ACEP Reimbursement Manager Adam Krushinskie put together a quick synopsis of what he has gathered from researching all of the major insurer bulletins and policy change notices regarding COVID-19, plus the MAC TPE updates he's been able to find so far. This resource will be updated as things change.
Commercial (and Managed Care where applicable):
- Telehealth (No Changes for EM): waiving CMS originating site restriction for Medicare Advantage, Medicaid and commercial members, so that care providers can bill for telehealth services until 6/18/2020. Member cost sharing will be waived for COVID-19 testing-related visits during this national emergency. UHC lists the following for coding:
- Commercial: Recognized by CMS and appended with modifiers GT or GQ and, recognized by the AMA included in Appendix P of CPT and appended with modifier 95.
- Medicaid: Recognized by CMS and appended with modifiers GT or GQ and, recognized by the AMA, included in Appendix P of CPT and appended with modifier 95
- Medicare Advantage: All CPT/HCPCS codes, payable as telehealth when billed with POS 02 and the GQ or GT modifiers, as appropriate, under Medicare, will be covered on our MA plans for members at home during this time.
- Coding & Reimbursement: (Updated May 1 to include coverage for both testing and treatment, timely filing deadlines, and policy delays)
- COVID-19 Testing-Related Visits: waiving cost sharing for COVID-19 testing-related visits during this same time, whether the testing-related visit is received in a health care provider’s office, urgent care center, emergency department or telehealth visit. This coverage applies to Medicare Advantage, Medicaid, Individual and Group Market health plan members.
- COVID-19 Treatment: waiving member cost sharing for the treatment of COVID-19 through May 31, 2020 for its Medicare Advantage, Medicaid plans, Individual and Group Market fully insured health plans. Note: some self-funded plans will implement a similar plan option, but must opt-in.
- Submitting Testing: UHC requires "proper office visit E/M code"
- Extending Timely Filing Guidelines: Extended timely filing deadlines for claims during the COVID-19 public health emergency period for Medicare Advantage, Medicaid, and Individual and Group Market health plans. Claims with a date of service (DOS) on or after Jan. 1, 2020 will not be denied for failure to meet timely filing deadlines if submitted through June 30, 2020.
- Medicare Advantage ED Coding Policy delayed: implementation date delayed until Aug. 1, 2020 due to the COVID-19 public health emergency. The policy focuses on professional ED claims submitted with a level 5 (99285) E/M code for Medicare Advantage claims.
- Coverage: This link takes patients to the COVID-19 resources available from UHC
- Credentialing: UHC is temporarily updating their credentialing policies until June 18, 2020 to implement provisional credentialing for OON care providers who are licensed independent practitioners and want to participate in one or more of their networks. For providers who are already credentialed, they will not require additional credentialing to practice in a new location. Additionally, they're waiving site visit requirements.
- Telehealth: Coverage will depend on the type of plan the patient has. Only members with coverage for telehealth visits will be covered as a regular office visit for providers who offer the service. Some plans also provide access to MDLive or a similar vendor with a network of physicians who provide telehealth services. The revised 3/10/20 policy also does not include ED E/M codes as appropriate for telehealth services.
- Testing: (New 4.23.20) coverage for medically necessary testing and antibody testing will be covered without cost sharing.
- Credentialing: Temporarily updating credentialing policy and processes. This complies with emergency state and federal regulations and is effective April 3, 2020. The temporary modifications are only in place during the COVID-19 emergency and subject to change based upon state and federal action. Otherwise, standard credentialing and processes will apply.
- Coding & Reimbursement: covering testing to diagnose COVID-19 for most members with no prior authorization needed and no member copays or deductibles. For treatment of COVID-19, they cover medically necessary health benefits, including physician services, hospitalization and emergency services consistent with the terms of each member's benefit plan.
- Coverage: Patient newsletter on COVID-19 details coverage options
Anthem: (Note: Anthem will ask you to select your state)
- Telehealth: as of March 17, 2020 and until further notice, Anthem and its delegated entities will waive cost sharing for members using Anthem’s telemedicine service, LiveHealth Online, as well as care received from other in-network providers delivering virtual care through internet video + audio services for our fully insured employer plans, Individual plans, Medicare plans and Medicaid plans. Self-insured plan sponsors may opt out of this program.
- Coding & Reimbursement: limitations in coverage for treatment of an illness/virus/disease: standard health plan contracts do not have exclusions or limitations on coverage for services for the treatment of illnesses that result from an epidemic.
- Claims Audits, Retrospective Review, and Policy Changes: (New April 24, 2020)
- Hospital claims audits requiring additional clinical documentation will be limited for next 90 days, though Anthem reserves the right to conduct retrospective reviews with expanded lookback recovery periods. Anthem will offer electronic submission of clinical documents through the provider portal.
