COVID-19 Updates for Providers

Patients in Peoples Health plans that offer a benefit for purchasing approved OTC items may use the benefit to buy approved brands of COVID-19 at-home test kits. There are limits on the number of tests that can be purchased, and approved brands vary by plan. Patients should visit their over-the-counter benefit website for more information. They can also review their benefit’s ordering options on our website.

Reduced Prior Authorization Requirements

We’re working to helping people access health care to the fullest extent possible as we come together to address this public health emergency. We’re adopting measures that will reduce administrative burden for physicians and facilities, helping patients more easily access the care they need under their benefit plan, and adjusting programs and services, as needed, to protect our plan members and help limit the spread of the COVID-19 virus in communities.

 

The following authorization provisions were effective March 24, 2020, through May 31, 2020. Normal prior authorization requirements resumed June 1, 2020:

 

• Suspension of prior authorization requirements to a post-acute care setting through May 31, 2020.
  Details:
  • Waiving prior authorization for admissions to: long-term care acute facilities, acute inpatient rehabilitation and skilled nursing facilities.
  • The admitting facility must notify us by 6 p.m. on the next business day of transfer.
  • Length of stay reviews still apply, including denials for days that exceed approved length.
  • Discharges to home health will not require prior authorization.
• Suspension of prior authorization requirements when a patient transfers to a new facility through May 31, 2020.
  Details:
  • Providers are not required to submit a new prior authorization when a patient moves to a different yet similar site of care for the same service (e.g., hospital transfers or practice transfers).
  • The admitting facility must notify us within 48 hours of transfer so that the existing authorization can be transferred. Penalties may apply.

Waiver of Network Specialist Physician Office Visit Cost-Sharing

For claims with dates of service from May 11, 2020, through Sept. 30, 2020, cost-sharing for all network specialist office visits, as well as network office visits for therapy services, was waived for processed claims. Standard plan cost-sharing amounts for specialist and therapy office visits applied starting Oct. 1, 2020.

Waiver of Network Primary Care Physician Office Visit Cost-Sharing

For claims with dates of service from May 11, 2020, through Dec. 31, 2020, cost-sharing for processed claims was waived for network primary care physician visits, including telehealth visits, between Peoples Health patients and their assigned network primary care physicians.

The waiver didn’t require a COVID-19 diagnosis, and it applied to physician evaluation and management services provided in physician offices, facility-based clinics, patient homes (via telehealth), rural health clinics, and federally qualified health centers, as well as to outpatient therapy services. 

If the office visit included additional services, such as labs and diagnostic tests, a Peoples Health patient may have had cost-sharing based on their plan benefits, unless cost-sharing was already waived because it was for COVID-19-related diagnosis or treatment.

The cost-sharing waiver did not apply to the following additional services:

Unless cost-sharing was already waived because it was for COVID-19-related treatment, cost-sharing was not waived for these services when performed in an office or in other settings:

• Lab services
• Diagnostic procedures and tests
• Diagnostic radiological services
• Therapeutic radiological services
• X-rays
• Part B drugs and chemotherapy drugs
• Medicare-covered dental services
• Medicare-covered eyewear
• Part D drugs
• DME, prosthetics/orthotics and medical supplies
• Blood and blood products
• Hearing aids
• Diabetes monitoring supplies, therapeutic shoes or inserts
• Dialysis

Cost-sharing for any services below/rendered in the below settings was also not eligible for the waiver:

• Inpatient hospital
• Outpatient surgery or observation services
• Skilled nursing facilities
• Home health
• Emergency services, urgently needed services and ambulance services

Waiver of COVID-19 Treatment Cost-Sharing

Cost-sharing for COVID-19 treatment was waived through March 31, 2021, for both inpatient and outpatient treatment, if services were provided based on a confirmed COVID-19 diagnosis. The waiver applied when care was received from either network or out-of-network providers, including when provided through telehealth.

Temporary Suspension of Authorization for Contracted SNF and LTAC Providers

Peoples Health values the commitment you make to deliver care to our health plan members in Louisiana. As the public health emergency continues to evolve, Peoples Health will be there to support you.

 

Therefore, Peoples Health is suspending authorization requirements for contracted skilled nursing facilities (SNFs) and contracted long-term acute care (LTAC) providers for the members of our Medicare Advantage plans through August 20, 2021.

 

Notification of admission is still required within 24 hours to allow us to work with you and the members. The authorization suspension applies to contracted providers only.

