment, along with the requirement for authorization to exceed quantity limits on gloves and masks.

** Respiratory services for acute treatment of COVID-19 will be covered. Prior authorization requirements are suspended where previously required.

>>>Click here to read past updates

UPDATE - COVID-19 Update: We recently updated prior authorization requirements for patient transfers from acute inpatient hospitals to skilled nursing facilities. Prior authorization requirements are suspended for patient transfers from acute IP hospitals to skilled nursing facilities effective December 21, 2020 through January 15, 2021. READ MORE 
These adjustments apply for our fully-insured and self-funded employer, individual, Medicare and Medicaid plan members receiving care from in-network providers. While prior authorization is not required, we continue to require notification of the admission via the usual channels and clinical records on day two of admission to aid in our members’ care coordination and management. Anthem reserves the right to audit patient transfers.

9/29/2020 - COVID-19 Update: Guidance for telehealth/telephonic care for Behavioral Health services. We are extending cost share waivers for telehealth and telephonic-only care. READ MORE 
Q: How is Anthem approaching the provision of mental health outpatient and substance abuse outpatient services via telephonic-only visits?

A: Anthem is making adjustments in our policy in the provision of these telephonic-only services to address the need for expanded access outside of telehealth (audio + video) to include telephonic only visits with in-network providers and out-of-network providers where required. We expect all mental health outpatient and substance abuse outpatient will still be provided within benefits limits, authorization limits, medical necessity criteria, and within state and federal regulatory requirements and licensure requirements, including HIPAA compliance and the regulations regarding how substance use information in handled. These changes for telephonic-only visits will be effective from March 19 through December 31, 2020. We will continue to actively monitor the rapidly evolving situation.

>>>Click here to read past updates

UPDATE - COVID-19 Update: Guidance for telehealth/telephonic care for Behavioral Health services. We are extending cost share waivers for telehealth and telephonic-only care. READ MORE 
Q: How is Anthem approaching the provision of mental health outpatient and substance abuse outpatient services via telephonic-only visits?

A: Anthem is making adjustments in our policy in the provision of these telephonic-only services to address the need for expanded access outside of telehealth (audio + video) to include telephonic only visits with in-network providers and out-of-network providers where required. We expect all mental health outpatient and substance abuse outpatient will still be provided within benefits limits, authorization limits, medical necessity criteria, and within state and federal regulatory requirements and licensure requirements, including HIPAA compliance and the regulations regarding how substance use information in handled. These changes for telephonic-only visits will be effective from March 19 through December 31, 2020. We will continue to actively monitor the rapidly evolving situation.

>>>Click here to read past updates

UPDATE - As COVID-19 cases increase and many hospitals across the state approach peak admissions, Blue Cross and Blue Shield of Alabama is improving needed access for patients. READ MORE
Effective December 17, 2020, we are streamlining admissions to long-term acute care hospitals (LTACH) for Blue Cross members with one or more specified diagnoses. These facilities offer appropriate and needed services to meet the needs of patients admitted for complex medical care. This streamlined process for Blue Cross members, including our Blue Advantage® Plan, extends through January 31, 2021. Visit our COVID-19 Treatment page for additional details.

12/15/2020 - We do not reimburse providers for CPT code 99072, which is defined as: “Additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency as defined by law, due to respiratory-transmitted infectious disease.” Code 99072 has been added to our List of Procedures and Services Not Separately Paid, which outlines CPT and HCPCS codes that are not separately payable services. READ MORE

12/15/2020 - Codes for COVID-19 vaccines and monoclonal antibodies as well as their administration have been published on our COVID-19 Treatment page. READ MORE
 Vaccine codes are effective after the U.S. Food and Drug Administration approves the vaccine for emergency use. Important note about Blue Advantage® members: Providers administering COVID-19 vaccines to Blue Advantage members must submit those claims to the CMS Medicare Administrative Contractor (MAC) for payment.

12/9/2020 - DME Update: Oxygen Therapy: In response to the ongoing COVID-19 public health emergency, the suspension of the oxygen saturation requirement for both certification and recertification has been extended through the end of the federal public health emergency. Refer to our COVID-19 Treatment page for additional treatment information. READ MORE 

12/4/2020 - In response to the ongoing COVID-19 pandemic, expanded telehealth services coverage for eligible Blue Cross members including Blue Advantage® will continue through the end of the federal public health emergency. Continue to check our COVID-19 Provider Update Center for important announcements. READ MORE 
Because benefits can vary depending on a member’s plan, it’s important to always check eligibility and benefits through ProviderAccess or your practice management system to confirm coverage and cost-sharing details.

>>>Click here to read past updates

UPDATE - COVID-19 Telehealth Update. Arkansas Blue Cross and Blue Shield and Health Advantage described a temporary change to our policy in the March issue of Arkansas Blue Cross Providers’ News. We revised that temporary policy on March 24, 2020, making it retroactive to March 16, 2020. READ MORE

>>>Click here to read past updates

UPDATE - FEP will waive prior authorizations for diagnostic tests and for covered services that are medically necessary and consistent with CDC guidance if diagnosed with COVID-19. FEP members have NO out-of-pocket costs when they receive any of the vaccines approved by the FDA with emergency use authorization. READ MORE 

12/15/2020 - No member cost share for vaccines. READ MORE 

3/31/2020 - FEP will waive prior authorizations for diagnostic tests and covered services that are medically necessary and consistent with CDC guidance if diagnosed with COVID-19. Similarly, FEP will waive any cost-share for diagnostic tests or treatment that are medically necessary and consistent with CDC guidance if diagnosed with COVID-19. FEP will increase access to prescription medications by waiving early medication refill limits on 30-day prescription maintenance medications. FEP will waive copays for all telehealth services provided by Teladoc®. READ MORE

Blue Cross Blue Shield
Florida

UPDATE - Blue Email update 12/31/2020. COVID-19 Vaccine Billing Information. Now that the Pfizer/BioNTech and Moderna mRNA-1273 COVID-19 vaccines have received emergency use authorization by the Food and Drug Administration, we want to make sure you are paid correctly for administering the vaccines. READ MORE 

Florida Blue Medicare Advantage: Providers should submit claims for COVID-19 vaccines to Original Medicare through your Medicare Administrative Contractor (MAC) as outlined in the Medicare institutional and professional instructions here. If a provider bills Florida Blue for a vaccine or vaccine administration for a Medicare Advantage member, it will not be reimbursed. If submitted through Availity®1 , it will be returned electronically.

Other Lines of Business - Since the federal government is covering the cost for the initial doses of the vaccine, providers only need to submit a claim for the vaccine administration. Please submit your appropriate administration fee for the corresponding vaccine, using the code information below for your Commercial, Truli for Health and Federal Employee Program® members. The administration fee is covered at 100 percent of your contracted allowance, with no cost share for the member.

The following codes are for vaccines for all lines of business.

12/14/2020 - Medicare Advantage Updates. Medical Test/Testing-Related Visits and Related Services cont'd. Additional visit information. READ MORE 
While we have already been waiving some member cost shares related to COVID-19, we are waiving additional member cost shares regardless of whether it is related to COVID-19.

This is in effect for the following:

o In-network primary care visits (office and telemedicine).
o In-network behavioral health visits (office, outpatient and telemedicine).
o This is in addition to the $0 cost share for general medicine visits through Teladoc®. Dates - June 1 through Jan. 21, 2021.

COVID-19 Medical Treatment. We have extended waiving the member’s cost share for those who have a positive diagnosis for COVID-19 and must undergo treatment.

▪ In-patient and observation hospital admissions will be at $0 cost share to the member.
▪ All specialist office and outpatient visits will be at $0 cost share to the member.
▪ Florida Blue medical policy guidelines and the terms of the member’s contract still apply. ▪ All primary care treatment, regardless of whether it’s related to COVID-19, will be at $0 cost share to the member.
▪ Florida Blue medical policy guidelines and the terms of the member’s contract still apply. Dates - through Jan. 21, 2021.

Telemedicine. In-network primary care and behavioral health providers:

o The virtual visit reimbursement will be based on your current fee schedule.
o Virtual visits are at $0 cost share to the member.
Date - through Jan. 21, 2021.

>>>Click here to read past updates

UPDATE - From Nov. 12, 2020 to Feb. 28, 2021, Blue Cross and Blue Shield of Illinois (BCBSIL) will not require a post-acute care facility to wait for prior authorization to transfer our members from an inpatient hospital to an in-network medically appropriate, post-acute site of care such as long-term acute care hospitals, skilled nursing facilities, rehabilitation facilities and in-patient hospice. The receiving facility must call and inform us of the transfer by the next business day. READ MORE 

12/22/2020 - BCBS Illinois supports telehealth as an emerging and valuable mode of health care delivery that can help improve the health of our members when appropriate. READ MORE 
As we continue under the national public health emergency order, as well as the Illinois state disaster order, telehealth benefits will continue in 2021 for members participating in commercial fully-insured PPO, Blue Choice PPOSM and HMO plans receiving medically necessary covered services provided by in-network or out-of-network providers.

12/21/2020 - Guidelines for COVID-19 vaccines and how it will be covered by BCBS Illinois. READ MORE 

11/25/2020 - In March, we announced that, as of April 1, 2020, BCBS Illinois would start implementing new electronic claim submission validation edits for commercial Professional and Institutional claims (837P and 837I transactions). READ MORE 
This new duplicate rejection edit does not apply to Medicare Advantage or Illinois Medicaid electronic claim submissions. Starting this month, duplicate claim validation edits will be implemented for commercial 837P and 837I transactions when submitted to BCBS Illinois. Upon implementation, you may see new duplicate claim rejection messages on the response files from your practice management/hospital information system or clearinghouse vendor(s).

From Nov. 12, 2020 to Dec. 31, 2020, Blue Cross and Blue Shield of Illinois (BCBSIL) will not require a post-acute care facility to wait for prior authorization to transfer our members from an inpatient hospital to an in-network medically appropriate, post-acute site of care such as long-term acute care hospitals, skilled nursing facilities, rehabilitation facilities and in-patient hospice. This will help promote availability of acute care capacity for COVID-19 patients. It also allows our members to continue to access medically necessary care. READ MORE

>>>Click here to read past updates

UPDATE - Payer is covering telehealth services with a $0 copay for sick and wellness visits. READ MORE

>>>Click here to read past updates

UPDATE - Modifiers (GT, 95, GO, GQ) are required on all video/telehealth claims. READ MORE

>>>Click here to read past updates

UPDATE - BCBS of Michigan Sees Volume of Health Care Claims Returning to Pre-Pandemic Levels. READ MORE 

>>>Click here to read past updates

UPDATE - BCBSNE will continue to pay eligible providers at the assigned office fee schedule rates and prefers that providers use a HIPAA-secure platform. The video component is not required. Member cost shares will apply beginning January 1, 2021 and after but only applies to a limited number of codes when related to a COVID-19 diagnosis. READ MORE 

12/11/2020 - COVID-19 Treatment and Vaccine: You can find an updated COVID-19 FAQ on NaviNet. All updated information is highlighted in yellow. This includes information on how to bill for COVID treatment and vaccines. READ MORE 

>>>Click here to read past updates

UPDATE - BCBS NC will waive prior authorization requirements for all conditions, including non-COVID-19 conditions, and require notification only for covered services incurred at in-network skilled nursing facilities (SNFs) and residential treatment centers (RTCs). READ MORE 
This temporary change goes into effect on Dec. 21, 2020, and will be reevaluated every 30 calendar days. This waiver only applies to services incurred at in-network SNFs or RTCs for members discharging from inpatient level of care. Medical necessity review is required for length-of-stay extensions beyond the days allowed on the initial approval. This measure applies to fully insured, self-funded employer groups (including State Health Plan) and all Medicare Advantage plans offered or administered by Blue Cross NC, including Experience Health. This does not apply to Federal Employee Program members.

12/21/2020 - BCBS NC will cover COVID-19 vaccines that are FDA approved for emergency use authorization (EUA) at no cost for all members, both during the public health emergency and after. READ MORE 
BCBS NC will continue its expanded virtual care policy through June 30, 2021. Prior Authorization Waiver for COVID-19 Related Services through March 31, 2021. COVID-19 Treatment Cost-Share Waivers through March 31, 2021. COVID-19 Testing and Doctor Visit Cost-Share Waivers will continue.

12/10/2020 - As we anticipate an emergency use approval from the FDA for a COVID-19 vaccine soon, Blue Cross and Blue Shield of North Carolina (Blue Cross NC) is preparing so the vaccine will be available at no cost to all Blue Cross NC members. READ MORE 
While additional guidance may be released by the North Carolina Department of Health and Human Services (NCDHHS) later, we’re providing you with critical information that is known at this time. The vaccine will be allocated, distributed and administered to the public in phases based on availability determined by federal, state and local government authorities.

>>>Click here to read past updates

3/31/2020 - "Blue Care On Demand" is for video or health provider visits for members inside or outside SC without COVID-19 symptoms. Cost is $0 for members when you use code "COVID19." "Doctors Care Anywhere" is for video visits with Doctors Care providers and should be used by members in SC with any acute symptoms. Cost is $0 for members when you use code "INS." "S.C. Department of Health and Environmental Control (DHEC)-Virtual Triage" is for video visits with health providers for members in SC who have specific COVID-19 symptoms. Cost is $0 for members when you use the code "COVID19." READ MORE

UPDATE - BlueCross Tennessee Shares Plan to Cover Costs for COVID-19 Vaccination. READ MORE 
BlueCross BlueShield of Tennessee wants to make members aware that it will cover the administration cost for all coronavirus vaccines that receive Food and Drug Administration (FDA) approval and emergency use authorization. The cost of the vaccine itself is covered by the federal government. BlueCross will cover the fees associated with its administration. If a BlueCross member is charged for any part of their vaccine visit, they can call the Member Services number on the back of their Member ID card for help. As more FDA-approved COVID-19 vaccines are produced and distributed, anyone who wants a vaccine should be able to get one. Members should check BCBSTUpdates.com for answers to vaccine-related questions, and with the Tennessee Department of Health at tn.gov/health for additional information on the state’s vaccine distribution plan.

9/24/2020 - BlueCross Extends Cost Waiver for Medicare Advantage Members Seeking Primary, Behavioral Care Through Dec. 31. READ MORE 
BlueCross BlueShield of Tennessee will continue waiving Medicare Advantage member copayments for visits with in-network primary care and behavioral health care providers through the end of 2020. This includes in-person and telehealth visits.

UPDATE - This article relates only to telemedicine/telehealth services rendered between March 10, 2020 and Dec. 31, 2020. READ MORE 
Refer to Telehealth 2021 for additional information related to telemedicine/telehealth coverage effective Jan. 1, 2021. 

1/5/2021 - Telehealth: Member cost share. READ MORE 
As of Jan. 1, 2021, copays, deductibles and coinsurance apply to telehealth visits for most members. The cost share varies according to the member’s benefit plans. Check eligibility and benefits for each member for details. Our self-funded employer group customers make decisions for their employee benefit plans and may choose to waive telemedicine cost share. Check eligibility and benefits for any variations in member benefit plans.

Members will have access to the expanded telemedicine services through Dec. 31, 2020. READ MORE 
The cost-share waiver will end on Dec. 31, 2020* for commercial and retail members. Copays, deductibles and coinsurance will apply after Dec. 31, 2020. The cost-share waiver will end on Dec. 31, 2020* for Medicare members.

12/30/2020 - Blue Cross and Blue Shield of Texas (BCBSTX) is making it easier to transfer our members from acute-care facilities to in-network, medically necessary alternative post-acute facilities through Feb. 28, 2021. READ MORE 

11/30/2020 - (Originally Posted 04/15/2020) COVID-19: Claims for Telephone Medical Services (Audio Only) – Texas Medicaid. READ MORE 
Effective November 30, 2020, the Texas Health and Human Services Commission in continued response to COVID-19, is extending the end date to December 31, 2020.

We are authorizing providers to bill the following procedure codes for medical evaluation and management services delivered by a physician by telephone (audio only):

Description of Services
Procedure Codes
Evaluation and Management (E/M)
99201, 99202, 99203, 99204, 99205, 99211, 99212,
99213, 99214, 99215

When is this effective?
This is effective for all services rendered from March 20, 2020, through December 31, 2020 (previously November 30, 2020).

COVID-19: RURAL HEALTH CLINICS (RHC) and TELEHEALTH/TELEMEDICINE. READ MORE 
What is changing? Effective November 24, 2020, per Texas Health and Human Services Commission (HHSC) , we are amending the end date to December 31, 2020 , in continued response to COVID-19. The RHC telehealth and telemedicine reimbursement is extended through December 31, 2020 (previously November 30, 2020).We are continuing to evaluate the evolving state and federal legislative and regulatory landscape relating to COVID-19 and will continue to update our practices accordingly.

• Will RHCs be reimbursed for telehealth/telemedicine? Yes, per the Health and Human Services Commission, Blue Cross and Blue Shield of Texas (BCBSTX) Medicaid will reimburse RHCs as telemedicine and telehealth distant site providers statewide for service dates from March 24, 2020 until December 31, 2020. RHCs should use the modifier 95 on claims to indicate use of the telehealth or telemedicine modality.
• How should RHCs bill for reimbursement? RHCs should submit claims using current RHC procedure codes T1015 and 99381.
• Should a modifier be billed? Yes, providers should use the 95 modifier with place of service 02 to indicate the occurrence of remote delivery when delivering service.

>>>Click here to read past updates

UPDATE - Update on Billing of U0001. READ MORE 
Updated June 18, 2020 and retroactive to February 4, 2020: Healthcare providers using the Centers for Disease Control and Prevention (CDC) 2019 Novel Coronavirus Realtime RT-PCR Diagnostic Test Panel may bill for that test using this newly created HCPCS code (U0001). It is eligible for reimbursement and does not apply member liabilities. 

3/17/2020 - For BCBSVT members to receive a zero-cost share for the coronavirus testing, services must be provided in an office (place of service 11), or Urgent Care (place of service 20) or Emergency Room (place of service 23) setting. CPT codes U0001, U0002, 87635 and 87631; refer to complete billing details. READ MORE

UPDATE - COVID-19 Vaccines: Here's What You Need to Know About Coverage.
READ MORE 
Blue Shield of California members can receive COVID-19 vaccinations, considered a preventive service, at no member cost share and with no provider order. Coverage will be provided for both in-network and out-of-network providers through the duration of the COVID-19 Public Health Emergency. During the initial phase of vaccinations, the cost of the vaccine itself will be covered by the federal government, but the cost of the administration of the shots will be the responsibility of health plans. For fully-insured plans, Blue Shield will cover this cost. For self-funded plans, the plan will be responsible for reimbursing the cost of administration. For network providers, reimbursement will be based on the contracted rate, and for non-network providers, plans are required to reimburse a “reasonable” rate. According to Center for Medicare & Medicaid Services (CMS), the Medicare reimbursement rate will be considered reasonable. That rate will be $16.94 for the first dose and $28.39 for the second dose, when applicable.

10/14/2020 - Blue Shield of California Provides Over $50 Million in Premium Relief for Customers to Help Ease Financial Burden During COVID-19 Pandemic. READ MORE 
Blue Shield is applying a one-time premium credit to bills issued for the month of November or December for its fully-insured employer customers. Premium credits will also be applied to November bills for people enrolled in Blue Shield dental and/or vision plans, plus those enrolled in Blue Shield’s Medicare Supplement plans. The credit, which will vary by customer, will appear on their November or December billing statement. Today’s announcement is part of Blue Shield’s ongoing support for members, employer customers, providers and communities during the COVID-19 crisis.