- Retrospective utilization management review will also be limited during this 90-day period, and Anthem "reserves the right to conduct retrospective utilization management review of these claims when this period ends and adjust claims as required."
- Peer to peer reviews will be suspended except where required pre-denial per operational workflow or where required by State until further notice for all lines of business except Medicare.
- Special Investigation programs targeting provider fraud will continue, as well as other program integrity functions that ensure payment accuracy.
- New payment and utilization management policies and policy updates will be minimized for the next 90 days, "unless helpful in the management of the COVID-19 pandemic."
- Credentialing: (New April 24, 2020) Continue to process provider credentialing within the standard timeframe. If they are unable to verify provider application data due to disruptions to licensing boards and other agencies then then they will verify this information when available.
If Anthem finds that a practitioner fails to meet minimum criteria because of sanctions, disciplinary action etc., they will follow the normal process of sending these applications to committee review which may add to the standard timeframe.
- Coverage: Anthem has a page that's updated daily for both patients and providers.
- Telehealth: (Updated April 27, 2020) until June 4, 2020, Aetna will waive member cost sharing for a covered telemedicine visit regardless of diagnosis. Aetna will cover evaluation and management services care services rendered via telephone - expanded from minor and acute services prior to this date. A visual connection is not required.
- Coding & Reimbursement: No changes to coding or reimbursement practices. Note; Aetna has reaffirmed that self-funded plans can opt out of certain COVID-19 telehealth and other temporary provisions.
- Coverage: See the FAQs and news updates daily from Aetna News
- Telehealth: (Updated May 1, 2020) Effective March 23rd, Humana will temporarily reimburse for telehealth visits with participating/in-network providers at the same rate as in-office visits. In order to qualify for reimbursement, telehealth visits must meet medical necessity criteria, as well as all applicable coverage guidelines. For providers or members who don’t have access to secure video systems, we will temporarily accept telephone (audio-only) visits. Humana is also waiving member cost share for all telehealth services delivered by participating/in-network providers.
- Extending member cost-share waivers through the end of the calendar year for in-network telehealth visits
Extending cost-share waivers through the end of the year for individual and group Medicare Advantage members. This waiver applies to audio and video telehealth visits with all participating/in-network providers, including primary care, behavioral health and other specialist providers. In support of this waiver, please do not collect a copay from any Humana individual or group Medicare Advantage patients for any of and telehealth visits outlined above.
- Coding & Reimbursement: (Updated April 21, 2020)
- Claims Processing and Payments: Temporarily reduced administrative requirements to streamline processes and increase access to care.
- Suspension of pre- and post-paid claim reviews
- Effective April 1, suspend all medical records requests for pre-and post-paid claim review processes for individual and Group Medicare Advantage, Commercial Group, and Medicaid
- This suspension applies to all professional and facility claims from in-network and out-of-network providers
- Humana will release any claims currently under medical record review as of April 1 and issue payment to providers
- Although medical record claim reviews are suspended, we may request medical records retrospectively once the suspension is lifted
- We will continue to reassess the need for this suspension as the COVID-19 public health crisis evolves and circumstances change
- Coverage: Humana has a detailed plan on their website for the continuity of service as well as member outreach. Credentialing-wise, they are waiving site visit requirements, approving licensed providers to practice outside of their licensed state, and placing a hold on the decredentialing process (only for providers missing information)
- Credentialing: applying any federal or state emergency regulations for COVID-19 including such items as:
- Waiving site visit requirements
- Approving licensed providers to practice outside of their licensed state
- Placing a hold on the decredentialing process (only for providers missing information)
Centene: (applies to Medicaid, Medicare, and Marketplace plans as well as commercial) (No new updates)
- Telehealth: Centene intends to cover COVID-19 testing and screening services for Medicaid, Medicare and Marketplace members and is waiving all associated member cost share amounts for COVID-19 testing and screening. To ensure that these members receive the care they need as quickly as possible, they will not require prior authorization, prior certification, prior notification or step therapy protocols.
- Coding & Reimbursement: Centene announced on March 12th they would be allowing for treatment of COVID-19 without cost-sharing for telehealth services: "Waiving cost-sharing for COVID-19 treatments in doctor's offices or emergency rooms and services delivered via telehealth"
- Coverage: No additional information on coverage expansion or if any costs to treat COVID-19 (the E/M service).
- Telehealth: Cigna is waiving out-of-pocket costs for COVID-19 visits with providers, whether at a provider’s office, urgent care center, emergency room, or via virtual care, through May 31, 2020 for diagnostic visits and testing. Treatment is covered according to the member's plan. Note: ERISA plans may be able to opt out.