All other services, including acute inpatient and rehabilitation facility admissions, continue to follow the standard authorization process.

 

COVID-19 At-Home Test Kits

Peoples Health patients have several options for obtaining at-home COVID-19 test kits through May 11, 2023:

• Order free at-home-COVID-19 test kits through covidtests.gov.
• Obtain Medicare-covered tests each month from participating pharmacies and health care providers.

Sequestration Suspension Ended

The suspension of sequestration payments has ended. Sequestration is being reinstituted in phases as follows:

• No payment adjustment for claims with dates of service through March 31, 2022.
• 1% payment adjustment for claims with dates of service April 1 through June 30, 2022.
• 2% payment adjustment for claims with dates of service July 1, 2022, through the end of the year.

COVID-19 Vaccine Billing Changes for 2022

Starting Jan. 1, 2022, Medicare is making changes regarding how to bill for the administration of FDA-authorized and FDA-approved COVID-19 vaccines. For patients enrolled in a Medicare Advantage plan, the cost of COVID-19 vaccine administration should be billed to the plan; Original Medicare won’t pay these claims. This includes for approved booster doses. More information about COVID-19 vaccine policies and guidance is available through CMS COVID-19 vaccine toolkits.

COVID-19 FDA-Authorized Testing and Testing-Related Services Cost-Sharing Waivers Extended Through May 11, 2023

In accordance with the federal government extending the end date for the COVID-19 public health emergency, the end date for certain COVID-19 cost-sharing waivers has also been extended:

• Cost-sharing is waived for FDA-authorized COVID-19 testing—including antibody testing—conducted through May 11, 2023; tests must be FDA-authorized to be covered without cost-sharing. FDA-authorized tests include tests approved for patient use through pre-market approval or emergency use pathways, and tests that are developed and administered in accordance with FDA specifications or through state regulatory approval. Tests must be ordered by a physician or appropriately licensed health care professional.
• Cost-sharing is waived for COVID-19 testing-related services provided through May 11, 2023, if the services are provided based on a suspected COVID-19 diagnosis

FDA-Authorized Antibody Testing Cost-Sharing Coverage

Peoples Health patients are covered without cost-sharing for FDA-authorized COVID-19 antibody tests when ordered by a physician or appropriately licensed health care professional.

 

An antibody test may determine if a person has been exposed to COVID-19, while a COVID-19 diagnostic test determines if a person is currently infected. FDA-authorized tests include tests approved for patient use through premarket approval or emergency use pathways and tests that are developed and administered in accordance with FDA specifications or through state regulatory approval. According to the FDA, an antibody test should not be used to diagnose a current infection. Virus detection should be used to diagnose a current infection. Peoples Health strongly supports the need for reliable testing and encourages health care providers to use reliable FDA-approved tests.

FQHC and RHC Claim Guidelines

Federally qualified health centers (FQHCs) and rural health clinics (RHCs) should use the following guidelines when submitting claims for distant site telehealth services, to ensure the claims accurately indicate the services were provided via telehealth:

• For telehealth services rendered from January 27, 2020, through June 30, 2020: Include modifier 95 and modifier CG
• For telehealth services rendered between July 1, 2020, and the end of the COVID-19 public health emergency: Use the RHC/FQHC-specific G code, G2025

Claims will be paid according to CMS reimbursement guidelines for each time period. Note: FQHCs and RHCs are required, per Medicare, to waive cost-sharing for COVID-19 services, including telehealth. RHCs and FQHCs may also include the modifier “CS” on the service line for these services.

Home Health Agencies

Home health agencies can provide more services to patients using telehealth within the 30-day episode of care, so long as it’s part of the patient’s plan of care and does not replace needed in-person visits as ordered on the plan of care. We acknowledge that the use of such technology may result in changes to the frequency or types of in-person visits outlined on existing or new plans of care.

COVID-19 Testing and Testing-Related Services

• FDA-authorized COVID-19 testing conducted through May 11, 2023; tests must be FDA-authorized to be covered without cost-sharing. FDA-authorized tests include tests approved for patient use through pre-market approval or emergency use pathways, and tests that are developed and administered in accordance with FDA specifications or through state regulatory approval. Tests must be ordered by a physician or appropriately licensed health care professional.
• COVID-19 testing-related services provided through May 11, 2023, if the services are provided based on a suspected COVID-19 diagnosis

Prior authorization is not required for COVID-19 testing and COVID-19 testing-related services.