Blue Shield of California and its subsidiary Blue Shield of California Promise Health Plan efforts include:

^^ Extending the commitment to waive co-payments, coinsurance, and deductibles for treatment of COVID-19 through December 31, 2020.
^^ Continuing to cover costs for virtual care (medical and behavioral) services provided by Teladoc Health through 12/31/20.

>>>Click here to read past updates

UPDATE - Buckeye Health Plan is closely following advancements in the prevention and treatment of COVID-19, including vaccinations. READ MORE 
As a healthcare provider, you will play an integral role as COVID-19 vaccines become available. We want to update you on important new information about vaccine coverage. To prepare for vaccine administration, the Centers for Medicare and Medicaid (CMS) have published billing guidance (PDF) for Medicaid and Children’s Health Insurance Program (CHIP) providers. Similar to other COVID-19 services, the vaccines will be offered at no cost to your patients. Member liability will be $0. Non-participating provider pre-auth requirements will be waived.

7/20/2020 - Effective July 1, 2020, all medical & behavioral health prior authorizations requirements have resumed. READ MORE 
These updates are accurately reflected in the Buckeye Health Plan Secure Provider Portal. Also, BHP is performing retrospective medical necessity reviews of claims paid without authorization from March 9-June 30, 2020. 

7/20/2020 - Allwell from Buckeye Health Plan EXTENDS $0 MEMBER LIABILITY FOR Primary Care, Behavioral Health, and Telehealth SERVICES for Remainder of 2020. READ MORE 

>>>Click here to read past updates

UPDATE - CareFirst BlueCross BlueShield Extends COVID-19 Benefits into 2021, Encourages Flu and Childhood Vaccinations. READ MORE 
Today, CareFirst BlueCross BlueShield (CareFirst) announced an additional extension of benefits for fully insured members to ensure the health and well-being of those it serves as the community and national spread of the coronavirus continue to accelerate.

The benefits, which include the patient cost share waivers for the testing and treatment of COVID-19, were initially put in place last spring and set to expire on December 31, 2020, except as otherwise required by law. The benefits will be extended into 2021. COVID-19 vaccines are expected to gain Emergency Use Authorization (EUA) from the U.S. Food and Drug Administration this year and will also be a covered benefit at no cost for CareFirst members. CareFirst is committed to helping communities access the vaccine as quickly and easily as possible but cautions patience as each state finalizes vaccination plans.

In addition to the extensions announced today, CareFirst encouraged individuals to get a flu shot and keep up to date on the immunizations vital to their children's health.

>>>Click here to read past updates

UPDATE - COVID-19: Temporary Change to PAs for Transition to Post-Acute Care.
READ MORE
Effective Nov. 12, 2020 prior authorization requirements for long term acute care facilities (LTACH), skilled nursing facilities (SNF) and inpatient rehabilitation facilities (IRF/hospitals) have been lifted. CareSource will still need notifications from providers related to the start of care, admissions and discharge planning in order to ensure tracking referrals to case management, as well as claims processing. Prior authorization waivers for admission to LTACHs, SNFs and IRFs will be in place until further direction from the Ohio Department of Medicaid (ODM) (refer to memo below). This notification applies to all Ohio products (Medicaid, MyCare, Medicare Advantage, DSNP and Marketplace).

To: Ohio Long-Term Acute Care Hospitals, Skilled Nursing Facilities, and Inpatient Rehabilitation Facilities. RE: COVID-19 Temporary Changes to PA's for Transition to Post-Acute Care. READ MORE 
Please note: This notification applies to all Ohio products (Medicaid, MyCare, Medicare Advantage, DSNP and Marketplace). Effective Nov. 12, 2020 prior authorization requirements for long term acute care facilities (LTACH), skilled nursing facilities (SNF) and inpatient rehabilitation facilities (IRF/hospitals) have been lifted.
CareSource will still need notifications from providers related to the start of care, admissions and discharge planning in order to ensure tracking referrals to case management, as well as claims processing. Prior authorization waivers for admission to LTACHs, SNFs and IRFs will be in place until further direction from the Ohio Department of Medicaid (ODM).

11/9/2020 - COVID-19 SNF Prior Authorization Process Temporary Update, Effective 11/16/20. READ MORE 
CareSource is committed to assisting providers and members during the COVID-19 pandemic. To further partner with the provider community and help mitigate the obstacles providers and members face as a result of COVID-19, CareSource is modifying the prior authorization process to allow movement of members to skilled nursing facilities (SNFs) in order to reduce barriers and increase timeliness of member discharge/admission.

Impact: Beginning Nov.16 2020, upon notification of a SNF admission, CareSource will issue a 3-day authorization. A medical necessity review will be required for continued SNF stay.
The normal authorization process is expected to resume Feb. 1, 2021. During the COVID-19 pandemic CareSource continues to partner with the provider community as changes occur to reduce unnecessary burden and improve member transition across the continuum of care. As a result, CareSource is temporarily relaxing the prior authorization requirement for members seeking SNF admission.

 >>>Click here to read past updates

UPDATED - Centene will expand its Medicare Advantage offerings for 2021. READ MORE 
The company's Medicare plans – branded WellCare, Allwell, Fidelis, and Health Net – will operate in 1,249 counties across 33 states in 2021 – a 30% increase since 2020. This includes 122 new plan designs across 30 states, Medicare Advantage plans in Vermont (10 counties) and Rhode Island (statewide), and Preferred Provider Organization (PPO) plans in 10 additional states including Alabama, Arizona, Illinois, Kansas, Kentucky, Louisiana, Mississippi, New Jersey, Rhode Island, and Vermont.

"At a time when many seniors are grappling with the effects of COVID-19, we are committed to expanding choice and access to high-quality, affordable Medicare plans that support our members' health and well-being during the pandemic and beyond," said Michael F. Neidorff, Chairman, President and CEO for Centene.

>>>Click here to read past updates

UPDATE - Provider Enrollment for Mass Immunizers. READ MORE 
The Centers for Medicare & Medicaid Services (CMS) has informed the Medicare Administrative Contractors (MACs) to accept provider enrollments via the hotline telephone number 1-855-769-9920 from providers wanting to enroll as mass immunizers in order to provide the COVID-19 vaccine and/or the Monoclonal antibodies.

NOTE: If you are already enrolled in Medicare under the institutional or non-institutional provider types listed on the CMS Enrollment for Administering COVID-19 Vaccine Shots CMS web page, no additional enrollment action is necessary.

NOTE - If you are attempting to register as a centralized biller (billing in three or more MAC jurisdictions) for the COVID-19 vaccine, you must enroll with and submit claims to a single Medicare Administrative Contractor (MAC), Novitas, for payment, regardless of where you administer the shots. Please contact Novitas to be enrolled as a centralized biller. Refer to the CMS Definitions for helpful definitions for Mass Immunizers, Roster billing, and Centralized Billers.

When calling the hotline number, CGS staff will collect various information from you. Please be prepared by having the following information ready before you call.
** Legal business name;
** National Provider Identifier (NPI);
** Tax Identification Number (TIN);
** State license;
** Address information;
** Ownership/managing employee information; and
** Contact information.

CGS will either send a letter or email (if an email address is provided) notifying the applicant that they have been granted temporary billing privileges.

12/3/2020 - CGS News/ COVID-19. READ MORE 
Antibody Treatment - The U.S. Food and Drug Administration issued an Emergency Use Authorization (EUA) for the investigational monoclonal antibody therapy, casirivimab and imdevimab, administered together, for the treatment of mild-to-moderate COVID-19 in adults and pediatric patients with positive COVID-19 test results who are at high risk for progressing to severe COVID-19 and/or hospitalization. Casirivimab and imdevimab, administered together, may only be administered in settings in which health care providers have immediate access to medications to treat a severe infusion reaction, such as anaphylaxis, and the ability to activate the Emergency Medical System (EMS), as necessary. During the COVID-19 Public Health Emergency (PHE), Medicare will cover and pay for these infusions the same way it covers and pays for COVID-19 vaccines (when furnished consistent with the EUA).

>>>Click here to read past updates

UPDATE - CDC Guidance for Expanded Screening/Testing to Reduce Silent Spread of SARS-CoV-2. READ MORE 
This interim guidance is based on what is currently known about the novel coronavirus (SARS-CoV-2) and coronavirus disease (COVID-19) as of the date of posting, December 1, 2020. Guidance from the U.S. Centers for Disease Control and Prevention (CDC) are meant to supplement—not replace—any federal, state, local, territorial, or tribal health guidance. Note: This document is intended to provide considerations for expanding screening testing for SARS-CoV-2, the virus that causes COVID-19 and does not dictate the determination of payment decisions or insurance coverage of such testing, except as may be otherwise referenced (or prescribed) by another entity or federal or state agency. CDC has no regulatory authority over testing; therefore, the information in this document is meant to assist health departments in making decisions rather than in establishing any regulatory requirements.

>>>Click here to read past updates

UPDATE - CMS Newsroom. CMS Launches Automated Web Tool for 1135 Waiver Requests and Public Health Emergency-Related Inquiries During Crises Like COVID-19. READ MORE 
Today, the Centers for Medicare & Medicaid Services (CMS) launched an innovative web-based platform to help standardize “Section 1135” waiver requests and other Public Health Emergency (PHE)-related inquiries the agency receives. Under Section 1135 of the Social Security Act (the Act), the Secretary of Health and Human Services may waive selected provisions of Titles XVIII, XIX, and XXI of the Act in the event of an emergency declared by the President and the Secretary.

Available from CMS.gov’s Waivers and Flexibilities webpage, the web tool’s user-friendly submission process will reduce burden on providers by streamlining how they document and submit 1135 waiver requests and PHE-related inquiries. It also will enhance how CMS reviews waivers and inquiries, which can now be submitted any time, any place, and for an array of qualifying emergencies. While the information providers share for 1135 waiver requests and other PHE-related inquiries will remain the same, the new web portal allows for instant inquiry or waiver application delivery and remote review for submissions on or after January 11, 2021. These improvements, coupled with faster tracking and reporting, will help CMS ensure accelerated innovation and improved health system responsiveness, especially when services and supports are constrained during national emergencies and shorter, location-specific crises like natural disasters.

1/7/2021 - CMS COVID-19 Frequently Asked Questions on MCR FFS Billing (updated 1/7/2021). Hospital Inpatient Prospective Payment Systems (IPPS) Payments.  
READ MORE 
Question: How did CMS implement the increased payment under the IPPS for COVID-19 patients under the provisions of section 3710 of the CARES Act?

Answer: To implement this temporary statutory adjustment, the IPPS Pricer will apply an adjustment factor to increase the Medicare Severity-Diagnosis Related Group (MS-DRG) relative weight that would otherwise apply by 20 percent when determining IPPS operating payments (including the calculation of payments such as for disproportionate share hospitals (DSHs), indirect medical education (IME), outliers, new technologies, and low-volume hospitals and the hospital specific rates for sole community hospitals (SCHs) and Medicare-dependent hospitals (MDHs)) for discharges of patients with a principal or secondary diagnosis of COVID-19. For additional information regarding which claims are eligible for the 20 percent increase in the MS-DRG weighting factor, please see the Medicare Learning Network (MLN) Matters article “New COVID-19 Policies for Inpatient Prospective Payment System (IPPS) Hospitals, Long-Term Care Hospitals (LTCHs), and Inpatient Rehabilitation Facilities (IRFs) due to Provisions of the CARES Act” available on the CMS website at https://www.cms.gov/files/document/se20015.pdf. 

1/7/2021 - MLN Connects 1/7/21 Special Edition - Physician Fee Schedule Updates. READ MORE 
On December 27, the Consolidated Appropriations Act, 2021 modified the Calendar Year (CY) 2021 Medicare Physician Fee Schedule (MPFS):

^^ Provided a 3.75% increase in MPFS payments for CY 2021
^^ Suspended the 2% payment adjustment (sequestration) through March 31, 2021
^^ Reinstated the 1.0 floor on the work Geographic Practice Cost Index thru CY 2023
^^ Delayed implementation of the inherent complexity add-on code for evaluation and management services (G2211) until CY 2024

CMS has recalculated the MPFS payment rates and conversion factor to reflect these changes. The revised MPFS conversion factor for CY 2021 is 34.8931. The revised payment rates are available in the Downloads section of the CY 2021 Physician Fee Schedule final rule (CMS-1734-F) webpage.

1/7/2021 - MLN Connects 1/7/2021. COVID-19 Vaccines: CDC Long-Term Care Facility Toolkit. READ MORE 
The CDC recommends early vaccination of long-term care facility health care personnel and residents. Read their Long-Term Care Facility toolkit to: Prepare for COVID-19 vaccination AND build confidence in the vaccine.

2020 MIPS Extreme and Uncontrollable Circumstances Exception Application: Deadline February 1. To further support clinicians during the COVID-19 Public Health Emergency (PHE), CMS extended the 2020 Merit-based Incentive Payment System (MIPS) Extreme and Uncontrollable Circumstances Exception application deadline to February 1. For the 2020 performance year, MIPS eligible clinicians, groups, and virtual groups can submit an application asking us to reweight one or more performance categories to 0% due to the current COVID-19 PHE. If you have concerns about the effect of the COVID-19 PHE on your performance data, including cost measures, submit an application and cite COVID-19 as the reason for your application.

Publications: Complying with Laboratory Services Documentation Requirements — Revised.
CMS revised the Medicare Learning Network fact sheet, Complying with Laboratory Services Documentation Requirements. Learn about:
^^ Documentation and signature requirements
^^ Ordering or referring services.

Quarterly Update to Home Health (HH) Grouper - CMS issued a new MLN Matters Article MM12047 on Quarterly Update to Home Health (HH) Grouper (PDF). Learn about diagnosis code changes for COVID-19.

1/7/2021 - CMS COVID-19 Frequently Asked Questions on MCR FFS Billing (updated 1/5/2021). READ MORE 
Cost Reporting -
Question: Will CMS delay the filing deadline for cost reports impacted during the COVID-19 PHE?  Answer: Yes, 42 CFR 413.24 (f)(2)(ii) allows this flexibility.

CMS will delay the filing deadline of Fiscal Year End (FYE) 10/31/2019 and FYE 11/30/2019 cost reports until June 30, 2020. CMS will also delay the filing deadline of the FYE 12/31/2019 cost reports until August 31,2020. For the FYE 01/31/2020 cost report, the extended due date is August 31, 2020. For the FYE 02/29/2020 cost report, the extended due date is September 30, 2020. For any cost reporting period not previously identified and ending on a date falling in the period of March 1, 2020 through December 31, 2020, providers are granted an additional 60 days from the initial due date to file their cost reports.

In summary the extension impacts the following cost reporting fiscal year ends for all provider types (hospitals, SNFs, HHAs, hospices, ESRDs, RHCs, FQHCs, CMHCs, OPOs, histocompatibility labs and home office cost statements).

Question: Will Medicare pay for monoclonal antibody products to treat COVID-19 and their administration under Part B? Could monoclonal antibody products authorized under an Emergency Use Authorization (EUA) to treat COVID-19 be paid for under Medicare Part B, if so, how? Answer: Yes, in order to ensure immediate access during the COVID-19 public health emergency (PHE), Medicare will pay for monoclonal antibody products authorized for emergency use to treat COVID-19, furnished consistent with the terms of the EUA, or approved by the FDA to treat COVID-19.

Medicare payment for monoclonal antibody products for the treatment of COVID-19 will be in accordance with Section 3713 of the Coronavirus Aid, Relief, and Economic Security Act (CARES Act). As of December 11, 2020, the FDA has issued emergency use authorizations for bamlanivimab2, and casirivimab and imdevimab (administered together). Should additional monoclonal antibodies for the treatment of COVID-19 be authorized or approved by the FDA, the same Medicare payment policies would apply.

Medicare will make a payment to the provider or supplier for the monoclonal antibody product to treat COVID-19 (when it is not received by the provider for free) and will make a separate payment for its administration (infusion). Medicare will not provide payment for the monoclonal antibody products to treat COVID-19 that health care providers receive for free, as will be the case upon the product’s initial availability in response to the COVID-19 PHE.

1/6/2021 - COVID-19 Update - 2021 ICD-10-CM. In response to the national emergency that was declared concerning the COVID-19 outbreak, the Centers for Disease Control and Prevention’s (CDC) National Center for Health Statistics (NCHS) is implementing 6 new diagnosis codes into the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), effective January 1, 2021. READ MORE 

The new ICD-10-CM diagnosis codes are:

• 12.82 Pneumonia due to coronavirus disease 2019
• M35.81 Multisystem inflammatory syndrome
• M35.89 Other specified systemic involvement of connective tissue
• Z11.52 Encounter for screening for COVID-19
• Z20.822 Contact with and (suspected) exposure to COVID-19
• Z86.16 Personal history of COVID-19

12/31/2020 - MLN Matters MM12126 12/31/20 "2021 Annual Update to the Therapy Code List." CR # R10542CP, Effective Date 1/1/2021, Implementation Date 1/4/2021. READ MORE 
CMS designated some HCPCS/CPT codes as “sometimes therapy,” to permit physicians and certain Non-Physician Practitioners (NPPs), including nurse practitioners, physician assistants, and clinical nurse specialists, to render these services outside a therapy plan of care when appropriate. Further, these HCPCS/CPT codes are considered communication technology-based (CTB) services so other NPPs can render these services, such as psychologists and social workers, in addition to therapists (physical therapists, occupational therapists, and speech-language pathologists) whether in private practice or those that are facility-based. Also, these codes for CTB services replace codes for similar services that CMS included in CR 11791.

For the five codes below (2 HCPCS and 3 CPT codes), CY 2021 rulemaking made these codes permanent, meaning they are no longer restricted by the effectiveness timeline of the Public Health Emergency (PHE) for COVID-19. The HCPCS codes are G2250 and G2251. Editorial Panel for CY 2020 created CPT codes 98970, 98971, and 98972. During MPFS rulemaking for CY 2021, CMS decided to use these codes in place of G2061, G2062, and G2063, since their descriptors were similar. CR 11971 added the CPT codes for telephone assessment as “sometimes therapy” codes effective for the duration of the PHE for COVID-19. As with the other CTB services noted above, therapists in private practice and therapists who work for institutional providers may furnish these services.

We are removing the following HCPCS codes from the therapy code list, effective for dates of service on and after January 1, 2021:
• G2010
• G2012
• G2061
• G2062
• G2063

MLN Connects 12/28/20 Special Edition. Medicare FFS Claims: 2% Payment Adjustment (Sequestration) Suspended Through March. READ MORE 
The Coronavirus Aid, Relief, and Economic Security (CARES) Act suspended the payment adjustment percentage of 2% applied to all Medicare Fee-For-Service (FFS) claims from May 1 through December 31. The Consolidated Appropriations Act, 2021, signed into law on December 27, extends the suspension period to March 31, 2021.

