NHN Resource Library

IOWA COVID-19 PAYER RESOURCES

Updated 10/20/2021

Current Public Health Emergency: Renewed Oct. 18, 2021

Community Relay

Nebraska Health Network assembled this growing list of resources for you and your patients. This list includes resources from our payers and data extracted from the new Community Relay website. Community Relay is a social care network that enables users to search for free or reduced cost services like food, job training, legal services and more.

In addition, we have a dedicated Patient Resource Library filled with educational materials to help patients track their medications, record their blood pressure, manage chronic conditions and more. Materials can be viewed online or downloaded and emailed directly to patients.

Community Relay logo
PAYER INFORMATION

Aetna Medicare Advantage

Testing

Aetna will cover, without cost share, diagnostic (molecular PCR or antigen) tests to determine the need for member treatment. This applies to direct-to- consumer/home-based diagnostic or antigen tests. Aetna’s health plans generally do not cover a tests performed at the direction of a member’s employer in order to obtain or maintain employment or to perform the member’s normal work functions or for return to school or recreational activities, except as required by applicable law. Aetna will cover, without cost share, serological (antibody) tests that are ordered by a physician or authorized health care professional and are medically necessary. Aetna’s health plans do not cover serological (antibody) tests that are for purposes of: return to work or school or for general health surveillance or self-surveillance or self-diagnosis, except as required by applicable law. This policy for diagnostic and antibody testing applies to Commercial, Medicare and Medicaid plans.

  • Cost-sharing waiver applies to testing performed or ordered by in-network or out-of-network providers. The policy aligns with Families First legislation and regulations requiring all health plans to provide coverage of COVID-19 testing without cost share. An order can often take place as part of being tested at a COVID-19 drive-through test site or purchasing a direct-to-consumer/home-based test.
  • An order from an authorized health care professional is required for covered COVID-19 tests for Aetna Commercial and Medicare plans. An order can often take place as part of being tested at a COVID-19 drive-through test site or purchasing a direct-to-consumer/home-based test.
  • In effort to expand testing capabilities, U.S. Department of Health & Human Services (DHS) authorized pharmacists to order and administer COVID-19 tests, including serology tests, that the FDA has authorized. Pharmacists, in partnership with other health care providers, are well positioned to aid COVID-19 testing expansion.
  • Aetna is waiving member cost-sharing (Cost sharing is defined as co-pay, co-insurance and deductible) for diagnostic testing related to COVID-19. This policy covers the cost of a physician-ordered test and the office, clinic or emergency room visit that results in the administration of or order for a COVID-19 test. The member cost-sharing waiver applies to all commercial, Medicare and Medicaid lines of business. Per guidance from the Centers for Medicare & Medicaid Services (CMS), the Department of Labor and the Department of the Treasury, all Commercial and Medicaid plans must cover serological (antibody) testing with no cost-sharing.

Treatment: EXPIRED

Commercial

  • For all Aetna-insured Commercial plans, Aetna waived member cost-sharing for inpatient admissions for treatment of COVID-19 or health complications associated with COVID-19 through February 28, 2021. This waiver may remain in place in states where mandated. Self-insured plan sponsors offered this waiver at their discretion.

Medicare

  • Aetna will cover treatment of COVID-19 for our Medicare Advantage members. Please note that copays, deductibles and coinsurance will apply according to the member’s benefit plan.

Medicaid

  • Regulations regarding cost-sharing for Medicaid beneficiaries vary by state and continue to evolve in light of the current situation. We have suspended cost-sharing requirements, including premiums and copays, for adults and children covered by Medicaid and CHIP, in those states where permitted to do so by the appropriate regulators.
To address circumstances where PCP offices are closed due to COVID-19, Aetna has not changed its PCP referral requirements for commercial plans.

Telehealth: EXPIRED

For Individual Aetna Medicare Advantage members co-pays for in-network telehealth visits for primary care and behavioral health through March 31, 2021. Cost share waivers for specialist telehealth visits expired on January 31, 2021 for all Medicare Advantage members. A telehealth visit with a specialist provider will now result in the same cost share as an in-person office visit.

Vaccine Information

  • Aetna members in Commercial and Medicaid plans will not have to pay any out-of-pocket costs for a COVID-19 vaccine. For Medicare beneficiaries, CMS will cover the full cost of the vaccine, including those in a Medicare Advantage plan.
  • Aetna will cover COVID-19 vaccine administration fees without cost-sharing for both in- and out-of-network providers, for both Commercial and Medicaid members.
  • Aetna will cover any COVID-19 vaccine that has received FDA authorization, at no added cost to members.

Additional Information and Links

PAYER INFORMATION

Blue Cross Blue Shield of Nebraska

Testing

Appropriate medically necessary (symptomatic or known + COVID-19 exposure) in-network diagnostic testing for COVID-19 will be paid without member cost share for all members through the end of the Public Health Emergency.