- Coding & Reimbursement: Cigna has not yet decided to change its claims submission process, so all claims must be submitted under the same time constraints as normal.
- Coverage: Cigna released a guide to COVID-19 with FAQs in early March.
- Credentialing: (Updated April 28, 2020) Effective April 1, 2020, Cigna is accelerating the initial credentialing process for COVID-19 related applications. They anticipate that the majority of providers will be initially credentialed through this accelerated credentialing process to address COVID-19 related services. This accelerated initial credentialing process will be available until June 30, 2020. Providers are asked to identify that their credentialing request is a COVID-19 application upon submission.
Kaiser: (select your state for specific Kaiser details and facility closings) (No new updates)
- Telehealth: Only where facilities are closed is telehealth being applied. Currently, some in-person appointments may be affected by closures and will be converted to a telephone appointment (with or without video depending on location). Kaiser is expected to comply with CMS on availability of free diagnostic testing.
- Coding & Reimbursement: Kaiser is covering diagnostic testing visits, however they are following the member's plan for treatment: "You won’t have to pay for costs related to COVID-19 screening or testing if referred by a Kaiser Permanente doctor. If you’re diagnosed with COVID-19, additional services, including hospital admission (if applicable), will be covered according to your plan details.
- Coverage: Kaiser has released a guide for providers and patients for COVID-19 coverage
Molina: (Revised telehealth policy as of April 30, 2020)
- Telehealth: Molina will offer zero co-pay and cost share for participating telemedicine visits, including the ED (where these are a covered benefit)-for any diagnosis until the end of the PHE.
- Coding & Reimbursement: Molina will waive co-pays and cost share for office visits, urgent care visits, and ED visits where the diagnosis rendered is specifically related to COVID-19 until May 1, 2020. Visits for other symptoms or diagnoses will not have co-pay or cost share removed. This includes not removing cost share for other laboratory testing (besides COVID-19 testing), x-rays, or other add-on testing.
- Coverage: Molina has created a member FAQ for coverage changes.
Well Care (Medicaid) (Medicare): (No new updates)
- Telehealth: Well Care will fully reimburse telehealth services beginning on March 18, 2020 for diagnostic testing. Treatment will follow the member's plan. For Medicare, starting April 1st, 2020, providers performing the COVID-19 test can begin billing for services that occurred after February 4, 2020.
- Coding & Reimbursement: All member cost share (copayment, coinsurance and/or deductible amounts) will be waived across all products for any claim billed with the new COVID-19 testing codes. They are also temporarily waiving requirements that out-of-state Medicare and Medicaid providers be licensed in the state where they are providing services when they are licensed in another state.
- Coverage: Well Care has a FAQ for both providers and members
Note: AHIP has maintained a great resource for all of the insurer policies in every statewhich is especially useful when attempting to identify changes to smaller regional insurer policies:
Targeted Probe and Educate (TPE) COVID-19 Changes:
- Novitas (Medicare JH: AR, CO, LA, MS, NM, OK, TX, Indian Health & Veteran Affairs) Novitas has announced they are implementing new procedures for their TPE program beginning on March 26. No further details at this time. (No new updates)
- First Coast (Florida): March 4, 2020 effective immediately and, until further notice, state survey agencies and accrediting organizations will focus their facility inspections exclusively on issues related to infection control and other serious health and safety threats, like allegations of abuse. (No new updates)
- NGS: (Updated 4.28.20) Targeted Probe and Educate: NGS is in the process of pausing TPE Medical Reviews. At this time, they are unable to provide additional clarity on when or how TPE reviews will resume, but they will share information as it’s made available. They will work with providers who previously scheduled educational sessions to reschedule them. They are contacting providers to let them know we released claims and there is no need to respond to an ADR for medical records. Effective 3/1/2020, claims that auto-denied for nonresponse or late response to the ADR will be reversed and allowed for payment unless an appeal has already been filed. In that case, the appeal will follow the normal appeals process.
- Palmetto: (Medicare M: NC, SC, VA, WV J: AL, GA, TN) (No new updates) TPE program suspended with TBA for a restart.
- CGS: (KY, OH): (Updated 4.30.20) COVID-19 updates page has been updated without information on TPE audits.
- WPSGHA: (J5: IA, KS, MO, NE J8: IN, MI) Due to COVID-19 impacts, WPSGHA is suspending Provider Enrollment revalidations. If you are designated for provider enrollment revalidation, please do not send in your revalidation documentation until WPS GHA notifies you to do so. They will not deactivate your billing privileges.