12/23/2020 - MLN Matters MM12093 12/23/20 "Addition of the QW Modifier to HCPCS Codes 87811 and 87428." CR Transmittal R10529OTN, Effective Date 10/6/2020, Implementation Date 4/5/2021. READ MORE 
This article informs you of the addition of the QW modifier to the following CMS HCPCS codes:

• 87811 [Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)
(Coronavirus disease [COVID-19])]; and code
• 87428 [Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence
immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; severe acute respiratory syndrome coronavirus (eg, SARS-CoV, SARS-CoV-2 [COVID-19]) and influenza virus types A and B]

12/23/2020 - MLN Matters R10530OTN 12/23/20 Instructions to Medicare Administration Contractor (MAC) on COVID-19 Emergency Declaration Blanket Waivers for Medicare-Dependent, Small Rural Hospitals and Sole Community Hospitals. Effective Date 1/26/2021, Implementation Date 3/29/2021, CR# 12070. READ MORE 
All items covered in related CR 12070 are effective for hospital discharges or cost-reporting periods, as applicable, occurring on or after the start of the COVID-19 emergency declaration blanket waiver period, effective March 1, 2020, through the end of the emergency declaration.

Hospitals Classified as Sole Community Hospitals (SCHs) - We are waiving certain eligibility requirements as set forth in the regulations at 42 Code of Federal Regulations (CFR), Section 412.92(a), for hospitals classified as SCHs prior to the Public Health Emergency (PHE). Specifically, we are waiving the distance requirements at 42 CFR 412.92(a), (a)(1), (a)(2), and (a)(3), which require that SCHs, among other criteria, be located either more than 35 miles, 25-35 miles, 15-25 miles, or a 45-minute drive time from another like hospital, respectively. These waivers will continue for the duration of the PHE. MACs will resume standard practice for evaluation of all eligibility requirements after the conclusion of the PHE. We are also waiving the “market share” requirement at 42 CFR 412.92(a)(1)(i), which requires that no more than 25% of residents who become hospital inpatients or no more than 25% of the Medicare beneficiaries who become hospital inpatients in the hospital's service area are admitted to other like hospitals located within a 35-mile radius of the hospital, or, if larger, within its service area. Lastly, we are waiving the bed requirement at 42 CFR 412.92(a)(1)(ii), which requires that the SCH have fewer than 50 beds.

Hospitals Classified as Medicare-Dependent, Small Rural Hospitals (MDHs) - - We are waiving certain eligibility requirements as set forth in the regulations at 42 CFR 412.108(a), for hospitals classified as MDHs prior to the PHE. Specifically, we are waiving the requirement that the hospital have 100 or fewer beds during the cost-reporting period at 42 CFR 412.108(a)(1)(ii). We are also waiving the requirement that at least 60% of the hospital’s inpatient days or discharges were attributable to individuals entitled to Medicare Part A benefits during the specified hospital cost-reporting periods at 42 CFR 412.108(a)(1)(iv)(C).
These waivers will continue during specified hospital cost reporting periods that include any portion of the blanket waiver period that began March 1, 2020 to allow these hospitals to meet the needs of the communities they serve during the PHE. MACs will resume standard practice for evaluation of all eligibility requirements after the conclusion of the PHE, beginning with cost reporting period(s) that begin on or after the end of the PHE.

MLN Connects 12/23/20. ICD-10 Code Files for FY 2021. READ MORE 
In response to the COVID-19 public health emergency, new ICD-10 codes are effective January 1:

^^ 21 procedure codes (ICD-10-PCS): CMS will implement new codes to describe the introduction or infusion of therapeutics, including monoclonal antibodies and vaccines for COVID-19 treatment

^^ 6 diagnosis codes (ICD-10-CM): CDC National Center for Health Statistics

For More Information:
** 2021 ICD-10-PCS webpage: code files, guidelines, and additional information
** 2021 ICD-10-CM webpage: code files, guidelines, and additional information
** Medicare Severity Diagnosis Related Group (MS-DRG) Version 38.1 (ZIP): announcement about assignment of new codes
** MS-DRG Classifications and Software webpage. COVID-19: PC-ACE Software Vaccine Roster Billing Issue.

Part B providers: When you select a roster bill for a COVID-19 vaccine in PC-ACE 4.8.100 software, it inappropriately auto-populates HCPCS code G0008 on the claim for the administration. This code is valid for traditional roster billing vaccines like pneumococcal and flu but not for administering the COVID-19 vaccine. Your Medicare Administrative Contractor will provide updated PC-ACE 4.9 software. Download the update to ensure proper billing of roster-billed COVID-19 vaccines.

MLN Matters R10533DEMO 12/22/2020 Telehealth Expansion Benefit Enhancement under the Pennsylvania Rural Health Model (PARHM) - Implementation. Effective date 1/1/2021, Implementation date 1/4/2021, CR# 11870. READ MORE 
Note: We revised this article due to a revised CR 11870, issued on December 22. The CR revision updated some denial edits. We added that information starting near the bottom of page 3 of this article. Also, we updated the CR release date, transmittal number, and the web address of the CR. All other information remains the same.

MACs will deny incoming PARHM claims if the Date of Service (DOS) on the claim is prior to January 1, 2021 using the following messages:
• CARC: 96- “Non-covered charge(s).”
• RARC: N83- (No appeal rights. Adjudicative decision based on the provisions of a demonstration project)
• Group Code: CO MACs will deny PARHM claims when you elect this benefit enhancement for the DOS on the claim, the claim contains one of the appropriate HCPCS codes (that is, G0438, G0439, G9481, G9482, G9483, G9484, G9485, G9486, G9487, G9488, or G9489) and the POS is not (2). In this case, the MAC will use:
• CARC: 16 - (Claim/service lacks information or has submission/billing error(s))
• RARC: M77- (Missing/incomplete/invalid/inappropriate place of service)
• Group Code: CO

MLN Connects 12/22/20 Special Edition. COVID-19 Vaccine Codes: Updated Effective Date for Moderna. READ MORE  
On December 18, 2020, the U.S. Food and Drug Administration issued an Emergency Use Authorization (EUA) for the Moderna COVID‑19 Vaccine (PDF) for the prevention of COVID-19 for individuals 18 years of age and older. Review Moderna’s Fact Sheet for Healthcare Providers Administering Vaccine (Vaccination Providers) regarding the limitations of authorized use. During the COVID-19 Public Health Emergency (PHE), Medicare will cover and pay for the administration of the vaccine (when furnished consistent with the EUA). Review our updated payment and HCPCS Level I CPT code structure for specific COVID-19 vaccine information. Only bill for the vaccine administration codes when you submit claims to Medicare; don’t include the vaccine product codes when the vaccines are free.

12/18/2020 - MLN Connects 12/18/20 Special Edition. COVID-19: Add-on Payment for New Treatments. CMS issued an Interim Final Rule with Comment Period, which established the New COVID-19 Treatments Add-on Payment (NCTAP) under the Medicare Inpatient Prospective Payment System (IPPS), effective from November 2, 2020, until the end of the Public Health Emergency (PHE) for COVID-19. READ MORE

To mitigate potential financial disincentives for hospitals to provide new COVID-19 treatments during the COVID-19 PHE, the Medicare program will provide an enhanced payment for eligible inpatient cases that involve use of certain new products with current Food and Drug Administration approval or emergency use authorization to treat COVID-19. Visit the NCTAP webpage for more information at https://www.cms.gov/medicare/covid-19/covid-19-treatments-add-payment-nctap

12/18/2020 UPDATE - MLN Matters MM12080 12/18/20.  "Calendar Year (CY) 2021 Annual Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment." Effective 1/1/2021, Implementation 1/4/2021, CR Transmittal R10523CP. COVID-19 Policy Updates - Payment for High Throughput Technologies. READ MORE

On October 15, 2020, CMS issued ruling CMS-2020-1-R2 which amends CMS Ruling 2020-1-R, which articulated CMS’s policy concerning the designation and payment of certain CDLTs related to COVID-19 under the Medicare Part B CLFS.  CMS Ruling 2020-1-R defined certain highly sophisticated equipment called “high throughput technology.” It also established a payment amount for molecular genomic CDLTs making use of high throughput technologies for the detection of SARS–CoV–2 or the diagnosis of the virus that causes COVID-19 and that are administered during the ongoing emergency period defined in paragraph (1)(B) of Section 1135(g) of the Act. C

MS Ruling 2020-2-R amends CMS Ruling 2020-1-R by modifying the payment amount established in that Ruling for such CDLT based on a re-evaluation of the resources necessary for the timely administration of these tests. The ruling:
• Establishes a revised payment amount for HCPCS codes U0003 and U0004 of $75
per procedure (previously was $100)
• Sets a new add-on payment amount of $25 for HCPCS code U0005 which is to be
used to indicate that the corresponding CDLT (U0003 or U0004) that makes use of high throughput technology for the detection of SARS–CoV–2 or diagnosis of the virus that causes COVID-19 is completed within 2 calendar days of the specimen being collected, and the laboratory completed a majority of these CDLTs (for all patients during the prior calendar month) in 2 calendar days or less from when the specimen was
collected. 

12/18/2020 UPDATED - MLN Matters MM12080 continued. We update the fees for clinical laboratory travel codes P9603 and P9604 on an annual basis. READ MORE You may bill the clinical laboratory travel codes only for traveling to perform a specimen collection for either a nursing home or homebound patient. If there is a revision to the standard mileage rate for CY 2021, CMS will issue a separate instruction on the clinical laboratory travel fees.

12/17/2020 - UPDATE - MLN Connects  12/17/20. Summary of Policies in the Calendar Year (CY) 2021 Medicare Physician Fee Schedule (MPFS) Final Rule, Telehealth Originating Site Facility Fee Payment Amount and Telehealth Services List, CT Modifier Reduction List, and Preventive Services List. READ MORE

CMS issued a new MLN Matters Article MM12071 on Summary of Policies in the Calendar Year (CY) 2021 Medicare Physician Fee Schedule (MPFS) Final Rule, Telehealth Originating Site Facility Fee Payment Amount and Telehealth Services List, CT Modifier Reduction List, and Preventive Services List (PDF). Learn about the policy changes that apply to Medicare Part B.

The CY 2021 changes are - Medicare Telehealth Services - - We are finalizing the proposal to add several HCPCS codes to the list of telehealth services on a permanent basis. We are also finalizing the proposal to add additional HCPCS codes to the list of telehealth services on a temporary basis until the end of the CY in which the Public Health Emergency (PHE) for COVID-19 ends or December 31, 2021. The list of codes we added to the telehealth services list are at https://www.cms.gov/Medicare/Medicare-GeneralInformation/Telehealth/Telehealth-Codes.

12/16/2020 - UPDATE - COVID-19 Frequently Asked Questions on MCR FFS Billing (Revised 12/16/20).  Pages 17 - 18 High Throughput COVID-19 Testing.  READ MORE

11. Question: CMS has indicated that in order to bill Medicare for HCPCS code U0005 the majority of a laboratory’s COVID-19 CDLTs performed using high throughput technology in the previous calendar month must have been completed in 2 calendar days or less from the date of specimen collection for all of their patients (not just their Medicare patients). What does “majority” mean in this context?
Answer: For purposes of CMS Ruling No. CMS 2020-1-R2, https://www.cms.gov/files/document/cms-ruling-2020-1-r2.pdf, “majority” means 51% or greater. We note that the requirement that the majority of a laboratory’s COVID-19 CDLTs performed using high throughput technology in the previous calendar month must have been completed in 2 calendar days or less from the date of specimen collection pertains to the laboratory’s ability to bill Medicare for the $25 add-on payment using HCPCS code U0005. Laboratories may continue to bill Medicare for COVID-19 CDLTs making use of high throughput technology described by HCPCS codes U0003 and U0004, regardless of whether they meet this requirement. Effective date: CMS 2020-1-R2 is effective January 1, 2021. New: 12/16/20    
                                                                                                                                               12. Question: Can a laboratory submit a claim for HCPCS code U0005 (the add-on payment) by itself, or does U0005 need to be reported with either HCPCS code U0003 or U0004 (CDLTs for COVID-19 performed using high throughput technology)?
Answer: As required by the HCPCS code U0005 code descriptor, laboratories must report HCPCS code U0005 on the same claim as either HCPCS code U0003 or U0004. Effective date: CMS 2020-1-R2 is effective January 1, 2021. New: 12/16/20

13. Question: CMS Ruling No. CMS 2020-1-R2 states that for a laboratory to be able to bill Medicare for HCPCS code U0005, the test described by HCPCS code U0003 or U0004 must be completed in 2 calendar days. Please clarify when the 2-calendar day timeframe begins and ends.
Answer: Beginning with dates of service on or after January 1, 2021, laboratories can bill Medicare for the $25 add-on payment using HCPCS code U0005 when: 1) they completed the COVID-19 CDLT in 2 calendar days or less from the date of specimen collection; and 2) the majority of their COVID-19 CDLTs performed using high throughput technology in the previous calendar month were completed in 2 calendar days or less for all of their patients (not just their Medicare patients). For example, if the specimen is collected anytime Wednesday then the COVID-19 CDLT would need to be completed, that is, results are finalized and ready for release, by 11:59PM Friday. In other words, the specimen collection day (Wednesday) is day 0, Thursday is day 1, and Friday is day 2. Effective date: CMS 2020-1-R2 is effective January 1, 2021. New: 12/16/2020

12/14/2020 - UPDATE - MLN Connects 12/14/20 Special Edition. COVID-19 Vaccine Codes: Updated Effective Date for Pfizer-BioNTech. READ MORE 
On December 11, 2020, the U.S. Food and Drug Administration issued an Emergency Use Authorization (EUA) for the Pfizer-BioNTech COVID‑19 Vaccine for the prevention of COVID-19 for individuals 16 years of age and older. Review Pfizer’s Fact Sheet for Healthcare Providers Administering Vaccine (Vaccination Providers) regarding the limitations of authorized use.

During the COVID-19 Public Health Emergency (PHE), Medicare will cover and pay for the administration of the vaccine (when furnished consistent with the EUA). Review our updated payment and HCPCS Level I CPT code structure for specific COVID-19 vaccine information. Only bill for the vaccine administration codes when you submit claims to Medicare; don’t include the vaccine product codes when vaccines are free.

12/14/2020 - COVID-19 Vaccine Administration. CMS released a set of toolkits for providers, states and insurers to help the health care system prepare to swiftly administer the vaccine once it is available. READ MORE 
These resources are designed to increase the number of providers that can administer the vaccine and ensure adequate reimbursement for administering the vaccine in Medicare, while making it clear to private insurers and Medicaid programs their responsibility to cover the vaccine at no charge to beneficiaries. In addition, CMS is taking action to increase reimbursement for any new COVID treatments that are approved by the FDA. Vaccine doses purchased with U.S. taxpayer dollars will be given to the American people at no cost.

Providers that participate in the CDC COVID-19 Vaccination Program contractually agree to administer a COVID-19 vaccine regardless of an individual’s ability to pay and regardless of their coverage status, and also may not seek any reimbursement, including through balance billing, from a vaccine recipient. Providers who have questions about billing or reimbursement of vaccine administration for patients covered by private insurance or Medicaid should contact the respective health plan or state Medicaid agency. People without health insurance or whose insurance does not provide coverage of the vaccine can also get COVID-19 vaccine at no cost. Providers administering the vaccine to people without health insurance or whose insurance does not provide coverage of the vaccine can request reimbursement for the administration of the COVID-19 vaccine through the Provider Relief Fund.

*Updated* Additionally, you can find information about a monoclonal antibody infusion for treating COVID-19. During the COVID-19 public health emergency (PHE), Medicare will cover and pay for these infusions the same way it covers and pays for COVID-19 vaccines (when furnished consistent with the EUA).

12/10/2020 - MLN Connects Special Edition 12/10. CMS Proposes New Rules to Address Prior Authorization and Reduce Burden on Patients and Providers. READ MORE 
On December 10, under President Trump’s leadership, CMS issued a proposed rule that would improve the electronic exchange of health care data among payers, providers, and patients and streamline processes related to prior authorization to reduce burden on providers and patients. By both increasing data flow and reducing burden, this proposed rule would give providers more time to focus on their patients and provide better quality care.

12/10/2020 - MLN Connects 12/10/20. 2020 MIPS Extreme and Uncontrollable Circumstances Exception Application: Deadline February 1. READ MORE 
To further support clinicians during the COVID-19 Public Health Emergency (PHE), CMS extended the 2020 Merit-based Incentive Payment System (MIPS) Extreme and Uncontrollable Circumstances Exception application deadline to February 1. For the 2020 performance year, MIPS eligible clinicians, groups, and virtual groups can submit an application asking us to reweight one or more performance categories to 0% due to the current COVID-19 PHE. If you have concerns about the effect of the COVID-19 PHE on your performance data, including cost measures, submit an application and cite COVID-19 as the reason for your application.

For More Information, contact the Quality Payment Program at QPP@cms.hhs.gov or 866-288-8292; customers who are hearing impaired can dial 711 for a TRS Communications Assistant.

COVID-19: Hospital Operations Toolkit. READ MORE 
The Office of the Assistant Secretary for Preparedness and Response (ASPR) Technical Resources, Assistance Center, and Information Exchange (TRACIE) released an Express message with new resources:

^^ Healthcare Operations Toolkit: Helps hospitals prepare to manage large numbers of patients during the COVID-19 pandemic
^^ Baltimore Convention Center Field Hospital/ Alternate Care Site: Experiences on standing up and maintaining this ACS
^^ Role of Community Pharmacists in COVID-19: Discusses the role of pharmacists during the pandemic
^^ Physician Well-Being: Discusses mitigation of staff stress and increasing wellness and resilience within a health system.

For More Information:
** ASPR TRACIE fact sheet
** ASPR TRACIE website
** ASPR TRACIE Novel Coronavirus Resources webpage

Telehealth Services: Bill Correctly. READ MORE 
An Office of Inspector General report found that CMS improperly paid for some telehealth claims associated with services that didn’t meet Medicare requirements. Watch the Medicare Coverage and Payment of Virtual Services video to help you bill correctly.

Additional resources:
^^ Telehealth Services (PDF) booklet
^^ Medicare Claims Processing Manual, Chapter 12 (PDF), Section 190
^^ Medicare Telehealth Payment Eligibility Analyzer
^^ List of Covered Telehealth Services webpage

ICD-10 MS-DRG Grouper V38.1 & 2021 ICD-10-PCS Code Files. READ MORE 
In response to the COVID-19 public health emergency, new ICD-10 codes are effective January 1:

^^ 21 procedure codes (ICD-10-PCS): CMS will implement new codes to describe the introduction or infusion of therapeutics, including monoclonal antibodies and vaccines for COVID-19 treatment
^^ 6 diagnosis codes (ICD-10-CM): CDC National Center for Health Statistics.
See the announcement (ZIP) for more information about assignment of these new diagnosis and procedure codes under the ICD-10 Medicare Severity Diagnosis Related Group (MS-DRG).

For More Information:
** MS-DRG Classifications and Software webpage: ICD-10 MS-DRG 1 grouper software, Definitions Manual, and Definition of Medicare Code Edits
** 2021 ICD-10-PCS webpage: Code files and information on COVID-19 updates
** CDC ICD-10-CM webpage: Index and Tabular Addenda will be available soon

MLN Connects 12/9/20 Special Edition. In Case You Missed It: CMS Announces Guidance for Medicare Coverage of COVID-19 Antibody Treatment. READ MORE 
On December 9, CMS posted updates to FAQs and an infographic about coverage and payment for monoclonal antibodies to treat COVID-19. The FAQs include general payment and billing guidance for these products, including questions on different setting types. The infographic has key facts about expected Medicare payment to providers and information about how Medicare beneficiaries can receive these innovative COVID-19 treatments with no cost-sharing during the public health emergency (PHE). CMS’ November 10, 2020 announcement about coverage of monoclonal antibody therapies allows a broad range of providers and suppliers, including freestanding and hospital-based infusion centers, home health agencies, nursing homes, and entities with whom nursing homes contract, to administer this treatment in accordance with the Food & Drug Administration’s Emergency Use Authorization (EUA), and bill Medicare to administer these infusions. Currently, two monoclonal antibody therapies have received EUA’s for treatment of COVID-19.