The COVID-19 testing kit, swab, interpretation of the test and the related office(including telehealth/urgent care/emergency room visit will be paid without member cost share. This waiver of cost shares applies to all fully insured group and individual health plan members, along with those who receive insurance through our Medicare Supplement and Medicare Advantage plans. Members enrolled in a self-funded group health plan should check with their employer about their benefits.

Treatment: NEW

Starting Jan. 1, 2021, BCBSNE will apply member cost shares to treatment of COVID-19. Self-funded groups that are currently covering treatment of COVID-19 without member cost shares may extend that coverage past Dec. 31, 2020. Employees of self-funded groups should check with their employer to find out about their cost shares.

Telehealth

  • Member costs shares will continue to be waived for all in-network telehealth visits directly related to a COVID-19 diagnosis through the end of the Public Health Emergency.
  • For all other covered telehealth services, normal plan cost shares will once again apply beginning July 1, 2020.

Treatment: NEW

Information for Members with high deductible health plans:

  • Recent federal legislation allows high deductible health plans linked to an HSA to waive member cost shares for the following without tax penalty:
    • COVID-19 testing, including the office/urgent care/ emergency room visit Telehealth (for both COVID-19 and non-COVID-19-related services)
  • In addition, the legislation allows individuals to use HSA/ FSA funds for the purchase of over-the-counter medical products without requiring a doctor’s prescription.

Vaccine Information

  • BCBSNE members will receive the FDA-approved vaccinations (Pfizer-BioNTech, Johnson and Johnson and Moderna) at no cost. Through the CARES Act, the government is paying for the cost of the vaccine and health plans will cover the cost of the administration and related office visit is applicable.
  • The Nebraska Department of Health and Human Services launched a website where residents can register to receive their COVID-19 vaccine. 
PAYER INFORMATION

Bright Health

  • The COVID-19 diagnostic test is included with preventative care, at no cost to members regardless of network. Testing for other purposes, such as return to work or checking one’s own antibody levels will not be covered through the health plan. (mail-order and OTC COVID-19 tests do not qualify)
  • Early medication refills are authorized for members impacted by the outbreak. Contact your pharmacist and ask them to request approval for early refills through Bright Health’s pharmacy help line.

  • Telehealth: All telehealth services (online and virtual care) obtained in connection with doctor-ordered COVID-19 testing and diagnosis are now covered, at no cost to our members.

    • If you choose to use a telehealth provider other than Doctor On Demand you may be required to pay upfront and submit a claim to be reimbursed by Bright Health. The reimbursement forms are located here for: Individual and Family and Employer- sponsored health plans  or Medicare 

    • Bright Health is making non-emergency transportation available to all members and is waiving ride limits for non-emergency visits to and from your doctor.

COVID-19 Vaccine:

  • As FDA-authorized vaccines for COVID-19 become available, Bright Health will cover the cost of the administration of the vaccine for our members. The vaccine will be available to providers at no cost until further notice. When vaccinating a member, a provider doesn’t need to bill for a visit unless other services are provided at the same time.

Authorizations

  • For post-acute care setting we do not require an authorization for admission.
  • For contracted SNF providers we auto-approve the first seven days of the stay and required an authorization for services starting on day eight.
  • For contracted home care providers, Bright Health will auto-approve the first six visits and require an authorization for services that go beyond the six visits.
  • Bright Health does require a prior authorization for LTACs and Acute Rehabilitation.

Additional Information and Links

PAYER INFORMATION

Humana

NEW

  1. Humana offers LabCorp at home COVID-19 testing and has collaborated with Walmart and Quest Diagnostics on drive-thru testing for Humana members.

    • Humana has developed an online coronavirus risk-assessment tool to help members navigate COVID-19 testing.

    • Members who have symptoms consistent with COVID-19 infection, or those without symptoms who may have been exposed to the virus, qualify for testing and will be given the option to request an in-home test or drive-thru testing

    • Members do not need to consult with a physician prior to completing the risk assessment. The intent of this program is to help members understand their risk for COVID-19 and offer two convenient methods to obtain a test. Throughout our process, we recommend that members contact their primary care physician (PCP) if they have questions or need to be seen in person.

    • For more information, visit the COVID-19 Testing FAQs.

    • Please note: Quest and LabCorp do not collect COVID-19 samples directly from patients. Refer specimens to these labs and do not send patients directly to their patient service centers.

  2. For 2021, Medicare Advantage benefits include no member cost share for in-network telehealth visits for primary care, urgent care and behavioral health

    • Members will have no copays, deductibles or coinsurance for the telehealth visits outlined above. For specialty telehealth visits, please verify member plan benefits as any applicable member cost-share would apply. Please refer to Humana’s COVID-19 Telehealth and Other Virtual Services policy, opens new window, for further information. Medicaid plans will continue to follow state requirements for telehealth services.