12/4/2020 - MLN Matters R10505CP dated 12/4/20 "Summary of Policies in the Calendar Year (CY) 2021 Medicare Physician Fee Schedule (MPFS) Final Rule, Telehealth Originating Site Facility Fee Payment Amount and Telehealth Services List, CT Modifier Reduction List, and Preventive Services List." CR# 12071, Implementation Date 1/4/2021. READ MORE

^^ For CY 2021, CMS is finalizing the proposal to add several Healthcare Common Procedure Coding System (HCPCS) codes to the list of telehealth services on a permanent basis. CMS is also finalizing the proposal to add additional HCPCS codes to the list of telehealth services on a temporary basis until the end of the calendar year in which the Public Health Emergency (PHE) for the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) or COVID-19 ends or December 31, 2021.

^^ Section 1834(m)(2)(B) of the Act establishes the payment amount for the Medicare telehealth originating site facility fee for telehealth services provided from October 1, 2001, through December 31, 2002, at $20. For telehealth services provided on or after January 1 of each subsequent calendar year, the telehealth originating site facility fee is $27.02 (The beneficiary is responsible for any unmet deductible amount and Medicare coinsurance).

MLN Matters R105404CP dated 12/4/20 "CY 2021 Update for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule." CR# 12063, Implementation Date 1/4/2021. READ MORE 
Background: This recurring update notification provides instructions regarding the 2021 update for the DMEPOS fee schedule. The DMEPOS fee schedules are updated on an annual basis in accordance with the statute and regulations. The update process for the DMEPOS fee schedule is located in publication 100-04, Medicare Claims Processing Manual, chapter 23, section 60. The Coronavirus Aid, Relief, and Economic Security (CARES) Act, 2020 - Since the public health emergency has not ceased, the update for the 2021 DMEPOS and PEN fee schedule files continue to include the rural and non-contiguous non-CBA 50/50 blended fees and the non-rural contiguous non-CBA 75/25 blended fees required by section 3712 of the CARES Act.

12/3/2020 - COVID-19 Frequently Asked Questions on MCR FFS Billing (Revised 12/3/20). Pages 120 - 128 Drugs and Vaccines under Part B, Questions 5 - 16 regarding monoclonal antibody products to treat COVID-19 and what Medicare will pay.
READ MORE 

12/3/2020 - MLN Connects 12/3/20. Events for Providers. Physician Fee Schedule Final Rule: Understanding 4 Key Topics Call (Thursday, December 10, 1:30 to 3 pm ET). Register for this Medicare Learning Network event. READ MORE
The calendar year 2021 Physician Fee Schedule final rule provisions reduce burden, recognize clinicians for the time they spend taking care of patients, remove unnecessary quality measures, and make it easier for clinicians move toward value-based care:

^^ Extending telehealth and licensing flexibilities beyond the public health emergency
^^ Updating Evaluation and Management (E/M) coding guidance
^^ Updating the Quality Payment Program and Merit-based Incentive Payment System Value Pathways
^^ Updating opioid use disorder and substance use disorder provisions

During this call, CMS experts briefly cover provisions from the final rule and address your questions. We encourage you to review the final rule (PDF) prior to the call. Target Audience: Medicare Part B Fee-for-Service clinicians; office managers and administrators; state and national associations that represent health care providers; and other stakeholders.

12/2/2020 - MLN Connects 12/2/20 - On December 2, CMS finalized policy changes that will give Medicare patients and their doctors greater choices to get care at a lower cost in an outpatient setting. READ MORE 

12/1/2020 - COVID-19 Frequently Asked Questions on MCR FFS Billing (Revised 12/1/20). READ MORE

12/1/2020 - MLN Connects 12/1/20 Special Edition. Professional Scope of Practice and Supervision. READ MORE

>>>Click here to read past updates, MLN Newsletters, Webinar recordings, etc.

OHA (Ohio Hospital Association) presentation 5/19/2020 w ODM (Ohio Department of Medicaid) clarification.

1.) When should hospitals use the Q3014 vs the telehealth E&Ms like 99211-99215 with modifiers and condition codes for outpatient hospital dept telehealth visits? A: provider may submit a claim for an E&M and for a telehealth originating site fee if they:

i. Provided no other service to the presenting patient; or
ii. Provided a separately identifiable evaluation and management service.
iii. Examples:

a. The patient presents to an office location and staff initiate the telehealth visit with a practitioner who is offsite.
b. The patient does not present to an office location, but office staff provided technical assistance or troubleshooting to set up or join the telehealth visit with the practitioner who is either onsite or offsite.

Providers are encouraged to review ODM’s COVID-19 Emergency Telehealth Guidance web page for possible examples and clarification on how to bill. READ MORE

UPDATE - The cost-share waiver for COVID-19 diagnostic testing and related office visits is in place until January 21, 2021. The cost-share waiver for COVID-19 related treatment is in place until February 15, 2021. Other interim accommodations (e.g., for credentialing and authorizations) are extended through March 31, 2021, as outlined on this page. READ MORE 

12/21/2020 - As the first COVID-19 vaccines are being distributed across the country, we are committed to ensuring that Cigna commercial and Medicare customers receive the COVID-19 vaccine with no out-of-pocket costs and according to the federal and state priority grouping. Providers receive timely information and reasonable reimbursement consistent with CMS rates for administering EUA-approved COVID-19 vaccines and treatments. READ MORE 

12/7/2020 - Cigna Medical Coverage Policy 0557 effective 11/18/2020. COVID-19: In Vitro Diagnostic Testing. READ MORE 
This Coverage Policy addresses in vitro diagnostic testing methods to detect the presence of, or suspected exposure to the SARS-CoV-2 virus which causes COVID-19 infection. Molecular tests and antigen tests are considered diagnostic of an active infection with the SARS-CoV-2 virus. In general, antibody (serology) tests are not diagnostic; rather, they are used to identify individuals who have developed antibodies against the SARS-CoV-2 virus and may be used for public health purposes such as population prevalence estimates. The Coverage Policy applies to both individual and pooled testing methods.

NOTE - Effective November 1, 2020, Cigna is denying COVID-19 claims when billed only with diagnosis code Z11.59 (asymptomatic screening).

In vitro testing (i.e., molecular, antigen, antibody) is considered not diagnostic and not medically necessary when performed for screening purposes in the general population, including but not limited to the following indications:
• population or public health screening
• determine prevalence of COVID-19 infection in the community
• screening assessment in a congregate setting
• encounter for screening of other viral diseases (ICD-10 code Z11.59)

>>>Click here to read past updates

UPDATE - Update to Administrative Policy AP-26 COVID-19 Viral and Antibody Testing and Supplies – Diagnosis Code B97.29. READ MORE 
Administrative Policy AP-26 COVID-19 Viral and Antibody Testing and Supplies has been updated  for claims billed on or after February 1, 2021, to remove interim diagnosis code B97.29 (Coronavirus as the cause of diseases classified elsewhere).  This update applies to all lines of business and is in line with guidance that the Centers for Disease Control and Prevention will implement as of January 1, 2021.

Claims for medically appropriate COVID-19 testing must be submitted with one of the following CPT® codes U0001, U0002, U0003, U0004, 0202U, 87635, 86328 86769, 86413, 0225U, 87636, 87637, 87811, 0240U, 0241U, and/or 87428 and billed with a diagnosis of U07.1, Z03.818, and/or Z20.828 will be reimbursed.

Laboratories may bill G2023 and G2024 for the purpose of specimen collection at a skilled nursing facility or for homebound patients with a diagnosis of U07.1, Z03.818, and/or Z20.828 and it will be reimbursed during public  health  emergency.

For specimen collection purposes, when HCPCS code C9803 is billed with diagnosis code U07.1, Z03.818, and/or Z20.828, it will be reimbursed during public health emergency.

12/23/2020 - Excellus BCBS Updates on COVID-19 (Coronavirus). READ MORE 
Audience: All Insurers Authorized to Write Accident and Health Insurance in New York State, Article 43 Corporations, Health Maintenance Organizations, Student Health Plans Certified Pursuant to Insurance Law § 1124, Municipal Cooperative Health Benefit Plans, Prepaid Health Services Plans, Utilization Review Agents, and Licensed Independent Adjusters.
RE: Coronavirus and the Suspension of Certain Utilization Review and Notification Requirements under the “Surge and Flex” Protocol.

12/11/2020 - COVID-19 Reinstating Reimbursement of Preventive Visits via Telehealth. READ MORE 
Excellus BlueCross BlueShield is steadfast in its commitment to ensuring continuity of care for our members during the COVID-19 public health emergency. Due to the recent surge in COVID-19 cases in the communities that we serve, we will reinstate reimbursement for preventive health visits for children and adults conducted via telehealth when an in-person visit is not advisable, and postponement is not feasible. This assistance contingency is effective immediately; we will provide advance notice to you prior to discontinuance of this contingency. We want to stress that this is an option, not a requirement, and we strongly encourage in-person visits whenever possible, consistent with recent recommendations from the Centers for Medicare & Medicaid Services and the American Academy of Pediatrics. This update applies to all lines of business, but it’s important to note that New York state regulations prohibit the submission of claims for members with coverage under Medicaid managed care (MMC) products, including the Health and Recovery Plan (HMOBlue Option, Blue Choice Option, Premier Option, Blue Option Plus, and Premier Option Plus) until the entire service is completed.

12/4/2020 - Extension of In-Network Outpatient Behavioral Health Services for Essential Workers During the COVID-19 State of Emergency. Audience: Behavioral Health Providers and Outpatient Facilities. READ MORE 
On November 27, 2020, the New York State Department of Financial Services issued an extension of its emergency regulation and circular letter, which was set to expire on November 27. The regulation waives member cost-share for outpatient mental health services provided to essential workers during the COVID-19 state of emergency.

Under the extension, health plans are prohibited from imposing copayments, coinsurance, or deductibles for outpatient mental health visits rendered by in-network outpatient mental health service providers through January 26, 2021. However, collecting deductibles is permissible from members with coverage under a high-deductible health plan until the member has met the deductible amount.

Excellus BlueCross BlueShield will continue to waive member cost-share through January 26, 2021 for in-network outpatient behavioral health services provided to our members with coverage under:

^^ Commercial insured
^^ Medicare Advantage
^^ Essential Plan
^^ Healthy NY
^^ Qualified health plans
^^ Student plans
^^ Article 47 plans
^^ Self-funded plans that opt in to provide coverage
^^ High-deductible health plans where deductible has been met

This cost-share waiver does not apply to self-funded employer groups that have elected not to offer the waiver. It also does not pertain to Medicaid Managed Care or Child Health Plus members, as they already have no cost-share responsibility.

12/1/2020 - Administrative Policy AP-26 – COVID-19 Viral and Antibody Testing and Supplies; Reimbursement Update Effective March 1, 2021. Audience: Physicians and Facilities. READ MORE 
We advise you that Excellus BlueCross BlueShield Policy AP-26 COVID-19 Viral and Antibody Testing and Supplies will be updated effective March 1, 2021, to define the coverage, reimbursement and billing guidelines for COVID-19 testing. You can access the individual policies by clicking here. Note: You must login with your username and password to access our administrative policies.

>>>Click here to read past updates

Effective March 01, 2020, providers are responsible to ensure any copays, coinsurance, or deductible charges are waived for Fidelis Care members at the time of an office visit, urgent care visit, clinic, or emergency room visit when the purpose of that visit is testing for COVID-19.  Claims with correct coding will be adjusted to reflect provider payments with $0 member liability upon processing. Updating claiming systems to be able to receive new codes by April 1, 2020. Will add Healthcare Common Procedure Coding System (HCPCS) codes to system.  READ MORE

UPDATE - 2021 payment rates for COVID-19 vaccine and monoclonal administration.  READ MORE

2021 payment rates for COVID-19 vaccine and monoclonal administration  The Centers for Medicare & Medicaid Services (CMS) established national payment allowances for the administration of COVID-19 vaccines and monoclonal antibodies. These allowances will be geographically adjusted for many providers.

12/18/2020 UPDATE - 2020 payment rates for COVID-19 vaccine and monoclonal administration. READ MORE

The Centers for Medicare & Medicaid Services (CMS) established national payment allowances for the administration of COVID-19 vaccines and monoclonal antibodies. These allowances will be geographically adjusted for many providers. If you received the national, unadjusted payment allowance, you can bring the claim to our attention for reopening to receive the geographically adjusted payment rate. When submitting your request, ensure the billed amount is equal to or higher than the rate to obtain the adjusted rate.

For Part A claims, if you use Direct Data Entry for claims submission, you can resubmit your claim to obtain the geographically adjusted rate.

For Part B claims, you can use the Secure Provider Online Tool (SPOT) or the Reopening Gateway. To reopen your claim in SPOT or the Reopening Gateway, select the reopening request type Billed Amount and ensure the correct billed amount is present on the line item.

12/7/2020 UPDATE - First Coast Processing Issues/Part B. Allowing Claims With "Z" Diagnosis Codes. READ MORE 
The Centers for Medicare & Medicaid Services (CMS) provided guidance in the April 7, 2020, Dear Clinician letter for using diagnosis codes Z03.818, Z20.828, and Z11.59 for reporting encounters related to possible COVID-19 exposure. First Coast Service Options, Inc. (First Coast) has been erroneously denying claims as preventive/screening services when submitted with diagnosis codes Z03.818 and Z11.59.

Resolution - Effective for claims processed on or after July 17, 2020, for dates of service on or after January 27, 2020, First Coast will no longer deny claims when submitted with diagnosis codes Z03.818 and Z11.59, as long as all other coverage requirements are met for claims processing.

Status/date resolved - Beginning July 17, 2020, for dates of service on or after January 27, 2020, claims will no longer be denied when billed with diagnosis codes Z03.818 and Z11.59.

Provider action - First Coast will adjust claims when brought to our attention. If you have a claim that denied due to the diagnosis code of Z03.818 or Z11.59 and want to request an adjustment, please contact customer service.

>>>Click here to read past updates

UPDATE - FDA Statement on Following the Authorized Dosing Schedules for COVID-19 Vaccines. We want to remind the public about the importance of receiving COVID-19 vaccines according to how they’ve been authorized by the FDA in order to safely receive the level of protection observed in the large randomized trials supporting their effectiveness. READ MORE 

We have been following the discussions and news reports about reducing the number of doses, extending the length of time between doses, changing the dose (half-dose), or mixing and matching vaccines in order to immunize more people against COVID-19. These are all reasonable questions to consider and evaluate in clinical trials. However, at this time, suggesting changes to the FDA-authorized dosing or schedules of these vaccines is premature and not rooted solidly in the available evidence. Without appropriate data supporting such changes in vaccine administration, we run a significant risk of placing public health at risk, undermining the historic vaccination efforts to protect the population from COVID-19.

12/18/2020 - FDA issued an EUA for the second vaccine for prevention of COVID-19 caused by SARS-CoV-2. The emergency use authorization allows the Moderna COFID-19 Vaccine to be distributed in the US for use in individuals 18 years of age and older. READ MORE

12/15/2020 - COVID-19 Vaccine Codes: Updated Effective Date for Pfizer-BioNTech.
READ MORE 
On December 11, 2020, the U.S. Food and Drug Administration issued an Emergency Use Authorization (EUA) for the Pfizer-BioNTech COVID 19 Vaccine for the prevention of COVID-19 for individuals 16 years of age and older. Review Pfizer’s Fact Sheet for Healthcare Providers Administering Vaccine (Vaccination Providers) regarding the limitations of authorized use.

During the COVID-19 Public Health Emergency (PHE), Medicare will cover and pay for the administration of the vaccine (when furnished consistent with the EUA). Review our updated payment and HCPCS Level I CPT code structure for specific COVID-19 vaccine information. Only bill for the vaccine administration codes when you submit claims to Medicare; don’t include the vaccine product codes when vaccines are free.

COVID-19 Update - FDA Authorizes Antigen Test as 1st Over-the-Counter Fully At-Home Diagnostic Test for COVID-19. READ MORE
Today, the U.S. Food and Drug Administration issued an emergency use authorization (EUA) for the first over-the-counter (OTC) fully at-home diagnostic test for COVID-19. The Ellume COVID-19 Home Test is a rapid, lateral flow antigen test, a type of test that runs a liquid sample along a surface with reactive molecules. The test detects fragments of proteins of the SARS-CoV-2 virus from a nasal swab sample from any individual 2 years of age or older. “Today’s authorization is a major milestone in diagnostic testing for COVID-19. By authorizing a test for over- the-counter use, the FDA allows it to be sold in places like drug stores, where a patient can buy it, swab their nose, run the test and find out their results in as little as 20 minutes,” said FDA Commissioner Stephen M. Hahn, M.D.

12/9/2020 - FDA authorized LabCorp's Pixel COVID-19 Test Home Collection Kit for use by any individual 18 years and older without prescription. READ MORE 

12/1/2020 - The FDA has reissued the August 23, 2020 emergency use authorization (EUA) for the emergency use of COVID-19 convalescent plasma for the treatment of hospitalized patients with COVID-19. The Letter of Authorization has been revised to add the Mount Sinai COVID-19 ELISA IgG Antibody Test as an acceptable test to be used for the purpose of qualifying high and low titer COVID-19 convalescent plasma in the manufacture of COVID-19 convalescent plasma. READ MORE 

Further, the FDA has updated the guidance, Notifying CDRH of a Permanent Discontinuance or Interruption in Manufacturing of a Device Under Section 506J of the FD&C Act During the COVID-19 Public Health Emergency. The update is intended to further assist manufacturers in providing the FDA with timely and informative notifications about changes in the production of certain medical devices that could help the FDA prevent or mitigate shortages of such devices during the COVID-19 public health emergency. 

>>>Click here to read past updates

UPDATE - COVID-19 Claims Reimbursement Program Update for the Uninsured. More than $2.3B has been paid and over 170,000 health care providers have enrolled in the program to date.* (as of 12/4/2020). READ MORE 

10/27/2020 - The Provider Relief Fund supports healthcare providers in the battle against the COVID-19 pandemic. Through the Coronavirus Aid, Relief, and Economic Security (CARES) Act and the Paycheck Protection Program and Health Care Enhancement Act (PPPCHE), the federal government has allocated $175 billion in payments to be distributed through the Provider Relief Fund (PRF). READ MORE

Qualified providers of health care, services, and support may receive Provider Relief Fund payments for healthcare-related expenses or lost revenue due to COVID-19. These distributions do not need to be repaid to the US government, assuming providers comply with the terms and conditions. New funding is available. Applications for the Phase 3 General Distribution are now being accepted through November 6, 2020. Providers are encouraged to apply as soon as possible to expedite the calculation and distribution of payments. All recipients of Provider Relief Fund payments must sign an attestation within 90 days of the payment to confirm its receipt.

>>>Click here to read past updates

UPDATE - FAQs–Application of OIG's Administrative Enforcement Authorities to Arrangements Directly Connected to the Coronavirus Disease 2019 (COVID-19) Public Health Emergency. READ MORE 
The Office of Inspector General (OIG) recognizes that, in the current public health emergency resulting from the outbreak of the COVID-19, the health care industry must focus on delivering needed patient care.

1. As part of OIG's mission to promote economy, efficiency, and effectiveness in HHS programs, we are committed to protecting patients by ensuring that health care providers have the regulatory flexibility necessary to adequately respond to COVID-19 concerns. Therefore, OIG is accepting inquiries from the health care community regarding the application of OIG's administrative enforcement authorities, including the Federal anti-kickback statute and civil monetary penalty (CMP) provision prohibiting inducements to beneficiaries (Beneficiary Inducements CMP).
2. If you have a question regarding how OIG would view an arrangement that is directly connected to the public health emergency and implicates these authorities, please submit your question to OIGComplianceSuggestions@oig.hhs.gov. In your submission, please provide sufficient facts to allow for an understanding of the key parties and terms of the arrangement at issue.3 OIG will update the FAQ site as we respond to additional frequently asked questions.

UPDATE - Extended/Open Authorizations for professional and facility providers.
READ MORE
Highmark has extended the timeframe for new prior authorization requests for ancillary/DME and inpatient planned surgeries submitted and approved by March 31, 2021. Any new authorizations approved as of the effective dates indicated in the chart below will automatically be given the extended timeframes as noted and no further action is required. IMPORTANT: Highmark must be notified to extend authorization for existing authorized services. 

12/11/2020 - Telehealth and Virtual Visit. READ MORE 
Please be advised that any temporary modifications or provisions in our telemedicine policies and procedures are for dates of service from March 13 2020 through March 31, 2021 unless otherwise noted. Should this change at any time, we will update this information accordingly.

11/2/2020 - REMINDER: OUT-OF-AREA BLUE PLAN PROVIDERS REQUIRED TO OBTAIN PRIOR AUTHORIZATION FOR OUTPATIENT SERVICES. READ MORE 
Effective November 1, 2020, Highmark has expanded our prior authorization requirements for outpatient services to include those services provided by out-of-area providers participating with their local Blue Plans. This will assure that the care our members receive while living and traveling outside Highmark’s service areas is medically necessary and managed consistently as it is throughout our service areas. This was communicated in a Special eBulletin posted on September 1, 2020, which was shared with out-of-area Blue Plans on October 2, 2020. To allow for electronic submission, Highmark has enabled our NaviNet® portal functionality to accept authorization requests for outpatient services from out-of-area Blue Plan providers when submitted through their local provider portals.

>>>Click here to read past updates

Horizon
Blue Cross Blue Shield
New Jersey

Effective March 6, 2020:

◦ Waiving prior authorizations for a visit to a primary care physician, urgent care center, or emergency room for evaluation of upper respiratory symptoms, fever, shortness of breath or other conditions that may represent COVID-19.
◦ Waiving prior authorizations for diagnostic tests and for covered services that are medically necessary and consistent with CDC guidance if diagnosed with COVID-19.
◦ Waiving prior authorization for lab studies or diagnostic testing required during an ER evaluation or inpatient hospital stay.  Horizon will cover the full cost of the COVID-19 test. 
◦ Horizon members will have no cost, 24/7 access to licensed nurses who can assess and assist members with symptoms that are consistent with suspected COVID-19 infection.  READ MORE

UPDATE - HRSA eNews January 7, 2021. Claims Reimbursement: Testing, Treatment and Vaccine Administration for Those Without Health Care Coverage. READ MORE 
Health care providers who have conducted COVID-19 testing, provided treatment for uninsured individuals with a COVID-19 diagnosis, and/or incurred vaccination administration fees on or after February 4, 2020 can request claims reimbursement through the HRSA COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing, Treatment, and Vaccine Administration for the Uninsured program. More than $2.8 billion in claims have been paid for COVID-19 testing and treatment of uninsured individuals. Get started today to receive reimbursement typically within 30 working days.

12/17/2020 - HRSA eNews 12/17/2020.  HHS Increases and Begins Distributing Over $24 Billion in Phase 3 COVID-19 Provider Relief Funding December 16  READ MORE
Today, the Trump Administration, through the Health Resources and Services Administration (HRSA) is announcing it has completed review of Phase 3 applications from the Provider Relief Fund (PRF) program and will distribute $24.5 billion to over 70,000 providers. Up from the $20 billion originally planned, the addition of another $4.5 billion in funding is being used to satisfy close to 90 percent of each applicant’s reported lost revenues and net change in expenses caused by the coronavirus pandemic in the first half of 2020. The U.S. Department of Health and Human Services (HHS) recognizes this pandemic has upended the health care system and caused significant financial hardships. These resources, along with previous distributions, have provided much needed relief. Payment distribution started today and will continue through January, 2021.

12/17/2020 UPDATE - HRSA enews 12/17.  HRSA Funds Additional Rural Health Clinics to Expand COVID-19 Testing. READ MORE 
On December 7, HRSA disbursed $9.3 million to support COVID-19 testing at Rural Health Clinics (RHC). We used updated data from the Centers for Medicaid and Medicare Services to identify 188 previously unsupported RHCs and calculate more than $49,000 per site for the December 2020 paymen.

12/15/2020 - UPDATE - COVID-19 Claims Payment Guidelines for the Uninsured Program. READ MORE
Question - Beginning January 1, 2021, what is the HRSA COVID-19 Uninsured Program reimbursement rate for high-throughput COVID-19 polymerase chain reaction (PCR) testing claims with HCPCS codes U0003 and U0004? Answer - Beginning, January 1, 2021, Medicare will reimburse independent laboratories $75 per claim (HCPCS codes U0003 and U0004) with a potential add-on reimbursement of $25 (HCPCS code U0005) if the laboratory returned results to patients within 48 hours and returned results for a majority of its tests (Medicare and non-Medicare) during the previous calendar month within two days. The HRSA COVID-19 Uninsured Program plans to continue to reimburse independent laboratories at a rate of $100 for COVID-19 PCR testing claims with HCPCS codes U0003 and U0004 and will not implement the add-on reimbursement for HCPCS U0005 in January 2021.

12/3/2020 - COVID-19 Claims Payment Guidelines for the Uninsured Program.
READ MORE

Question - Will the HRSA COVID-19 Uninsured Program provide claims reimbursement for monoclonal antibody therapy?

Answer - The HRSA COVID-19 Uninsured Program will align claims reimbursement for monoclonal antibody therapy with the CMS guidance issued on November 10, 2020. Per CMS’s Medicare Monoclonal Antibody COVID-19 Infusion Program Instruction, “During the COVID-19 public health emergency (PHE), Medicare will cover and pay for these infusions the same way it covers and pays for COVID-19 vaccines (when furnished consistent with the EUA).” View information regarding coding and pricing. https://www.cms.gov/files/document/covid-medicare-monoclonal-antibody-infusion-program-instruction.pdf

>>>Click here to read past updates

UPDATE - COVID-19 Vaccine FAQs 12/23/20. READ MORE 
There are currently two authorized COVID-19 vaccines. Vaccines from Pfizer-BioNTech and Moderna have both received Emergency Use Authorization (EUA) in the United States, meaning that they can be made available to the public during the pandemic. There are three other COVID-19 vaccines in earlier stages of development in the United States.

How is Humana handling cost share for the vaccine? For Humana members, all FDA-authorized COVID-19 vaccines will be covered at no additional cost during the public health emergency. Coverage applies no matter where the Humana patient gets the vaccine -- including at both in-network and out-of-network providers. It also covers instances in which two vaccine doses are required.

For Medicare Advantage (MA) members specifically, the Centers for Medicare & Medicaid Services determined that coverage for COVID-19 vaccines administered to MA plan members during 2020 and 2021 will be provided through the Original Medicare program. This includes charges for the vaccine and its administration. All claims should be submitted to the Medicare Administrative Contractors. Humana will deny any vaccine product or administration claims received for Medicare Advantage members.

For Commercial and Medicaid members, the federal government is coordinating with the states to supply all vaccine products to providers. It is not necessary for a provider to submit a vaccine product code for a state-supplied vaccine. Humana will not reimburse for a state-supplied vaccine product, however the administration of a state-supplied
vaccine is reimbursable. Administration claims should be submitted to Humana using the administration codes listed below. Cost share for the administration of the vaccine will be waived.

What codes are reported for the COVID-19 vaccine? Providers should report charges for the vaccine product and its administration according to the Current Procedural Terminology (CPT®) coding standards established by the American Medical Association (AMA). Providers should report the code appropriate for the manufacturer-specific vaccine and dose administered. The AMA has created the codes listed in the chart below for reporting the COVID-19 vaccine. See the AMA’s website for more information on COVID-19 vaccine coding. If the AMA creates more CPT codes for additional COVID-19 vaccines, we will update this FAQ.

10/16/2020 - Humana is reinstating authorization requirements for COVID-19 related diagnoses for Medicare Advantage and commercial plans. Medicaid and commercial plans will continue to follow state regulations and existing state executive orders as applicable. READ MORE 

We are providing advanced notice so you can prepare for this change. Availity and telephonic authorization tools will continue to provide an approval upon submission of a COVID-19 related authorization request or notification through Oct. 23, 2020, and no process changes are required through that date. We will reinstate authorization requirements on COVID-19 diagnoses for Medicare Advantage and commercial plans for authorizations requested on or after Oct. 24, 2020.

This return to our standard authorization policy applies to participating/in-network and non-participating/out-of-network providers. As we resume regular authorization processes, we will continue to monitor local situations and adjust policy accordingly. This includes continuing to suspend authorizations wherever a state executive order to do so exists.

Please note: Humana continues to waive out-of-pocket costs related to COVID-19 testing. Additionally, Humana will waive out-of-pocket costs related to treatment for confirmed cases of COVID-19. These cost share waivers apply to all of our Medicare Advantage, Medicaid and fully-insured commercial members. Finally, there are no prior authorization requirements related to COVID-19 testing.

>>>Click here to read past updates

Provider Alert - Repricing Hospital Outpatient Claims Billed with COVID-19 Diagnosis and Procedure Codes. READ MORE 
This notice informs hospitals that certain outpatient claims containing COVID-19-related coding will be reprocessed. The information below applies specifically to traditional Medicaid fee-for-service claims; however, for managed care claims, the managed care plans will also identify any claims impacted by these changes and automatically reprocess them. Hospitals do not need to take any action on these claims.

Payer is expanding temporary suspension of prior authorization for acute in-network inpatient admissions from the emergency department to include all diagnoses (including COVID-19) and for in-network transfers and transportation between facilities. The change, which is for fully insured members, takes effect immediately and will remain in effect until June 4, 2020. READ MORE

This Bulletin pertains to all health plan issuers, including insurance companies, health insuring corporations, MEWAs, non-federal governmental health plans, and other entities transacting the business of insurance in the State of Ohio, or that are subject to the jurisdiction of the Superintendent of Insurance (collectively, Insurers), that reimburse the costs of health care services under a health benefit plan in Ohio.

Testing and treatment for COVID-19 diagnoses are provided by select hospitals in the State. If the hospital is an out-of-network hospital for an insured, emergency medical conditions (i.e., COVID-19) testing and treatment for an insured must be covered with cost-sharing at in-network rates and without preauthorization. Insurers must provide benefits for these emergency services equal to the greatest amount for contracted in-network providers, out-of-network providers, or the amount paid by Medicare without balance billing the patient. READ MORE

UPDATE - Update to Billing Policy for Infectious Agent Antigen Detection. READ MORE 
Effective for dates of service on or after January 1, 2021, CPT® code 87426 (infectious agent antigen detection by immunoassay technique, [eg, enzyme immunoassay (EIA), enzyme-linked immunosorbent assay (ELISA), fluorescence immunoassay (FIA), immunochemiluminometric assay (IMCA)] qualitative or semiquantitative; severe acute respiratory syndrome coronavirus [eg, SARS-CoV, SARS-CoV-2 (COVID-19)]) may now be reported in conjunction with any of the following codes: 87635, U0002, U0003 and U0004.

An Erroneous Payment Correction (EPC) will be implemented to reprocess affected claims. The updated provider manual pages reflecting this change will be released in a future Medi-Cal Update.

1/6/2021 - COVID-19 Vaccine Administration: Real-Time RTIP Pharmacy Claims Can Be Submitted. READ MORE 
This article (in the series) informs pharmacy providers that they may begin submitting real-time claims via the Real Time Internet Pharmacy (RTIP) claim submission system for the COVID-19 vaccine administration as specified in an earlier News article titled “COVID-19 Vaccine Administration: Preparing to Electronically Submit Pharmacy Claims”.

Medi-Cal requests pharmacy providers to remain aware of the below highlights as they begin submission. Clarification on system changes, reimbursement, and timelines has been added.

The Food and Drug Administration (FDA) has provided Emergency Use Authorization (EUA) for two vaccine manufacturers: Pfizer-BioNTech and Moderna. As other vaccine manufacturers are approved by the FDA, additional billing instructions will be issued.

DHCS will reimburse the associated COVID-19 vaccine administration fee at the Medicare allowable rate for all claim types, including pharmacy.

** When billed appropriately, providers will be reimbursed $16.94 for the first dose and $28.39 for the second dose (regardless of manufacturer).
** Claims are subject to all other applicable billing and program requirements.
** Pharmacy providers will not be reimbursed for the vaccine cost or a dispensing fee for a federally-provided vaccine.

1/4/2021 - Medi-Cal List of Contract Drugs: COVID-19 Vaccines Pfizer-BioNTech and Moderna Added. READ MORE
The following provider manual sections have been updated with Corona Virus Disease 2019 Vaccines: Drugs: Contract Drugs List Part 1 – Prescription Drugs and Drugs: Contract Drugs List Part 4 – Therapeutic Classifications.

A summary of drug that has been added is shown below. For additional information, click on the link to the manual section and scroll to the page indicated or use the find feature to search for the particular drug.

- Added Drug(s)/Effective Date - December 11, 2020, and December 18, 2020
- Drug - Corona Virus Disease 2019 Vaccine
- Summary of Changes - Drug added, administration added, restriction added
- Page(s) Updated - drugs cdl p1a (73), drugs cdl p4 (29)

12/22/2020 - COVID-19 Vaccine Administration - Initial and Upcoming Policy. READ MORE 
This is the first article in a series of articles regarding COVID-19 vaccine administration and the Department of Health Care Services’ (DHCS) role in supporting the state’s vaccination efforts. With the recent federal approval of COVID-19 vaccines, the DHCS is seeking federal approval to help support delivery of the vaccine to all Medi-Cal beneficiaries. The vaccine will be provided at no cost to all Californians. The purpose of this article is to provide an update in terms of how DHCS plans to reimburse the administration fee tied to the vaccine under Medi-Cal.

DHCS will follow California’s COVID-19 vaccination plan, which was approved by the California Department of Public Health (CDPH). Consistent with the approach being taken by Medicare through Medicare Advantage Plans, DHCS will carve out the COVID-19 vaccine from Medi-Cal managed care health plans and will reimburse providers under the fee-for-service delivery system for both medical and pharmacy claims. This approach will ease program administration, eliminate challenges with out-of-network provider reimbursements, and keep vaccine administration fee rates consistent for providers regardless of delivery system.

Medi-Cal proposes to reimburse the associated COVID-19 vaccine administration fee at the allowable Medicare rate for all claims (medical, outpatient and pharmacy) based on the number of required doses. As the federal government will pay for the initial vaccines, there is no Medi-Cal provider reimbursement for the COVID-19 vaccine itself. Providers will bill for administration of the COVID-19 vaccine on a medical, outpatient or pharmacy claim, based on current policy. DHCS will seek federal approval to pay the pharmacy claims at the Medicare administration rate, which is different than our current pharmacy administration fee today. DHCS will also be seeking federal approval to cover the cost of the vaccine administration for Medi-Cal beneficiaries who are in restricted scope coverage, the COVID-19 Uninsured population and enrollees of the Family Planning, Access, Care, and Treatment (Family PACT) program.

COVID-19 Vaccine Administration: COVID-19 Uninsured Group – Vaccine Reimbursement. READ MORE
This is the second article in the COVID-19 Vaccine Administration series. With the recent federal approval of COVID-19 vaccines, the Department of Health Care Services (DHCS) is seeking federal approval to help support delivery of the vaccine to all Medi-Cal beneficiaries. Effective November 2, 2020, Qualified Providers (QPs), who are also registered with the California Department of Public Health as a COVID-19 Vaccination Provider, can be reimbursed for the COVID-19 vaccine through the COVID-19 Uninsured Group Program. QPs should refer to the previously published article titled “COVID-19 Vaccine Administration: Initial and Upcoming Policy,” for specific billing instruction and policies regarding the reimbursement for the administration of the COVID-19 vaccine. Additionally, as a reminder, individuals who have a Medi-Cal Share of Cost (SOC), and have not met their SOC obligation, are eligible for the COVID-19 Uninsured Group Program if all other eligibility criteria are met.

The COVID-19 Uninsured Group program provides temporary, no cost diagnostic testing, testing-related services, hospitalization and other treatment and vaccination services, including all medically necessary care, which includes associated office, clinic, or emergency room visits related to COVID-19. This program is available to uninsured and underinsured individuals determined eligible by a QP based on preliminary applicant information. Providers should refer to the COVID-19 Uninsured Group’s Frequently Asked Questions for more information.

12/14/2020 - New Benefit for COVID-19 Detection. READ MORE 
Effective for dates of service on or after November 10, 2020, CPT® code 87428 (infectious agent antigen detection by immunoassay technique, [eg, enzyme immunoassay (EIA), enzyme-linked immunosorbent assay (ELISA), fluorescence immunoassay (FIA), immunochemiluminometric assay (IMCA)] qualitative or semiquantitative; severe acute respiratory syndrome coronavirus [eg, SARS-CoV, SARS-CoV-2 (COVID-19)] and influenza virus types A and B) is a Medi-Cal benefit. The frequency limit for code 87428 is once per day, any provider. Code 87428 is reimbursable for Presumptive Eligibility for Pregnant Women (PE4PW) services. An Erroneous Payment Correction (EPC) will be implemented to reprocess affected claims. The updated manual pages reflecting this change will be released in a future Medi-Cal Update.

12/11/2020 - COVID-19 Uninsured Group Program Retroactive Applications. READ MORE
Per federal guidance, applications for the COVID-19 Uninsured Group can be retroactive to April 8, 2020. Qualified providers can submit retroactive applications to COVID19Apps@dhcs.ca.gov for review and processing. Questions - Please email COVID19Apps@dhcs.ca.gov if you have questions about the COVID-19 Uninsured Group or COVID-19 aid code. Re-published 12/11/2020; originally published 10/1/2020.

12/8/2020 - Rates are Updated for CPT COVID-19 Testing Codes 87636, 87637, 87811.
READ MORE 
Effective for dates of service on or after October 6, 2020, the rates for CPT® codes 87636 (infectious agent detection by nucleic acid [DNA or RNA]; severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] [coronavirus disease (COVID-19)] and influenza virus types A and B, multiplex amplified probe technique), 87637 (infectious agent detection by nucleic acid [DNA or RNA]; severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] [coronavirus disease (COVID-19)], influenza virus types A and B, and respiratory syncytial virus, multiplex amplified probe technique) and 87811 (infectious agent antigen detection by immunoassay with direct optical [ie, visual] observation; severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] [coronavirus disease (COVID-19)]) are updated. 