  3. For 2021, Medicare Advantage benefits include no member cost share for COVID-19 treatment.
    • Members will have no copays, deductibles or coinsurance for covered services for treatment of confirmed cases of COVID-19. Members are encouraged to check their plan documents for details about their 2021 coverage. Medicaid plans will continue to follow state requirements for COVID-19 treatment.

    4.  For 2021, Medicare Advantage benefits include no member cost share on covered COVID-19  
         testing and related services.

    • In addition, Humana will waive member cost share in 2021 on COVID-19 testing and related services for Medicare Supplement, fully-insured group commercial and self-insured group commercial plan members during the COVID-19 public health emergency (PHE). Members will have no copays, deductibles or coinsurance for covered COVID-19 testing and related services; this includes laboratory testing, specimen collection and certain related services that result in the ordering or administration of the test, including physician office or emergency department visits. This is limited to the cost share for the coverage provided by the plan, e.g., medical cost only for Medicare Supplement. Medicaid plans will continue to follow state requirements for COVID-19 testing.

   5.  Members may have several options for prescription delivery

    • Members may be able to have their prescriptions delivered. Check with CVS, Walgreens and other local pharmacies to see if they offer local prescription delivery to support patients in social isolation. As an alternative, providers can support the movement of member prescriptions to Humana Pharmacy’s 90-day mail order faster by sending orders to Humana Pharmacy®.
    • HumanaPharmacy.com/prescribers, opens a new window for prescribing information. Please keep in mind that first-time setup takes approximately 5 days for processing and delivery after prescription orders are received.

  6.  Early prescription refills allowed through July 20, 2021

    • Humana is allowing early refills on prescription medicines for Medicaid members and Medicare members with Part D prescription drug coverage, including both MAPD and PDP members, so they can prepare for extended supply needs—an extra 30- or 90-day supply as appropriate. Does not apply for Medicare Advantage only members.

 7.  Member support line available.

    • Humana has trained a specialized group of call center associates to help support our members with specific coronavirus questions and concerns, including assistance in accessing their telemedicine benefits. Members can call Humana’s toll-free customer support line, which can be found on the back of their member ID card, to be connected to this dedicated team of professionals.

8.  Home oxygen is covered for temporary use.

    • Humana is now covering short-term home oxygen usage for members with a COVID-19-related diagnosis.
  • For providers with a current Practitioner Assessment Form (PAF) contract amendment in place, Humana will continue to pay providers for completing elements of the PAF they are able to address through telehealth or other virtual technology. We will continue to reassess the PAF program and communicate any updates with our physician groups at that time.

  • Stars and Risk Adjustment: 

    • In response to the COVID-19 PHE, the Centers for Medicare & Medicaid Services (CMS) released guidance via the Interim Final Rule, published April 6, 2020. This guidance minimizes exposure risks and grants flexibilities that enable health plans, healthcare providers and physician offices to focus on caring for Medicare beneficiaries – and avoid contributing to the strain on the healthcare system resulting from this pandemic.

    • For a summary of the changes to quality improvement and data collection activities for measurement years 2019 and 2020 that impact Star Ratings for plan years 2021 and 2022 please visit humana.com/provider/coronavirus/stars.

Vaccine Information

  • 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 does are required.

  • For MA members all Vaccine-related claims should be submitted to the Medicare Administrative Contractors. Humana will deny any vaccine product or administration claims received for Medicare Advantage members.