The codes above are exempt from the 10% payment reductions in Welfare and Institutions (W&I) Code section 14105.192, as described in Attachment 4.19-B, page 3.3, paragraph 13 of the State Plan. An Erroneous Payment Correction (EPC) will be implemented to reprocess affected claims.

12/4/2020 - New COVID-19 Testing Codes 87636, 87637 and 87811 are Medi-Cal Benefits. READ MORE
Effective for dates of service on or after October 6, 2020, new CPT® codes 87636, 87637 and 87811 are Medi-Cal benefits. All three codes do not have any gender or age restrictions, have a frequency limit of one each per day, any provider, per patient, and may be billed with any valid ICD-10-CM codes.

Two of the newly approved codes, 87636 (infectious agent detection by nucleic acid [DNA or RNA]; severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] [coronavirus disease (COVID-19)] and influenza virus types A and B, multiplex amplified probe technique) and 87637 (infectious agent detection by nucleic acid [DNA or RNA]; severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] [coronavirus disease (COVID-19)], influenza virus types A and B, and respiratory syncytial virus, multiplex amplified probe technique), allow a single test to simultaneously detect the novel coronavirus, and a combination of common viral infectious agents, including influenza A/B and respiratory syncytial virus.

Also approved is a new category I CPT code 87811 (infectious agent antigen detection by immunoassay with direct optical [ie visual] observation; severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] [coronavirus disease (COVID-19)]).

An Erroneous Payment Correction (EPC) will be implemented to reprocess affected claims. The updated manual pages reflecting this change will be released in a future Medi-Cal Update.

Effective for dates of service on or after September 8, 2020, the Department of Health Care Services (DHCS) updated the reimbursement rate for CPT® code 86413 (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] [Coronavirus disease (COVID-19)] antibody, quantitative). DHCS established the reimbursement rate at 100 percent of the Medicare rate for 86413. This code is exempt from the ten percent payment reductions in Welfare and Institutions Code (W&I Code) Section 14105.192. Upon expiration of the Public Health Emergency or National Emergency, this rate will be amended to correspond with the clinical laboratory services methodology in W&I Code Section 14105.22, including the application of the Assembly Bill (AB) 97 payment reduction. An Erroneous Payment Correction (EPC) will be implemented to reprocess the affected claims. The updated manual pages reflecting this change will be released in a future Medi-Cal Update.

>>>Click here to read past updates

UPDATE - Effective Nov. 18, 2020, Medical Mutual temporarily suspended skilled nursing facility (SNF) prior authorizations through Jan. 31, 2021, for all hospitals. We did this to help make bed space available for COVID-19 patients. This applies to our commercial and Medicare Advantage lines of business. Prior authorization remains in place for Long Term Acute Care and Inpatient Rehabilitation facilities. Also, Medical Mutual is allowing the expanded telehealth services through Dec. 31, 2020, at which time we will begin to follow Ohio telehealth regulations effective Jan. 1, 2021.
READ MORE

12/17/2020 - You will be able to get the vaccine from in-network or out-of-network providers or locations during the national public health emergency declared by the U.S. Department of Health and Human Services. READ MORE
After the national public health emergency ends, you will be able to get the vaccine from in-network providers or locations with no member cost sharing, similar to how we cover the flu vaccine. For the remainder of 2020 and all of 2021, Original Medicare will cover the costs of all necessary doses of the COVID-19 vaccine, as well as the cost to administer the vaccine, for Medicare Advantage and Medicare Supplement members. No member cost sharing will be applied.

11/18/2020 - Effective Nov. 18, 2020, Medical Mutual is temporarily suspending skilled nursing facility (SNF) prior authorizations through Dec. 31, 2020, for all hospitals.
READ MORE 
We are doing this to help make bed space available for COVID-19 patients. This applies to our commercial and Medicare Advantage lines of business. Some conditions apply, please review the link. Prior authorization remains in place for Long Term Acute Care and Inpatient Rehabilitation facilities.

>>>Click here to read past updates

The Michigan Department of Health and Human Services (MDHHS) has suspended the ability to scan paper claims received by U.S. postal mail. Providers can submit HIPAA 837P,837I or 837D electronic claims. If you currently do not have the ability to send electronic claims, please contact your Quadax Account Executive. READ MORE

MLO Medical Laboratory Observer

UPDATE - MLO Infectious Disease News 7/27/2020. READ MORE

7/10/2020 - Disease/Infectious Disease - WHO:  Aggressive Action Needed to Turn COVID-19 Around. READ MORE

UPDATE - Molina Healthcare, Inc. (NYSE: MOH) announced that it will continue waiving all out-of-pocket costs associated with COVID-19 testing and treatment for its Medicare, Medicaid, and Marketplace members nationwide through December 31, 2020.  READ MORE

>>>Click here to read past updates

UPDATE - NGS Upcoming Education for Providers. Let's Chat: COVID-19 Telehealth Services for Part B Providers. READ MORE 
Thursday, January 14, 2021 | 1:00 PM - 2:00 PM EST
Registration is required. Please join us for this hour session to learn about Telehealth services during COVID-19. We will provide current updates and address your questions.

1/12/2021 - Medicare Part B Billing for the COVID-19 Vaccine and Monoclonal Antibody. READ MORE
Refer to the link for detailed billing guidelines on these subjects:

^^ COVID-19 vaccine shot administration
^^ Helpful definitions of Mass Immunizers, Roster Billing, and Centralized Billers.
^^ Understand how to submit a claim if the Medicare Beneficiary is enrolled in a Medicare Advantage Plan.
^^ Medicare B payment for COVID-19 vaccines and certain monoclonal antibodies during the PHE.
^^ Payment allowances and effective dates for COVID-19 vaccines & COVID-19 monoclonal antibodies, and their administration during the PHE.
^^ Provider Eligibility and Enrollment in order to administer and bill for the COVID-19 vaccines.

1/6/2021 - NGS Newsletter January 2021. For Part B Providers - PC-ACE V4.8.100 Workaround for COVID-19 Roster Billing. READ MORE 
Current Issue - PC-ACE 4.8.100 allows users to bill for COVID-19 vaccinations. Within this PC-ACE functionality, when any roster bill vaccination is selected, PC-ACE auto-populates a ‘G0008’ HCPCS code on the claim. G0008 is a valid HCPCS code for administration of influenza virus vaccine or just “Admin influenza virus vac” for short, used in pneumococcal/flu vaccine. While the ‘G0008’ code is valid for traditional roster billing vaccinations (flu or pneumococcal), it is not the appropriate code to utilize for the administration of the COVID-19 vaccinations.

Workaround - While utilizing the roster billing functionality within PC-ACE, users are encouraged to review their claims within PC-ACE and update the claim to the appropriate administration code to meet their needs. PC-ACE allows users to select and modify the code to meet their business needs.

Long-Term Plan - Through collaboration with CMS, ABILITY will update PC-ACE functionality that will terminate the auto-population functionality of an administration code when a COVID-19 related vaccination code is utilized within roster billing functionality.

To ensure accurate billing for COVID-19 related items, users will be responsible to select and choose the administration code for proper reimbursement.

12/14/2020 - NGS Newsletter December 2020. TPE reviews remain suspended due to the PHE related to COVID-19.  READ MORE 
However, the NGS MR Department is currently performing service specific post-payment reviews for a random selection of claims billed to Medicare Part A and B. Providers are encouraged to visit the Medical Review Focus Areas on our website. This dedicated area will identify which services are being selected, what documentation will be requested, and provide more details on these service specific post-payment reviews.

Telehealth Video: Medicare Coverage and Payment of Virtual Services
CMS updated the Medicare Coverage and Payment of Virtual Services YouTube video that answers common questions about the expanded Medicare telehealth services benefit during the COVID-19 public health emergency. New information includes how CMS adds services to the list of telehealth services, additional practitioners that can provide telehealth services and the distant site services that RHCs and FQHCs can provide. Further, the video includes information about audio-only telehealth services, telehealth services that hospitals, nursing homes and home health agencies can provide, along with how to correctly bill for telehealth services.

12/10/2020 - To ensure broad access to the coronavirus disease 2019 (COVID-19) vaccine, Medicare will cover FDA-approved or authorized vaccines as a preventive service at no cost to your patients. READ MORE 
Please review our set of toolkits for providers, states and insurers to help you prepare to swiftly administer the vaccine once it is available. In addition, CMS released a set of toolkits for providers, states and insurers to help the health care system prepare to swiftly administer the COVID-19 vaccine once it is available. The toolkits include information to describe how health care providers can enroll in Medicare to bill for administering COVID-19 vaccines when available, the COVID-19 Vaccine Medicare coding structure, the Medicare reimbursement strategy for COVID-19 vaccine administration, and how health care providers can bill correctly for administering vaccines, including roster and centralized billing.

12/7/2020 - ANNUAL PARTICIPATION ENROLLMENT PERIOD EXTENDED TO JANUARY 31, 2021. READ MORE 
NOTE: CMS is extending the 2021 Annual Participation Enrollment Program. The participation enrollment period will now end 1/31/2021, instead of 12/31/2020.

Per 100-04, of the Internet Only Manual (IOM), Chapter 1, Section 30.3.12, contractors shall furnish participating physician/supplier data to the Railroad Retirement Board no later than 3/2/2021.

Per 100-06, of the IOM, Chapter 6, Section 390.2, contractors shall submit participation counts to the CMS’ Central Office via Contractor Reporting of Operational and Workload Data (CROWD) no later than 3/17/2021.

>>>Click here to read past updates

UPDATE - The services in this guidance document are currently reimbursable by NYS Medicaid fee-for-service (FFS) and Medicaid Managed Care (MMC) Plans. READ MORE
The fees are specific to Medicaid fee-for-service. For individuals enrolled in Medicaid Managed Care, providers should check with the individual’s plan for implementation details and billing guidance. Providers are reminded COVID-19 tests performed must be Food and Drug Administration (FDA) approved or granted Emergency Use Authorization (EUA) through the FDA and in agreement with the level of complexity assigned by Wadsworth Lab.

* The fees are current as of December 9, 2020. Providers should periodically check their respective fee schedules in eMedNY for updates: https://www.emedny.org/ProviderManuals/index.aspx

Complexity levels are available at the following link: https://www.cdc.gov/clia/test-complexities.html

Tests with EUA: https://www.fda.gov/medical-devices/emergency-situations-medical-devices/emergencyuse-authorizations#covid19ivd

12/10/2020 - New York State Medicaid Billing Guidance for COVID-19 Testing, Specimen Collection and Monoclonal Antibody Infusions. READ MORE 

11/12/2020 - Emergency Use Authorization (EUA) through the FDA and in agreement with the level of complexity assigned by Wadsworth Lab. CHHA specimen collection for homebound patients who do not receive nursing services is eligible for reimbursement on or after 11/01/2020. Please see the chart below for details. READ MORE 

• Rate Codes Used for CHHAs Only = 4921.
  • Descriptions = Specimen collection for severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID-19]), f rom a homebound*** individual on behalf of a home health agency, any specimen source(s). Reimburses $25.46.
• For CHHA use only. Rate Codes Used for CHHAs Only = 4922.
  • Descriptions = Travel for COVID-19 specimen collection. Reimburses $9.35 each way. For CHHA use only. When seeing multiple patients in the same location** only bill 1 trip charge for the first Medicaid member visit.

>>>Click here to read past updates

UPDATE - COVID-19 Mass Immunizer A/B Roster Billing Webinar. READ MORE
January 20, 2021 |1 p.m. CT

This event includes:
^^ COVID-19 Overview
^^ Enrollment
^^ Billing, Coding and Payment
^^ Roster Form
^^ Resources

12/23/2021 - COVID-19 Mass Immunizer A/B Roster Billing Webinar. READ MORE 
The Noridian Provider Outreach and Education (POE) staff is hosting the COVID-19 Mass Immunizer A/B Roster Billing webinar on January 7, 2021 at 1 p.m. CT. 

This event includes:
^^ COVID-19 Overview
^^ Enrollment
^^ Billing, Coding and Payment
^^ Roster Form
^^ Resources

To sign up for this webinar, visit the Noridian Schedule of Events.

12/8/2020 - Your Source for All Noridian COVID-19 Information. Are you feeling overwhelmed with the amount of information you are receiving on COVID-19? We hope to help by providing all COVID-19 related information for Part A, Part B, or DME on a single web page for each payer. READ MORE   
When you go to the main A, B, or DME Noridian home page for your jurisdiction, you will see the COVID-19 Banner in bright orange. In this box you will see the following sentence. Visit Noridian's COVID-19 page for information and guidance related to COVID-19.

12/8/2020 - New and Expanded Flexibilities for RHCs & FQHCs during the COVID-19 PHE - Revised. READ MORE 
Note: CMS revised this article to provide additional guidance on telehealth services that have cost-sharing and cost-sharing waived. You’ll find substantive content updates in dark red font (see page 5).

To provide as much support as possible to you and your patients during the COVID-19 PHE, both Congress and CMS have made several changes to the RHC and FQHC requirements and payments. These changes are for the duration of the COVID-19 PHE, and CMS will make other discretionary changes as necessary to make sure that your patients have access to the services they need during the pandemic. For more information, please see the RHC/FQHC COVID-19 FAQs at https://www.cms.gov/files/document/03092020-covid-19-faqs-508.pdf.

MLN Matters Number: SE20016 Revised
Article Release Date: December 3, 2020

>>>Click here to read past updates

UPDATE - COVID-19 Information 1/13/2021. 2021 COVID-19 monoclonal antibodies reimbursement. READ MORE 
The geographically adjusted payment allowances for the COVID-19 monoclonal antibody infusion administration fees have been updated due to changes made by the Consolidated Appropriations Act, 2021.

2021 COVID-19 vaccine reimbursement. The geographically adjusted payment allowances for the COVID-19 vaccine administration fees have been updated due to changes made by the Consolidated Appropriations Act, 2021.

1/6/2021 - Immunizations: COVID-19 roster billing collaborative webinar. READ MORE 
Join us on Tuesday, January 12, 2021, for the Novitas and First Coast Service Options multi-contractor collaborative webinar to learn about coding and billing mass immunization services for COVID-19 vaccines and monoclonal antibody (mAb) infusions This educational session will focus on the guidelines for roster billing COVID-19 vaccines and mAb infusions by mass immunizers, the forms to be completed, and available resources to assist in providing these important services during the public health emergency (PHE). Visit our calendar of events to register for this event.

12/28/2020 - Novitas Provider Enrollment Hotline for Temporary Enrollments.
READ MORE 
We have established the provider enrollment hotline at 855-247-8428, option 2, available 8:30 a.m. - 4 p.m. ET . Please contact the hotline if you need to enroll as an eligible provider for billing COVID-19 vaccines.

These are all of the supplier types who do not need to separately enroll to bill for COVID-19 vaccine administrations:

Institutional: Hospital; Hospital outpatient department; Skilled nursing facility (includes Parts A and B); Critical access hospital; End-stage renal disease facility; Home health agency; Hospice; Comprehensive outpatient rehabilitation facility; Federally qualified health center; Rural health clinic; and Indian health services facility.

Non-Institutional: Physician; Non-physician; Clinic/group practice; Pharmacy (enrolled as Part B); and Mass immunizer (roster bill only).

If you are not on the above list, you can temporarily enroll to bill for COVID-19 vaccine administrations via the hotline.

If you’re calling to initiate temporary billing privileges, you will receive the approval or rejection decision during the call, followed by a decision letter. Please ensure you have all necessary information available at the time of the call:

Legal business name
National provider identifier
Tax identification number
Practice location and state license, if applicable

For a list of eligible provider types, please see the CMS Enrollment for administering COVID-19 vaccine shots webpage.

12/21/2020 - Provider specialty: COVID-19 vaccine and monoclonal antibodies. This is a central location for all COVID-19 vaccine billing and monoclonal antibody infusion information, including links to related CMS resources and references. READ MORE

Categories include - Billing/Coding, Mass Immunizers/Roster Billers, Reimbursement, Enrollment, Incentives/Quality Reporting, and Resources. These services include information on the COVID-19 vaccine, monoclonal antibodies, and their administration. General information regarding the Medicare program overall can be found using the topics down your left navigation bar. Please subscribe to our mailing lists to stay current with Medicare.

12/21/2020 UPDATE - COVID-19 vaccine and monoclonal antibody billing for Part B providers.  This article will assist Medicare Part B providers with proper billing relating to COVID-19 vaccine and monoclonal antibody infusion. READ MORE

How to bill for COVID-19 vaccines and monoclonal antibodies To bill single claims for COVID-19 vaccines and monoclonal antibodies, follow the instructions below. For roster billing and centralized billing reference the Medicare billing for COVID-19 vaccine shot administration page.

When COVID-19 vaccine and monoclonal antibody doses are provided by the government without charge, only bill for the vaccine administration. Don’t include the vaccine codes on the claim when the vaccines are free.

If the patient is enrolled in a Medicare Advantage plan, submit your COVID-19 claims to Original Medicare for all patients enrolled in Medicare Advantage in 2020 and 2021.  *Providers should not bill for the product if they received it for free*

10/13/2020 - UPDATE - Provider News on CMS' Amended Repayment Process for the Accelerated & Advance Repayments. READ MORE 
Under the expanded Accelerated and Advance Payments (AAP) Program, the Centers for Medicare & Medicaid Services (CMS) issued payments to providers and suppliers to help ease financial strain due to a disruption in claims submission and/or claims processing related to the COVID-19 Public Health Emergency. Recently, Congress enacted amended repayment terms for the accelerated and advance payments through the Continuing Appropriations Act, 2021 and Other Extensions Act: Repayment will now begin one year after the date of the issuance of the payment.

** Other Notable Facts

• We highly recommend that providers/suppliers create a way during the 29-month recoupment period to track the claims submitted, Medicare reimbursement received, and Medicare reimbursements recouped. This will help you reconcile the payments recouped toward your AAP receivable in your system as they are a part of the payback process.
• Can I submit a voluntary refund instead of waiting for the amended repayment process to begin? Yes. Providers and suppliers that received an AAP payment can return the money via a check as long as the amount does not exceed $70M. You can use the return of monies form with a comment in the "Other" box stating it is for the AAP.

>>>Click here to read past updates

Ohio Governor Mike DeWine announced the Ohio Bureau of Workers' Compensation (BWC) is deferring the due date for employers to pay their June, July, and August premium installments until Sept.1. READ MORE

UPDATE - ANTIGEN TESTING UPDATE. Governor DeWine discussed the Ohio Department of Health aligning with the Center of Disease Control and Prevention’s (CDC) current case definition. READ MORE 
In August, the CDC changed the case definition of antigen testing to include case counts without additional verification.  Ohio has continued to manually verify an epidemiological link, such as a known positive contact, with an antigen positive test result.

On December 8, the department will begin including antigen tests without an epidemiological link in the total case count. This will result in a one-day spike in reported cases from pending positive antigen cases.  “After understanding more about the antigen testing, the CDC changed their definition. Our epidemiologists have alerted us that they are no longer able to keep up with the manual verification process of antigen testing because there is so much COVID-19 spread in Ohio,” said Governor DeWine. “Antigen tests have become a bigger part of our overall picture of understanding COVID-19, and it’s important to capture that information.”

>>>Click here to read past updates

UPDATE - Governor Mike DeWine signed Executive Order 2020-38D, which authorizes the Ohio Department of Medicaid to temporarily and substantially increase hospital-specific cost coverage add-ons, or CCAs. READ MORE 
Citing hardships hospitals have faced during the COVID-19 public health emergency and recognizing the need to mitigate the imbalance between managed care capitation rates and hospital rates in the executive order, ODM will increase hospital-specific CCAs to prospectively address CCA shortfalls. This temporary rate increase is equal to $145.1 million.

ODM filed an Emergency Rule to implement this rate increase for services provided on or after November 1st, and on or before December 31st. Hold on Submitting Claims - Due to the quick nature of this executive order and emergency rule, the Medicaid managed care organizations will not be ready to implement these rate changes by Nov. 1. Therefore, we recommend holding claims for at least seven to 10 days to allow the MCOs time to update their systems with the new rates. We anticipate Medicaid fee-for-service to be ready to process claims with the new rates on Nov. 1.

UPDATE - COVID-19 News Update: Governor DeWine announced that Ohio's Responsible Restart guidelines for higher education will now include a recommendation that all residential colleges and universities regularly test a sample population of asymptomatic students. READ MORE

"Some schools are already doing this, and screening asymptomatic students really gives school leaders a good idea about virus spread on their campuses," said Governor DeWine. "Our expectation is that colleges and universities will screen at least 3 percent of their at-risk population on a regular basis."

The updated Responsible Restart Ohio guidance will be posted to coronavirus.ohio.gov in the next few days.

>>>Click here to read past updates

NEW - COVID-19 Updates. Here are some of the steps we have taken to help providers and members. READ MORE 

- We are waiving the cost of diagnostic COVID-19 tests, related respiratory labs, and any visits associated with that test for both in-network and out-of-network facilities. Diagnostic testing included PCR and antigen tests used to inform patient treatment for COVID-19 or related complications, including serology testing for multi systemic inflammatory syndrome in children. Most non-diagnostic tests, including serology testing, testing for return to work, and public health surveillance testing, are not covered.

- We are waiving the cost of treatment related to COVID-19 delivered by in-network providers through at least September 30, 2020 for those testing positive. Prior authorization is required for all out-of-network care, including COVID-19 treatment, except for emergency care and COVID-19 testing (see above).

- We have expanded our telemedicine coverage policies in many states, including waiving the cost of any medically necessary care (related and unrelated to COVID-19, depending on the state) COVID-19 care delivered through telemedicine for our providers.

- We are supporting members with resources such as a risk assessment survey, testing site locator and answers to their most common questions at hioscar.com/covid19.

>>>Click here to read past updates

UPDATE - Retroactive to March 1, 2020, for those impacted by COVID-19, Medicare Fee-For-Service operations will implement the following policies and procedures for all claims, not just for the COVID-19 diagnoses: Additional Documentation Requests that have already been issued, Medicare contractors will release the claims for payment and not issue claim denials. Any claims auto-denied for non-response of an ADR from March 1, 2020, until March 26, 2020, will have the denial reversed and allow payment if an appeal has not been filed. If an appeal has been filed, normal appeals processes will be followed. As of March 26, 2020, future ADRs will not be sent until further notice from CMS. READ MORE

3/18/2020 - At this time, there will be regular processing of claims and issuing of payments and same level of support and service.  READ MORE

UPDATE - Claim Payment Issues Log. Resolved - Telehealth Procedure Codes and Skilled Nursing Facility Consolidated Billing edits. Issue - During the COVID-19 Public Health Emergency CPT codes 99441, 99442 and 99443, are not excluded from File 1 (Part A Stay – Physician Services) on the Skilled Nursing Facility Consolidated Billing (SNF CB) Part B file. As these three codes have now been added to the list of covered codes under the telehealth waiver during the COVID-19 PHE, they would also qualify for SNF CB exclusion and, thus, would be separately billable under Part B when furnished to a SNF’s Part A resident.  Status 7/29/20 -  Part B Medicare Administrative Contractors (MACs) will reprocess claims for CPT codes 99441, 99442 and 99443, with dates of service on or after March 1, 2020, until notified that changes made for the PHE are to be discontinued.  If you have already received payment from the SNF for these services, that payment should be returned to the SNF once your claims have been reprocessed. Status 9/10/20 - Resolved: Adjustments have been completed. READ MORE                                 

3/20/2020 Temporary Provisional Medicare Billing Privileges - Allows physicians and non-physician practitioners to initiate temporary provisional Medicare billing privileges via telephone and address questions regarding provider enrollment flexibilities afforded by the COVID-19 waiver. READ MORE

UPDATE - CMS COVID-19 Vaccine Toolkits. READ MORE 
Have questions about COVID-19 vaccines? Check out the CMS COVID-19 Vaccine Toolkits . CMS has developed these toolkits to provide you with up-to-date information about COVID-19 vaccines. In the Provider Enrollment, Becoming a Mass Immunizer, Billing and Administration Resource Toolkit at https://www.cms.gov/covidvax-provider, you’ll find useful information about COVID-19 vaccine topics such as enrollment, coding, billing, reimbursement and other helpful resources.

This toolkit includes information on:

^^ Enrollment for Administering COVID-19 Vaccine Shots
^^ Coding for COVID-19 Vaccine Shots
^^ Medicare COVID-19 Vaccine Shot Payment
^^ Medicare Billing for COVID-19 Vaccine Shot Administration
^^ SNF: Enforcement Discretion Relating to Certain Pharmacy Billing
^^ Beneficiary Incentives for COVID-19 Vaccine Shots
^^ CMS Quality Reporting for COVID-19 Vaccine Shots
^^Medicare Monoclonal Antibody COVID-19 Infusion

CMS makes periodic updates to these toolkits as new information becomes available. Refer to them often to answer your questions, reducing the need to contact the Provider Contact Center.

Claims Payment Issues Log posted 12/16/20. READ MORE

—Issue: COVID-19 Tests: HCPCS U0003 and U0004
—Resolved 12/23/2020 - Claim adjustments have been completed
—Issue Updated 12/16/20 - System edition has been updated
—Issue Updated 11/17/20 - The dates of service affected by this issue have been updated to include dates of service on or after July 1, 2020.

Some claims submitted with HCPCS codes U0003 and U0004 are denying incorrectly for required diagnosis coverage when submitted with dates of service on or after October 1, 2020. Provider Action: No provider action is necessary. Once system editing has been updated this claim payment issue will be updated and Palmetto GBA will proceed with adjusting affected claims.

—Identified Issue: 11/10/20
—Issue Status: Completed

12/23/2020 - Jurisdiction JM Part B Medicare Enrollment for Administering COVID-19 Vaccine Shots and/or Monoclonal Antibody Infusion Therapy Webinar.  READ MORE 
Join Palmetto GBA on December 29, 2020, at 11 a.m. ET for the Medicare Part B Enrollment for Administering COVID-19 Vaccine Shots and/or Monoclonal Antibody Infusion Therapy Webinar. This webinar is intended for providers that wish to explore enrollment requirements in order to be able to administer and bill for the COVID-19 Vaccine Shots or provide Monoclonal Antibody Infusion Therapy. While these two types of services are different, Medicare enrollment requirements for providers rendering either service is the same.
This webinar will not cover the specifics of billing for these services but is intended to give providers a better understanding of whether their provider is eligible to bill the services and whether any Medicare enrollment activities are needed. Future webcasts will be scheduled to address coverage and billing of these services.
This webinar will include answers to the following questions:
^^ Who can provide these services?
^^ Who must enroll to administer these services?
^^ What if I am already enrolled in Medicare, but my provider type doesn’t allow me to bill for administering vaccines?
^^ How do I enroll in Medicare to provide one of these services?
^^ What is a mass immunizer?
^^ What is a centralized biller?
Register here external link.

12/16/2020 - UPDATE - COVID-19 Laboratory Test Pricing. READ MORE

The following list includes Medicare payment amounts for COVID-19 tests. This list includes national pricing established by CMS and Jurisdiction J and M Palmetto GBA contractor-priced codes.  New codes with allowances in red.

HCPCS Code Allowance
U0001 $35.91
U0002 $51.31
U0003 $100.00
U0004 $100.00
CPT Code Allowance
0202U $298.60
0223U $298.60
0224U $42.13
0225U $298.60
0226U $42.28
0240U $142.63
0241U $142.63
86408 $42.13
86409 $79.61
86413 $51.43
86769 $42.13
87426 $35.33
87428 $63.59
87635 $51.31
87636 $142.63
87637 $142.63
87811 $41.38

12/16/2020 - UPDATE - Palmetto Claims Payment Issues Log.  COVID-19 Antibody Testing. READ MORE

Update 12/16/2020 - System editing has been updated.

Issue - Some claims submitted with CPT code 86769 are denying incorrectly for required diagnosis coverage when submitted with dates of service on or after April 10, 2020.                   

Issue Identified - 11/24/2020.                                                                            

Current Status - Open on 11/25/2020.  Provider Action - no provider action is necessary. Once system editing has been updated this claim payment issue will be updated and Palmetto GBA will adjust affected claims.                

UPDATE 12/16/2020   Claims Payment Issues Log posted 12/16/20. READ MORE   

Issue:  COVID-19 Tests: HCPCS U0003 and U0004.

Issue Updated 12/16/20 - System edition has been updated.

Issue Updated 11/17/20 - The dates of service affected by this issue have been updated to include dates of service on or after July 1, 2020.                                                                                 

Some claims submitted with HCPCS codes U0003 and U0004 are denying incorrectly for required diagnosis coverage when submitted with dates of service on or after October 1, 2020.          

Provider Action:  No provider action is necessary. Once system editing has been updated this claim payment issue will be updated and Palmetto GBA will proceed with adjusting affected claims.                                                                                                                                                          Identified Issue:  11/10/20                                                                                                                        Issue Status:  Open.                                                                                                                                                                                                                                                                                                       12/15/2020 - UPDATE - CMS COVID-19 Vaccine Toolkits. Have questions about COVID-19 vaccines? Check out the CMS COVID-19 Vaccine Toolkits external link . CMS has developed these toolkits to provide you with up-to-date information about COVID-19 vaccines. READ MORE

In the Provider Enrollment, Becoming a Mass Immunizer, Billing and Administration Resource Toolkit , you’ll find useful information about COVID-19 vaccine topics such as enrollment, coding, billing, reimbursement and other helpful resources.

This toolkit includes information on:
^^ Enrollment for Administering COVID-19 Vaccine Shots
^^ Coding for COVID-19 Vaccine Shots
^^ Medicare COVID-19 Vaccine Shot Payment
^^ Medicare Billing for COVID-19 Vaccine Shot Administration
^^ SNF: Enforcement Discretion Relating to Certain Pharmacy Billing
^^ Beneficiary Incentives for COVID-19 Vaccine Shots
^^ CMS Quality Reporting for COVID-19 Vaccine Shots
^^ Medicare Monoclonal Antibody COVID-19 Infusion

CMS makes periodic updates to these toolkits as new information becomes available. Refer to them often to answer your questions, reducing the need to contact the Provider Contact Center. 

>>>Click here to read past updates

UPDATE - To support people and communities facing unprecedented challenges, Regence health plans announced an extension of coverage for coronavirus (COVID-19) treatment without any out-of-pocket costs for fully insured members through December 31, 2020. This extends the previously announced coverage period through June 30, 2020. READ MORE

3/24/2020 - Claims can be submitted with CPT 87635 for DOS on and after 3/1/2020. READ MORE 

UPDATE - COVID-19 Testing. First Choice will cover all medically necessary services required to facilitate testing and treatment of COVID-19 for its eligible members, in accordance with federal and state guidance. No prior authorization is required for COVID-19 testing. READ MORE

Coronavirus testing codes follow: 

12/30/2020 - Public Health Emergency (PHE) Extended. As an important reminder, on Friday, October 2, 2020, U.S. Department of Health and Human Services Secretary Alex Azar renewed his declaration of a PHE due to the coronavirus pandemic. The renewal is effective October 23, when the previous 90-day renewal would have expired, and extends the PHE through January 20, 2021. READ MORE 

6/15/2020 - In accordance with guidance issued by South Carolina Department of Health and Human Services (SCDHHS), in the Medicaid bulletin dated April 16, 2020 Select Health will reimburse for well-child visits delivered via telehealth and/or telemedicine during the COVID-19 pandemic. READ MORE

3/30/2020 - No prior authorization is required for COVID-19 testing. Testing codes to use are U0001 and U0002. First Choice recommends that providers follow CDC, CMS, and State-specific guidelines with regard to COVID-19 evaluation, testing, diagnosis, treatment, and reporting. READ MORE

3/19/2020 - Effective for dates of service on and after 3/15/20 SCDHHS is expanding coverage for Telephonic and Telehealth services. SCDHHS will begin accepting claims for these services beginning 4/1/20. Codes to use for these services can be found on the website. READ MORE

UPDATE - Coronavirus Disease 2019 (COVID-19) Testing. In response to circumstances surrounding COVID-19, the South Carolina Department of Health and Human Services (SCDHHS) is announcing additional testing resources available to healthcare personnel within South Carolina Healthy Connections Medicaid-enrolled nursing facilities beginning Jan. 1, 2021. READ MORE 
The testing resources will help offset the unexpected cost of COVID-19 testing for nursing facilities and are being made available through a partnership with the Medical University of South Carolina’s Medical University Hospital Authority (MUHA). Through this partnership and consistent with Centers for Disease Control and Prevention (CDC) guidelines, the Medicaid portion of the cost of COVID-19 testing will be covered. This includes specimen collection, transport to laboratory and production of results with a turnaround for test results of less than 48 hours. To ensure consistent participation, Healthy Connections Medicaid-enrolled providers are required to participate in this program as a condition of reimbursement. The tests available to nursing facilities described in this alert may be conducted for full-time equivalent healthcare personnel within Healthy Connections Medicaid-enrolled nursing facilities. Nursing facilities that are provisionally enrolled in Healthy Connections Medicaid are not eligible to participate in this program. Healthy Connections Medicaid-enrolled nursing facilities should contact Precision Molecular Solutions LLC, who has contracted with MUHA, at (800) 290-8507 or c/o sc-snfsupport@precisiongenetics.com with questions regarding the number of tests available per facility and additional guidance related to this partnership.

12/23/2020 - COVID-19 Vaccination Administration Coverage. The South Carolina Department of Health and Human Services (SCDHHS) will reimburse for COVID-19 vaccine administration, without patient cost-sharing, when provided to Healthy Connections Medicaid members in a manner consistent with recommendations of the Advisory Committee on Immunization Practices (ACIP). READ MORE
The information contained in this bulletin is intended to provide guidance on vaccine administration coverage during the initial period of availability when the vaccine is being federally purchased. SCDHHS will provide additional information as the approach to vaccine and vaccine administration financing changes. For Medicaid members enrolled in a managed care organization (MCO), providers should bill the appropriate MCO for COVID-19 vaccine administration. Claims for fee-for-service (FFS) Medicaid members should be submitted to SCDHHS in the customary fashion.

The initial phase of vaccine distribution is outside of the Vaccines for Children (VFC) program, so providers do not need to be enrolled in the VFC program to administer a COVID-19 vaccine to children enrolled in Healthy Connections Medicaid. Since providers will not incur a cost for the vaccine itself, providers will only be reimbursed for the administration of the vaccine. The following guidelines apply to both FFS members and those enrolled in an MCO. Providers who generally submit claims using the CMS-1500 or 837P claim type will submit claims for COVID-19 vaccine administration using the appropriate current procedural terminology (CPT) code. SCDHHS will adopt the billing codes, reimbursement rates and effective dates published by the Centers for Medicare and Medicaid Services (CMS) for Medicare Part B coverage, which are available on CMS’ website

10/27/2020 - Provider Alert. U.S. Department of Health and Human Services Announces Expanded Pool of Providers Eligible for Additional Provider Relief Funds. READ MORE

The U.S. Department of Health and Human Services (HHS) recently announced it is broadening the categories of providers who are eligible to receive a Phase 3 provider relief payment provided by HHS under the Coronavirus Aid, Relief, and Economic Security (CARES) Act.

Providers who render services in the following areas are eligible to apply for provider relief funding regardless of whether they accept Medicaid or Medicare:

Behavioral Health Providers; Allopathic & Osteopathic Physicians; Dental Providers; Assisted Living Facilities; Chiropractors; Nursing Service and Related Providers; Hospice Providers; Respiratory, Developmental, Rehabilitative and Restorative Service Providers; Emergency Medical Service Providers; Hospital Units; Residential Treatment Facilities; Laboratories; Ambulatory Health Care Facilities; Eye and Vision Services Providers; Physician Assistants & Advanced Practice Nursing Providers; Nursing & Custodial Care Facilities; Podiatric Medicine & Surgery Service Providers.

Phase 3 applicants, including the expanded pool of providers listed above, must submit their application before 11:59 p.m. on Nov. 6, 2020, to be considered for payment. All recipients of provider relief payments will be required to attest to receiving the Phase 3 General Distribution payment and accept HHS’ associated terms and conditions.

>>>Click here to read past updates

UPDATE - Coverage of telehealth services extended through July 26, 2020. Also allowing early refills of prescriptions through July 26, 2020. SummaCare is temporarily suspending a 2% sequestration reduction in claims reimbursements to providers in fee-for-service arrangements in Medicare Advantage plans. The suspension aligns with the CARES Act legislation requiring all health plans to suspend the -2% sequestration payment adjustment in claims with dates of service from May 1, 2020 through December 31, 2020. READ MORE

3/26/2020 - Waiving any co-pays and deductibles related to provider-ordered testing of COVID-19 for our Medicare Advantage, Individual and Commercial members regardless of where the test is ordered and performed. Self-insured plans will determine how their coverage will apply. Will pay 100% Medicare rates for COVID-19 testing regardless of provider affiliation.  Will accept CPT code 87635 (effective 03/13/2020) or HCPCS Level II U0002 (effective 2-4-20) for the COVID-19 testing. There are no special modifiers at this time. 

UPDATE - New ICD-10 COVID-19 Diagnosis Code Updates Effective January 1, 2021.
READ MORE 
Effective for dates of service on or after January 1, 2021, in response to the COVID-19 pandemic, the Centers for Disease Control and Prevention’s (CDC) National Center for Health Statistics (NCHS) is implementing six new diagnosis codes into the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM). Added Diagnosis Codes - J1282, M3581, M3589, Z1152, Z20822 and Z8616. Discontinued Diagnosis Code - M358.

The updates to the ICD diagnosis codes will be included in the All Patient Refined-Diagnosis Related Groups (APR-DRG) software Version 38.1 update, scheduled to be released on December 29, 2020.

12/23/2020 - COVID-19 Vaccine Information. READ MORE 
On December 2020, the Food and Drug Administration (FDA) began issuing Emergency Use Authorizations for COVID-19 vaccines. The FDA issued the EUA for the Pfizer-BioNTech vaccine on December 11, and the EUA for the Moderna vaccine on December 18. HHSC will add these vaccines to the formulary for the Medicaid, Children’s Health Insurance Program (CHIP), and Healthy Texas Women (HTW) programs as a pharmacy benefit beginning December 28. VDP will back-date the effective date of formulary coverage to December 11, meaning pharmacy claims with dates of service starting December 11 are allowed starting December 28.

Reimbursement Rate Updates for Procedure Codes 87636, 87637 and 87811 Effective 10/6/2020. READ MORE 
Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, pre-certification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details. Effective 12/29/20, for DOS on or after 10/6/2020, the reimbursement rates for COVID-19 related procedure codes 87636/87637/87811 will be updated.