Additional Information and Links

PAYER INFORMATION

Medica

Telehealth

  • Medica is temporarily waiving the CMS and state-based site restrictions and will allow a member to be located at home when they receive telehealth services.
  • Home tests for COVID-19 that are FDA-approved, ordered by a practitioner and medically necessary are eligible, except when done for a return to work or public surveillance.
  • Medica is recommending that telehealth include both audio and visual, but is waiving the policy requirement of a visual component for the duration of the Emergency Telemedicine Reimbursement Policies related to COVID-19. Providers should continue to follow proper coding guidelines for services provided.
  • In accordance with CMS and state guidance, Medica will waive the HIPAA security requirements and allow audio-visual applications such as Skype and FaceTime, to be used for telehealth visits.
  • Applies to both medical and behavioral health services
  • Member liability will continue to apply in accordance with the member’s benefit plan except when a telemedicine visit results in an order for or administration of COVID-19 lab testing, as defined in CMS guidance and for other telemedicine services only to the extent as required by applicable law.
  • Medica is covering certain preventative health services provided via telehealth. Covered CPT Codes are 99381 – 99387 and 99391 – 99397. This temporary change applies for all Medica members (other than Medicare Members) receiving telehealth services from June 1, 2020 through July 31, 2020, dates of service, or for the duration of the public health emergency, whichever is later.
  • To ensure that provider reimbursements are not slowed down during the current Public Health Emergency, and ensure that members have uninterrupted access to health care services and medications at this critical time, Medica is paying Individual and Family Business (IFB) member claims even for members not current on their premiums, beginning with March 1, 2020, dates of service. However, when the national health emergency is over and IFB member accounts are fully reconciled, some provider recoupments may result if a member’s coverage is terminated retroactively due to non-payment of premiums.
  • Cost-sharing is waived for COVID-19 diagnostic testing and provider services for the testing. This change applies to Medicare, Medicaid, self-funded groups, fully-insured groups, and individual health insurance coverage, retroactive to March 1, 2020, and extended through July 31, 2021, dates of service.
    • Medica covers rapid diagnostic tests as well as standard nasal and saliva diagnostic tests. All tests must be medically necessary and ordered by a medical professional.
    • If COVID-19 testing takes place at an out-of-network provider, all other services associated with the out-of- network provider will be covered at the out-of-network benefit, including, but not limited to influenza tests, blood draws, strep tests, chest x-ray, etc.
  • To properly reflect the waiver of member cost-sharing for COVID-19 testing during the public health crisis (PHE), please use the CS modifier only for services relating to the order for or administration of a COVID-19 diagnostic test. Also, network providers may append the CS modifier to codes used for the evaluation of an individual for purposes of determining the need for diagnostic testing. This guidance applies for all Medica members.
  • Member cost-sharing for in-network COVID-19 hospital care will be waived. This includes copays, co-insurance and deductibles and applies to fully insured group, individual, Medicare and Medicaid members. Self-insured employers will have an opportunity to also waive member cost-sharing for inpatient hospital services. (Effective March 1, 2020, through June 30, 2021.)
  • Medica is waiving member cost-sharing for FDA- approved antibody tests for all Medica members, as long as tests are ordered by a medical professional and medically necessary. Our coverage for the antibody test applies both in-network and out-of-network and will extend to office visits and other charges related to the antibody test when performed at in-network locations for a suspected COVID-19 diagnosis. This new coverage runs at least through July 31, 2021, dates of service.
  • Extended through July 31, 2021: Medica will continue to suspend prior authorization for admission to a post-acute care setting. Also, for the repair or replacement of durable medical equipment (DME), we continue to waive a new physician’s order, face-to-face visit or medical necessity documentation.
  • Medica will temporarily suspend the “Medicare Sequester” from May 1, 2020, until December 31, 2021, as outlined in the Coronavirus Aid, Relief, and Economic Security (CARES) Act. This will apply for both in-network and out-of-network providers who have had the 2% sequestration applied to their Medicare rates.

Medication

  • Early refills will be available to Medica members. To request early refill, please contact Customer Service at 1-866-398-7411. Pharmacists can also enter a submission clarification code of 13 to allow the claim to process.
    • Effective May 4, 2020, Medica is adding quantity limits on certain drugs used for COVID-19. The fear of COVID-19 and subsequent stockpiling of medications used to treat this virus has put stress on the supply chain, limiting access and availability of these medications. In order to prevent stockpiling, as well as misuse and overuse, Medica is adding quantity limits (QLs) to certain medications effective May 4, 2020, as outlined below. These QLs apply to Medica’s commercial, Individual and Family Business (IFB) and Minnesota Health Care Programs (MHCP) members who have pharmacy drug coverage through Medica.
    • Details on specific limits 

Additional Updates

  • As the public health emergency (PHE) continues to evolve, additional codes may be created in order to accurately report and reimburse for services related to COVID-19. We encourage providers to reference Medica’s COVID-19 Testing reimbursement policy for the latest coding considerations. 

Vaccine Information

  • Medica will waive costs for the vaccine and administration of the vaccine for all members
  • Vaccines, once widely available, will be administered at various in-network and out-of-network retail pharmacies, doctor’s offices and hospitals.

Additional Information and Links

PAYER INFORMATION

Medicare

cms-logo
  • Medicare covers the lab tests for COVID-19. Patient pays no out-of-pocket costs.

  • Medicare covers all medically necessary hospitalizations. This includes if you’re diagnosed with COVID-19 and might otherwise have been discharged from the hospital after an inpatient stay, but instead you need to stay in the hospital under quarantine.

  • Medicare covers FDA-approved COVID-19 vaccines.

  • Waiving certain requirements for skilled nursing facility care.

  • If you have a Medicare Advantage Plan, you have access to these same benefits. Medicare allows these plans to waive cost-sharing for COVID-19 lab tests. Many plans offer additional telehealth benefits beyond the ones described below. Check with your plan about your coverage and costs.

  • As part of an effort to address the urgent need to increase capacity to care for patients, hospitals can now provide hospital services in other health-care facilities and sites that aren’t currently considered part of a health care facility. This includes off-site screenings.

Additional Information and Links

PAYER INFORMATION

Nebraska Total Care

Telehealth

Effective immediately, the policies we are implementing include:

  • Continuation of zero member liability (copays, cost sharing, etc.) for care delivered via telehealth
    • Any services that can be delivered virtually will be eligible for telehealth coverage
    • Telehealth services may be delivered by providers with any connection technology to ensure patient access to care** (**Providers should follow state and federal guidelines regarding performance of telehealth services including permitted modalities)

  • This coverage extension follows the Centers for Medicare & Medicaid Services’ (CMS) guidance that coronavirus tests will be fully covered without cost-sharing for Medicare and Medicaid plans, a decision that Nebraska Total Care fully supports for our members covered under these programs. We also support the administration’s guidance to provide more flexibility to Medicare Advantage and Part D plans. The specific guidance includes:

    • Waiving cost-sharing for COVID-19 tests

    • Waiving cost-sharing for COVID-19 treatments in doctor’s offices or emergency rooms and services delivered via telehealth

    • Removing prior authorizations requirements

    • Waiving prescription refill limits

    • Relaxing restrictions on home or mail delivery of prescription drugs

    • Expanding access to certain telehealth services

Vaccine Information

  • Nebraska Total Care will configure its systems to properly adjudicate COVID-19 vaccine-related claims, both for the vaccine and its administration, in accordance with Nebraska MLTC’s coverage determinations for Medicaid beneficiaries
  • Member liability will be $0
  • Non-participating provider pre-auth requirements will be waived
  • Additionally, CMS has also published a set of toolkits to help providers prepare to swiftly administer the vaccine once it is available. If you have any further questions about this upcoming vaccine or the COVID-19 services Nebraska Total Care covers, please contact Provider Relations.
  • The COVID-19 global pandemic has created unprecedented changes to our lives and healthcare systems. While we continue to connect our members to COVID-19 services, we wanted to reach out to our provider partners on how we can work together to better support their care needs.
  • As a primary care physician (PCP), you are at the heart of our members’ healthcare. They trust and rely on you to help them access appropriate, affordable, coordinated care from the right providers, at the right time. If you refer our members to an out-of-network provider – or send their test specimens to a non-participating laboratory – they could be responsible for the out-of-network charges according to their benefits. These costs can quickly add up, especially for patients who do not have out-of-network benefits.
  • You can help your patients avoid this and keep their medical costs down by referring them to providers within their Nebraska Total Care network, as denoted on their Member ID card. Understanding it can sometimes be challenging to navigate multiple payor networks to connect patients to appropriate in-network providers and facilities, we want to share two easy methods for you to access this information quickly:
    • Search In-Network Providers Online: Our provider directory offers the current list of our in-network providers
    • Call to your Provider Services Representative at 1-844-385-2192, Nebraska Relay Service 711. They can help you quickly identify in-network specialists and labs. Thank you for your continued partnership during this time of heightened concern. If you have any questions regarding our networks, please contact Provider Services at 1-844-385-2192, Nebraska Relay Service 711.
 
PAYER INFORMATION

UnitedHealthcare

UHC Medicare Advantage

COVID-19 Diagnostic Testing:

  • From Feb. 4, 2020 through the national PHE period, currently scheduled to end July 19, 2021, UHC is waiving cost-sharing for in-network and out-of-network tests. (Diagnostic tests (virus/antigen) must be medically appropriate and ordered by a physician or appropriately licensed health care professional. UHC will only cover testing for employment, education, public health or surveillance purposes when required by applicable law.).

COVID-19 Antibody Testing:

  • From April 10, 2020 through the national PHE period, currently scheduled to endJuly 19, 2021, UHC is waiving cost-sharing for in-network and out-of-network tests. (Tests must be FDA-authorized and ordered by a physician or appropriately licensed health care professional, consistent with CMS guidelines).

COVID-19 Testing-Related Visits:

  • From Feb. 4, 2020 through the national PHE period, currently scheduled to end July 19, 2021, UHC is waiving cost-sharing for in-network and out-of-network testing- related visits, including testing-related telehealth visits.

EXPIRED: COVID 19 TESTING

From Feb. 4, 2020 through March 31, 2021, UHC is waiving cost-sharing for in-network and out-of-network visits, for inpatient and outpatient COVID-19 treatment, including telehealth treatment visits. This includes:

  • Office visits
  • Inpatient hospital episodes
  • Urgent care visits
  • Acute inpatient rehab
  • Emergency department visits
  • Long-term acute care
  • Observation stays
  • Skilled nursing facilities

NEW

As of April 1,2021, no cost share waivers are in effect. Coverage and cost sharing is adjudicated in accordance with the member’s health plan. This includes telehealth, inpatient & outpatient COVID-19 treatment for both in-net work and out-of-network visits.

Transportation:

  • Coverage and cost sharing will be adjudicated in accordance with the member’s benefit plan.

NON-COVID-19 Telehealth Visits:

  • From Oct 1, 2020 through December 31,2020, UHC will extend the cost share waiver for in-network and covered out-of-network primary care telehealth services.
  • As of October 1, 2020, cost sharing for non-primary care telehealth services will be adjudicated in accordance with the member’s benefit plan.

Telehealth Expansion

  • From Jan. 1, 2021 through the end of the PHE, UHC will cover all in-network and out-of-network telehealth services as outlined in the current CMS guidelines

UHC Medicaid

  • State Regulations apply to all telehealth expansion and cost-share waivers.