Reimbursement Rate Updates for Procedure Codes 0011A and 0012A Effective 12/18/2020. READ MORE 
Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, pre-certification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details. Effective 12/22/20, for DOS on or after 12/18/2020, the reimbursement rates for COVID-19 vaccine administration procedure codes 0011A & 00112A have been updated.

Reimbursement Rate Updates for Procedure Codes 86328, 86769 and 87426 Effective 1/1/2021. READ MORE 
Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, pre-certification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details. Effective 12/29/20, for DOS on or after 10/6/2020, the reimbursement rates for COVID-19 related procedure codes 87636/87637/87811 will be updated.

Reimbursement Rate Updates for Procedure Codes 86328, 86769, and 87426 Effective January 1, 2020. READ MORE  
Effective December 29, 2020, for dates of service on or after January 1, 2020, the reimbursement rates for COVID-19 related clinical diagnostic laboratory services procedure codes 86328, 86769 and 87426 will be updated. The following link shows the updates: COVID-19 procedure codes 86328, 86769 and 87426. Affected claims with dates of service from January 1, 2020, through December 29, 2020, if any are identified, will be reprocessed. Providers are not required to appeal the claims unless they are denied for additional reasons after the claims reprocessing is completed.

Reimbursement Rate Updates for Procedure Code 86413 Effective September 8, 2020. READ MORE 
Effective December 29, 2020, for dates of service on or after September 8, 2020, the reimbursement rates for COVID-19 related procedure code 86413 will be updated.
The following link shows the updates: COVID -19 procedure code 86413
Affected claims with dates of service from September 8, 2020, through December 29, 2020, if any are identified, will be reprocessed. Providers are not required to appeal the claims unless they are denied for additional reasons after the claims reprocessing is completed.

12/16/2020 - Reimbursement Rate Updates for Procedure Codes 0001A and 0002A Effective December 11, 2020. READ MORE
Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, pre-certification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details. Effective December 15, 2020, for dates of service on or after December 11, 2020, the reimbursement rates for COVID-19 vaccine administration procedure codes 0001A and 0002A have been updated.

12/16/2020 - Reimbursement Rate Updates for Procedure Codes 0001A and 0002A Effective December 11, 2020. READ MORE 
Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, pre-certification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details. Effective December 15, 2020, for dates of service on or after December 11, 2020, the reimbursement rates for COVID-19 vaccine administration procedure codes 0001A and 0002A have been updated.

12/15/2020 - COVID-19 Update to Telehealth Guidance on CLASS Professional and Specialized Therapies - December 14. READ MORE 
The following CLASS professional and specialized therapy services are available by telehealth. This is effective March 15 through January 21, 2021, or through January 31, 2021, if the federal public health emergency continues beyond January 21, 2021. Acceptable telehealth formats are synchronous audiovisual interaction or asynchronous store and forward technology. Use these with synchronous audio interaction between the client and the distant site provider. The Office of Civil Rights has relaxed HIPAA requirements to allow use of video for telehealth services. Texas Medicaid recognizes OCR’s HIPAA enforcement discretion as it relates to telehealth platform requirements.

12/15/2020 - Multiple Medicaid COVID-19 Flexibilities Extended Through January 21, 2021, or Through January 31, 2021. READ MORE 
Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, pre-certification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details. Effective December 1, 2020, reimbursement for telemedicine (physician delivered) and telehealth (non-physician delivered) services for federally qualified health centers (FQHCs) became benefits of Texas Medicaid. Providers can refer to the articles “Benefits for Telemedicine Services to Change for Texas Medicaid December 1, 2020,” and “Benefits for Telehealth Services to Change for Texas Medicaid December 1, 2020,” for additional information about the benefit changes.

12/14/2020 - COVID-19 Emergency Rules for ICF Providers Extended. READ MORE 
Emergency rules related to COVID-19 mitigation and response in an intermediate care facility that were scheduled to expire on December 11, 2020, have been extended. The extension took effect on December 11 and will expire on February 9, 2021. 

12/14/2020 - COVID-19 Vaccine Administration Procedure Codes 0001A and 0002A Are Now Benefits. READ MORE 
Effective December 11, 2020, in accordance with the Food and Drug Administration’s issuance of Emergency Use Authorization for the Pfizer-BioNTech COVID-19 Vaccine, vaccine administration procedure codes 0001A and 0002A are benefits for Medicaid, Healthy Texas Women, Family Planning Program, and the Children with Special Health Care Needs Services Program for individuals who are 16 years of age and older. Vaccine procedure code 91300 is informational only while the vaccine is distributed to providers free of charge. Procedure codes 0001A and 0002A are benefits for the following providers and places of service: http://www.tmhp.com/news/2020-12-14-covid-19-vaccine-administration-procedure-codes-0001a-and-0002a-are-now-benefits

12/8/2020 - Emergency Rules for NF Providers Extended. READ MORE 
Emergency rules related to COVID-19 mitigation and response in nursing facilities that were scheduled to expire on December 4, 2020, have been extended. The extension took effect on December 4 and will expire on February 1, 2021. The following rules are extended: https://hhs.texas.gov/sites/default/files/documents/doing-business-with-hhs/provider-portal/long-term-care/nf/nursing-facility-covid-19-response-emergency-rule.pdf

CSHCN COVID-19 Telehealth and Telemedicine Extensions through December 31, 2020. 
As part of its continued response to COVID-19 (coronavirus), the Children with Special Health Care Needs (CSHCN) Services Program will provide reimbursement for previously identified telemedicine and telehealth services through December 31, 2020 dates of service. All services listed in the Children with Special Health Care Needs (CSHCN) Services Program Provider Manual, Chapter 19, “Federally Qualified Health Centers (FQHC) and Rural Health Clinics (RHC),” Chapter 29, “Outpatient Behavioral Health,” and Chapter 38, “Telecommunication Services,” continue to remain eligible for CSHCN Services Program reimbursement. Providers can refer to these chapters for additional information about the CSHCN Services Program telemedicine and telehealth service benefits.

Client Signature Requirement Waived on CSHCN Documentation of Receipt Form through December 31, 2020. To help ensure continuity of care during the COVID-19 (coronavirus) response, the requirement to obtain the client or guardian signature on the Children with Special Health Care Needs (CSHCN) Services Program Documentation of Receipt Form is waived through December 31, 2020. For more information, call the TMHP-CSHCN Services Program Contact Center at 800-568-2413.

Telemedicine (Physician-Delivered) and Telehealth (Non-Physician-Delivered) Services Extended Through December 31, 2020.  Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, pre-certification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details. This is an update to the article titled “More Updates to ‘Further Updates to Date-of-Service Extension for Telemedicine (Physician-Delivered) and Telehealth (Non-Physician-Delivered) Services,’” which was posted on this website on July 31, 2020. Healthy Texas Women and Family Planning Program COVID-19 related flexibilities have been extended through December 31, 2020.

12/4/2020 - Claims for Telemedicine and Telehealth Services for HTW Plus. READ MORE 
As part of the continued response to COVID-19 (coronavirus), the Texas Health and Human Services Commission (HHSC) has extended the Medicaid telemedicine and telehealth services COVID-19 flexibilities to the same procedure codes covered under the new Healthy Texas Women Plus (HTW Plus) benefit package. These services can also be delivered by telephone (audio only) as needed and when appropriate.

The HTW Plus telemedicine and telehealth services will be effective for dates of service from September 1, 2020, through December 31, 2020. Telemedicine and telehealth flexibilities only apply to a specific procedure codes - check the chart on the web site. To indicate use of the telemedicine or telehealth modality and that remote delivery occurred, providers should use the 95 modifier when submitting claims. The telemedicine or telehealth services must also meet applicable state statutory and rule scope-of-practice requirements.

12/3/2020 - 90-Day Prior Authorization Extensions to End December 31, 2020.
READ MORE 
To help ensure continuity of care during the COVID-19 (coronavirus) response, the Health and Human Services Commission will allow TMHP to extend for 90 days existing prior authorization requests that are set to expire through December 31, 2020, after which time the 90-day prior authorization extensions will end.

Note: Providers currently have an option to request prior authorization time periods other than the 90-day extension.

12/1/2020 - HHSC Has Updated Reporting Guidance for Long-Term Care Providers – Point-of-Care Antigen Testing (PL 20-46). READ MORE 
HHSC has updated Provider Letter 20-46 Reporting Guidance for Long-Term Care Providers – Point-of-Care Antigen Testing (PDF). The provider letter has been revised to include information for ICF providers offering point-of-care testing for COVID-19 and to clarify test reporting requirements for NFs. The letter outlines responsibilities related to reporting COVID-19 test results for providers conducting point-of-care antigen tests within their facilities. This letter is not intended for use by providers who do not conduct COVID-19 POC tests within their facility. Providers who do not conduct COVID-19 POC tests within their facility may refer to PL 20-37

>>>Click here to read past updates

UPDATE - Tricare Provider News Issue 4 2020. COVID-19 News: Serology testing -
COVID-19 serology/antibody testing is covered by TRICARE only when medically necessary and when the results of the test will impact the clinical management of the beneficiary. READ MORE  
For example, if a beneficiary exhibits late symptoms or sequelae of COVID-19, testing would be covered. It is not covered for general screening in asymptomatic individuals, to determine immunity from past infection, or for return to work/school purposes. For further guidance on COVID-19 serology/antibody testing, refer to CDC guidance on the proper use of COVID-19 serology testing. The Military Health System (MHS) follows CDC guidelines, while most civilian healthcare plans follow the CARES act.

Telemedicine policy updates - As telemedicine continues to play an important role in healthcare, TRICARE has updated its policy on the coverage and expansion of services, costs and other benefits. May 19, 2020 updated temporary benefits include:

• Audio-only healthcare visits are now covered
• No out-of-pocket costs for covered telemedicine services

TRICARE will now waive cost-shares, copayments and deductible (if applicable) for covered telemedicine services from a military provider or TRICARE network provider. This waiver applies to all covered in-network telemedicine services, not just the services related to COVID-19. For more information and entire list of all updates, visit COVID-19 Telemedicine coverage.

>>>Click here to read past updates

UPDATE - DME Reimbursement per the CARES Act - Update. READ MORE 
In August, we informed you about the Centers for Medicare and Medicaid (CMS) revised durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) rates following the passage of the Coronavirus Aid, Relief, and Economic Security (CARES) Act. TRICARE implemented CMS’ fee schedule on May 18, 2020, with a directed effective date of March 6 for the rate changes. Health Net Federal Services, LLC (HNFS) recently became aware the revised CARES Act DMEPOS rates were made effective back to Jan. 1 instead of March 6 in our claims systems. As a result, we will adjust reimbursement for affected claims. Additionally, providers no longer need to submit claim review requests for claims that qualify for a rate adjustment per the CARES Act. We are automatically adjusting DMEPOS claims affected by CMS’ revised fee schedule and the effective date correction.

12/18/2020 - COVID-19 Clinical Trials. READ MORE 
Participation in clinical trials can offer eligible TRICARE beneficiaries more options for Coronavirus Disease 2019 (COVID-19) treatment and recovery support. Effective retroactively beginning Oct. 30, 2020, TRICARE benefits are available to beneficiaries selected to participate in Phase I, II, III and IV National Institute of Allergy and Infectious Diseases (NIAID)-sponsored COVID-19 clinical trials. Coverage will continue through the end of the President’s National Emergency.

Locating Clinical Trials - to be eligible for this Tricare benefit, clinical trials must be NIAID-sponsored. Covered Services:

* * * Phase I, Phase II, Phase III and Phase IV COVID-19 clinical trials sponsored by NIAID for the prevention, screening, early detection, and treatment of COVID-19 and its associated aftereffects (e.g., cardiac and pulmonary complications).

* * * Medical care and testing required to determine clinical trial eligibility and as a result of participation. Covered services include: inpatient care, outpatient care; diagnostic and laboratory services; and rehabilitation and home health services.

12/18/2020 - TRICARE coverage of COVID-19 clinical trials. READ MORE 

11/24/2020 - Recent COVID-19 and TRICARE policy updates: investigational drugs, long-term care reimbursement, skilled nursing facility stays. READ MORE 

11/19/2020 - Tricare West Provider Resources for COVID-19 updated on 11/19/2020. Find up to date information regarding benefits, provider education and online resources. 
READ MORE 

>>>Click here to read past updates

UPDATE - Select Prior Authorization Suspensions in Effect Nationally Dec. 18, 2020 – Jan. 8, 2021. READ MORE 
UnitedHealthcare is temporarily suspending select prior authorization requirements for in-network hospitals and in-network Skilled Nursing Facilities (SNFs) nationwide, effective Dec. 18, 2020 through Jan. 8, 2021. 

After Jan. 8, 2021, we may retrospectively review select services rendered during this time period. Admission notification is still required during this time, in alignment with the current protocol to support you in arranging post-admission care or other support services, if needed. In most cases, notification of inpatient admission is provided to UnitedHealthcare by the hospital or facility through Link or an EDI 278N transmission that requires no intervention on the part of your staff.

12/30/2020 - COVID-19 Information Updates. Suspended prior authorization period.
READ MORE 
From Dec. 18, 2020 through Jan. 8, 2021, we are suspending prior authorization requirements for inpatient admissions to in-network hospitals and admissions to in-network skilled nursing facilities. This temporary suspension applies to Medicare Advantage, Medicaid, and Individual and Group Market health plan members nationwide. It is designed to reduce your administrative burdens during a period in which COVID-19 cases are overwhelming emergency departments, admissions and transfers.

COVID-19 - Extensions of Temporary Cost Share Waivers. READ MORE 
Individual and Group Market health plans: Beginning Jan. 1, 2021 through Jan. 31, 2021, we will waive cost sharing (copay, coinsurance and deductible) for inpatient COVID-19 treatment at in-network facilities. This includes UnitedHealthcare Individual Exchange health plans. Implementation for self-funded customers may vary.

Medicare Advantage: Cost sharing (copay, coinsurance and deductible) will be waived for in-network and out-of-network COVID-19 treatment, including inpatient and outpatient treatment, from Feb. 4, 2020 through Jan. 31, 2021. The cost share waivers were previously set to expire on Dec. 31, 2020.

COVID-19 Reminder on New Telehealth Policies. READ MORE 
Individual and Group Market health plans: Effective Jan. 1, 2021, most commercial benefits plans will include telehealth visits with in-network providers. Members will still be responsible for any copay, coinsurance or deductible according to their benefit plan. 

Medicare Advantage: We will continue to follow current CMS guidelines in allowing the current CMS Telehealth List, including the expanded CMS code list for telehealth services and billing requirements.

12/17/2020 - COVID-19 Vaccine Guidance. Medicare Advantage health plans: Charges for COVID-19 vaccine administration for all Medicare beneficiaries should be billed to the Center for Medicare & Medicaid Services (CMS) Medicare Administrative Contractor (MAC). READ MORE 
The MAC will reimburse claims for Medicare beneficiaries with no cost share (copayment, coinsurance or deductible) for the remainder of 2020 and through 2021. For more information, visit the CMS COVID-19 Insurers Toolkit. Any COVID-19 vaccine-related claims for Medicare beneficiaries that are submitted to UnitedHealthcare will be denied, and health care professionals will be directed to submit the claims to the MAC. Employer and Individual* health plans: UnitedHealthcare and self-funded customers will cover the administration of COVID-19 vaccines with no cost share (copayment, coinsurance or deductible) for in- and out-of-network providers, during the national public health emergency period. Administration fees for in-network providers will be based on contracted rates. Administration fees for out-of-network providers will be based on CMS published rates.
Medicaid: Medicaid state-specific rules and other state regulations may apply. For Medicaid and other state-specific regulations, please refer to your state-specific website or your state’s UnitedHealthcare Community Plan websiteOpens in a new window, if applicable. UnitedHealthcare will pay administration fees at CMS published rates unless otherwise specified.

12/4/2020 - COVID-19 Monoclonal Antibody Study. READ MORE 
A press release was issued by Eli Lilly on Dec. 4, 2020 about a COVID-19 monoclonal antibody study being conducted in partnership with UnitedHealth Group.  The national, 500,000-person pragmatic study will test their new monoclonal antibody treatment for people recently diagnosed with COVID-19. This treatment was authorized by the U.S. Food & Drug Administration for emergency use. This study will be offered to UnitedHealthcare Medicare Advantage members in 46 states who meet the study’s criteria for participation. Information about the study, including selection criteria and how UnitedHealthcare members can volunteer to be considered for the study, can be found at unitedinresearch.com.

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UPDATE - Physical Health Providers/COVID-19 Resources - Apple Health Medicaid Clinical Policy and Billing Facts for COVID-19 (updated 9/23/20) READ MORE

The Health Care Authority revised the Facts sheet and the following changes were made:

• Clarified billing requirements for providers who usually receive an enhanced rate for services
• Added billing for services provided via email to HCPCS code G2012
• Expanded the services allowed to be billed with GE modifier to include CPT® codes 99421-23, 99441-43, and HCPCS code G2012
  
• Added CPT code 86413 SARS-CoV2/COVID-19 antibody, quantitative to the list
• Ended coverage of CPT code 99001 for drive up/drive through COVID-19 specimen collection, effective 10/15/2020. Added HCPCS codes G2023, G2024, and C9803 to align with Medicare when billing for specimen collection.
  
• Added information that aligns with CMS guidance regarding payment for counseling patients at the time of the COVID-19 testing.

4/22/2020 - Retroactive to dates of service on and after February 29, 2020, ground and air ambulance providers are eligible to receive enhanced rates for transports related to COVID-19. Possible rate enhancements are available when transporting a suspected or confirmed case of COVID-19 or when performing interfacility transfers to clear beds for COVID-19 capacity. Providers must include modifier CR For COVID-19 related transports that have already been billed to HCA prior to this notice and did not include the CR modifier, providers may rebill to receive the enhanced rate. READ MORE

3/31/2020 - This page offers billing guidance for Providers COVID-19 related telemedicine, prior authorization requirements, and provider enrollment FAQs. READ MORE

UPDATE - We intend to cover COVID-19 testing and screening services for Medicare members and are waiving all associated member cost share amounts for COVID-19 testing and screening. READ MORE 
To ensure that our members receive the care they need as quickly as possible, WellCare will not require prior authorization, prior certification, prior notification or step therapy protocols for these services. Waiving cost-sharing for COVID-19 treatments in doctor’s offices or emergency rooms and services delivered via telehealth. Waiving prescription refill limits. Relaxing restrictions on home or mail delivery of prescription drugs. Expanding access to certain telehealth services.

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UPDATE - Due to COVID-19 impacts, WPS reports they are suspending Provider Enrollment revalidations at this time. They will not deactivate billing privileges and will notify Providers who were set to revalidate when they can do so. READ MORE

UPDATE - MCS Claims Processing Alerts. READ MORE

Description/Claims Coding Impact - Codes 99441, 99442 and 99443, for dates of service 03/01/2020 and after, were added to the list of telehealth codes coverable under the waiver during the COVID-19 PHE. These codes should bypass the Skilled Nursing Facility (SNF) Consolidated Billing (CB) edits.

Proposed Resolution/Fix/Action Required - The system was updated on 11/02/2020 to bypass the SNFCB edits for the codes 99441, 99442 and 99442 for dates of service 03/01/2020 and after. Adjustments have been initiated on the affected claims. No provider action is needed.

Status - Open
Last Updated - 11/5/2020
Provider Type Impacted - All
Date Issue Reported - 10/13/2020

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