UHC Individual and Group Market Health Plans

COVID-19 Diagnostic Testing:

  • From Feb. 4, 2020 through the national PHE period, UHC is waiving cost-sharing for in-network and out-of-network tests. (Diagnostic tests (virus/antigen) must be medically appropriate and ordered by a physician or appropriately licensed health care professional. UHC will only cover testing for employment, education, public health or surveillance purposes when required by applicable law.)

COVID-19 Antibody Testing:

  • From April 10, 2020 through the national PHE period, UHC is waiving cost-sharing for in-network and out-of-network tests (Tests must be FDA-authorized and ordered by a physician or appropriately licensed health care professional, consistent with CMS guidelines)

COVID-19 Testing-Related Visits:

  • From Feb 4, 2020 through the national PHE period, UHC is waiving cost-sharing for in-network and out-of-network testing- related visits, including testing-related telehealth visits

COVID-19 Treatment:

  • No cost share waivers are currently in effect. Coverage and cost sharing is adjudicated in accordance with the member’s health plan.

Transportation:

  • No cost share waivers are currently in effect. Coverage and cost sharing is adjudicated in accordance with the member’s health plan.

NON-COVID-19 Telehealth Visits:

  • As of October 1, 2020, benefits will be adjudicated in accordance with the member’s benefit plan

Telehealth expansion:

  • From Jan. 1, 2021 and beyond, UHC will reimburse in-network telehealth services as outlined in current CMS guidelines and additional codes as outlined in our telehealth reimbursement policy

COVID-19 Vaccine Trial

  • UnitedHealth Group is collaborating with Janssen to identify people to participate1 in a clinical research trial to test an investigational COVID-19 vaccine. For information about the study, visit ENSEMBLE study. Information about selection criteria can also be found at unitedinresearch.com.
  • This is an independent study and volunteer opportunity. Membership in a UnitedHealthcare benefit plan is not required for participation. If your patients have questions about their benefits, ask them to sign in to their health plan account.
  • Effective immediately through June 30,2021, UHC is temporarily updating the credentialing policies to implement provisional credentialing for out-of-network care providers who are licensed independent practitioners and want to participate in one or more of our networks. The full credentialing process will be completed within 180 calendar days from when provisional credentialing is granted.
  • For providers who are due for re-credentialing from March 1, 2020 through Dec. 31, 2020, UnitedHealthcare is following National Committee for Quality Assurance (NCQA) guidelines and is extending the care provider recredentialing cycle by two months, to 38 months. This will allow care provider offices additional time to respond to recredentialing requests. UnitedHealthcare will continue to initiate the recredentialing requests for information based on standard timeframes and will complete all that are received prior to the 38 months.

PT/OT/Speech Therapy

  • UnitedHealthcare will reimburse physical, occupational and speech therapy (PT/OT/ST) telehealth services provided by qualified health care professionals when rendered using interactive audio-video technology.
  • Reimbursable codes are limited to the specific set of physical, occupational and speech therapy codes listedbit.ly/2MHixTL
  • UnitedHealthcare will reimburse eligible codes using the place of service that would have been reported had the services been furnished in person on a CMS 1500 with 95 modifier or a UB04 form with applicable revenue codes.

Originating Site Expansion

  • UnitedHealthcare is continuing its expansion of telehealth access, including temporarily waiving the Centers for Medicare & Medicaid Services (CMS) originating site requirements.
  • Please review each health plan for specific plan details and reimbursement guidance.

Timely Filing

  • For Individual and group market plans: Extended timely filing deadlines follow the IRS/DOL regulation. This regulation pauses the timely filing requirements time clock for claims that would have exceeded the filing limitation during the national emergency period that began on March 1, 2020
  • Timely filing requirements have been extended an additional 60 days following the last day of the national emergency period; UHC standard filing requirements apply to claims that exceed requirements prior to the national emergency period**
    • **The national emergency as declared by the President, is distinct from the national public health emergency declared by the U.S. Department of Health and Human Services.

Controlled-Substance Rx Policy Change

  • Effective April 10, 2020, Optum Rx home delivery pharmacy is placing its mandatory ePrescribing policy for controlled substances (EPCS) temporarily on hold until further notice. The policy went into effect on March 1, 2020, and required care providers to send e-prescriptions for controlled substances. Optum Rx pharmacy will fill any controlled substance prescription the receive, as long as the prescription meets federal and state regulatory requirements.

Prior Authorization

  • To streamline operations for providers, we’re extending prior authorization time frames for open and approved authorizations and we’re suspending prior authorization requirements for many services. bit.ly/3iCqowe

Discharge Planning Assistance

  • If you need assistance with COVID-19 discharge planning, please email UnitedHealthcare at covid-19dischargeplanning@uhc.com. Your questions will be handled by a special team focused on COVID-19 discharge matters. During this national emergency, we will generally respond to requests within two hours, from 7 a.m. to 7 p.m. CST. Team members are available to assist you seven days a week.

Additional Information and Links

PAYER INFORMATION

Well Care of Nebraska: Not affiliated with the NHN

  • Coverage extension follows the Centers for Medicare & Medicaid Services’ (CMS) guidance that coronavirus tests will be fully covered without cost-sharing for Medicare and Medicaid plans, a decision that WellCare fully supports for our members covered under these programs. We also support the administration’s guidance to provide more flexibility to Medicare Advantage and Part D plans. The specific guidance includes:

    • Waiving cost-sharing for COVID-19 tests

    • Waiving cost-sharing for COVID-19 treatments in doctor’s offices or emergency rooms and services delivered via telehealth

    • Removing prior authorizations requirements

    • Waiving prescription refill limits

    • Relaxing restrictions on home or mail delivery of prescription drugs

    • Expanding access to certain telehealth services

  • We will not require prior authorization, prior certification, prior notification and/or step therapy protocols for medically necessary COVID-19 diagnostic testing, medical screening services, and/or treatment when medically necessary services are ordered and/or referred by a licensed health care provider.

  • We will temporarily waive 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.

  • All member cost share (co-payment, coinsurance and/or deductible amounts) will be waived across all products for any claim billed with the new COVID-19 testing codes.

  • We have configured our systems to apply $0 member cost share liability for those claims submitted utilizing the new COVID-19 testing codes.

  • In addition to cost share, authorization requirements will be waived for any claim that is received with those specified codes.

  • Providers billing with these codes will not be limited by provider type and can be both participating and non- participating.

  • Adjudication of claims is currently planned for the first week of April 2020.

Additional Information and Links

PAYER INFORMATION

Wellmark

Effective Sept. 1, 2020:

  • Fully Insured Members: Wellmark has and will continue to provide benefits for telehealth (or virtual) visits for fully insured members. The $0 member cost-share for virtual visits will expire on Aug. 31 for fully insured members. This has been offered since the start of the pandemic to help the health care systems in Iowa and South Dakota by minimizing in-person visits to ERs or clinics as they prepared to potentially care for COVID-19 patients. After Aug. 31, a fully insured member will need to pay their standard cost-share for that benefit, which is no more for telehealth than an in-person visit.
  • Self-Funded Members: Some employers are self-funded, which means they make the decisions as to what benefits are offered on their plan. A few self-funded employer group plans do not provide coverage for or have limited telehealth benefits. Now that the health care systems have adapted and are able to serve more patients in-office, some of these self-funded plans are returning to our standard telehealth benefits. After Aug. 31, providers are encouraged to log into the Provider portal to check members’ benefits prior to delivering telehealth services.
  • Telehealth Payment Parity: In addition, Wellmark will continue payment parity for appropriate medical and behavioral health virtual visits with an in-network provider in Iowa until June 30, 2021, and in South Dakota until further notice.
  • Wellmark is complying with the CMS, AMA and CDC coding guidelines for COVID-19.
    • More information is available at AMA Resource Center for Physicians.
  • Beginning March 21, 2020, fully insured members will be allowed to fill up to a 90-day supply of medication if, in the judgement of their physician or pharmacist, they should practice social distancing or remain quarantined for a long period of time. For self-funded customers who allow 90-day supply of medication, the process will be the same as fully insured. Without this benefit, they can still access up to 30-day supply on an early refill.
  • Effective March 23,2020, all prior authorizations for drugs that are due to expire before July will be extended through July to lessen the administrative burden on both pharmacies and provider offices.
  • Members will have no cost-share for appropriate testing to establish the diagnosis of COVID-19
  • Wellmark will waive members’ cost-share related to the treatment of COVID-19 (copay, coinsurance and deductible) when seeking care from an in-network provider, effective Feb. 4, 2020, through at least June 16, 2020. Effective for admissions beginning June 17, 2020, cost share will be waived for inpatient COVID-19 treatment only. Some self-funded plans that Wellmark administers may elect to require cost share of their members.
  • COVID-19 tests are covered by Wellmark when the member is under the care of a physician or other licensed practitioner who recommends and orders testing based on: direct exposure (e.g., family member) relevant symptoms, or asymptomatic patients for whom the testing would alter the course of care.
  • Testing of individual members that does not fall within the categories outlined under “Covered by Wellmark”. This would include: a COVID-19 test obtained by a member without an order by a health care practitioner; a COVID-19 antibody test requested by a member without known exposure, relevant symptoms or another clinically appropriate reason to order the test.
  • Public health surveillance and other broad population-based serologic/antigen testing. For example, serologic testing to meet university requirements for returning college students, regardless of symptoms or exposure, would not be covered by Wellmark.
  • Employee screening and COVID-19 testing for employment purposes, which is considered occupational health and the responsibility of the business and employee.
  • Any other purpose not primarily intended for individualized diagnosis or treatment of COVID-19. Examples include testing to return to school or to play sports.
  • Precertification and concurrent review requirements suspended bit.ly/3jR0AND. To facilitate inpatient capacity across the health care system during the COVID-19 pandemic, Wellmark had made the following changes for all in-network, eligible Iowa and South Dakota providers from October 23, 2020, through April 30, 2021:
    • Suspension of precertification and concurrent review requirements
    • Suspension of penalties, if applicable

Eligible facilities include:

  • Acute rehabilitation
  • Home health
  • Psychiatric medical institution for children (PMIC)
  • Residential treatment centers (RTC)
  • Skilled nursing facility (SNF)

Requirements that continue to apply:

  • Providers should continue to provide discharge dates and destination information.
  • Acute Facility (hospital)
    • Iowa and South Dakota: Notification of admission and discharge is required. Notifications by facilities will allow Wellmark nurses to assist members during their care transitions, including to the home.
    • Out-of-state: Precertification of admission and concurrent review, and discharge notification is required.

Long Term Acute Care (LTAC)

  • LTAC is not an approved provider type to apply for credentialing and network participation, nor is it a covered benefit, therefore is not applicable.

Prior Approval extensions:

  • Any new prior approval request received on or after November 17, 2020 for the below services, if approved, will have the approval end date extended to 180 days. This process will remain intact until further notice. Extending the end date will give both providers and members additional time to complete the service without the additional burden of submitting a new request. See Wellmark for detailed list of included procedures
PAYER INFORMATION

Amerigroup: Not affiliated with the NHN

  • Waive member costs for COVID-19 testing, prior authorization is not required for diagnostic services related to COVID-19 testing
  • Support telehealth—Anthem’s telehealth provider is LiveHealth Online
  • Prescription coverage Amerigroup is providing coverage for members to have an extra 30-day supply of medication on hand. We are encouraging that when member plans allow they switch from 30-day home delivery to 90-day home delivery.
  • There will be no cost sharing associated with COVID-19 testing. Test samples may be obtained in many settings including a doctor’s office, urgent care, ER or even drive-thru testing once available. While a test sample cannot be obtained through a telehealth visit, the telehealth provider may connect members with testing.
  • Telehealth (video + audio): There will be no cost sharing for telehealth visits, including visits for mental health or substance use disorders.
  • Telephonic-only care: Effective March 19, 2020 through the duration of the pandemic emergency as defined in each individual market, Amerigroup will cover telephonic-only visits with in-network providers. Out-of-network coverage will be provided where required through June 14th, 2020. This includes covered visits for mental health or substance use disorders and medical. 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. bit.ly/3aaI8gG

Vaccine Information

  • The cost of COVID-19 FDA-approved vaccines will initially be paid for by the government
  • Amerigroup will reimburse for the administration of COVID-19 FDA-approved vaccines in accordance with Federal and State mandates

Documenting, Coding and Billing Information

POS: 02 (indicates Telehealth visit)

Modifiers: Use for Telehealth services. Certifies the patient received services via an audiovisual telecommunications system

  • 95 mod (used by commercial plans) real-time audio and video telecommunications system
  • GT mod (used by Medicare) service rendered via interactive audio and video telecommunication system
  • G0 mod (telestroke services) services for diagnosis, evaluation, or treatment, of symptoms of an acute stroke

ICD-10 Codes

  • B34.2 - Coronavirus infection, unspecified
  • B97.2 - Coronavirus as the cause of diseases classified elsewhere
  • B97.21 - SARS-associated coronavirus, causing diseases classified elsewhere
  • B97.29 - Other coronavirus as the cause of the diseases classified elsewhere
  • U07.1 - COVID-19, virus identified
  • J12.81 - Pneumonia due to SARS-associated coronavirus
  • Z03.818 - Possible exposure to COVID-19 (ruled out after evaluation)
  • Z20.828 - Contact with (suspected) and exposure (to other biological agents ruled out) Used for cases when there is an actual exposure to someone who is confirmed to have COVID-19

CPT Codes

  • 87635 effective March 13, 2020, and issued as “the industry standard for reporting of novel coronavirus tests across the nation’s health care system.” Lab testing code for SARS-CoV-2: (severe acute respiratory syndrome)

HCPCS

  • U0001 - For CDC developed tests only - 2019-nCoV Real-Time RT-PCR Diagnostic Panel.
  • U0002 - For all other commercially available tests - 2019-nCoV Real-Time RT-PCR Diagnostic Panel.
PROVIDER RESOURCES

Payer Information

Information for specific insurance plans including:

  1. CDC Information Page
  2. CDC Symptoms Check
  3. Confirmed Cases of COVID-19
  4. Health Insurance Providers Respond to (COVID-19)

Updates from payers will be published here as they are received.

OUR PARTNERS

Methodist Health System and Nebraska Medicine

Methodist Health System and Nebraska Medicine both have informational pages on their website to address patient and provider questions. Visit the sites regularly for the latest information.

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