COVID-19 Updates for Providers

Peoples Health is temporarily waiving the CMS and state-based originating site restrictions and audio-video requirement, where applicable, for patients. Providers will be able to bill for telehealth services performed using audio-video or audio only communication while a patient is at home. 

By removing the originating site and audio-video requirement, Peoples Health has broadened access to telehealth services. Telehealth services will be reimbursed, based on national reimbursement determinations, policies and contracted rates, as outlined in a provider’s participation agreement.

These changes apply to patients whose benefit plans cover telehealth services, and allows those patients to connect with their doctor through live, interactive audio-video or audio only visits.

There is no change to the type of provider who may submit claims for broad telehealth services. Peoples Health generally follows CMS’ policies on the types of providers eligible to deliver telehealth services, although individual states may define eligible care providers differently. These include:

• Physician
• Nurse practitioner
• Physician assistant
• Nurse-midwife
• Clinical nurse specialist
• Registered dietitian or nutrition professional
• Clinical psychologist
• Clinical social worker
• Certified registered nurse anesthetists

It depends on the type of telehealth service being provided.

For non-therapy services: Peoples Health has waived audio-video requirements and will reimburse telehealth services provided through live, interactive audio-visual or audio-only transmission to new or existing patients whose medical benefit plans cover telehealth services, unless otherwise permitted by state law.

For physical, occupational, and speech therapy services, as well as annual wellness visits: Peoples Health will reimburse physical, occupational and speech therapy telehealth services, as well as annual wellness visits, provided by qualified health care professionals only when rendered using interactive audio/video technology.

Peoples Health is following the CMS standards for technology. The Health and Human Services Office for Civil Rights (OCR) is exercising enforcement discretion and waiving penalties for HIPAA violations against health care providers that serve patients in good faith through everyday communications technologies.

Providers are responsible to provide telehealth services in accordance with OCR’s Notice and may use:

• HIPAA-approved telehealth technologies
• The following platforms may be used during the current nationwide public health emergency: Popular applications that allow for video chats — including Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, or Skype — may be utilized to provide telehealth without risk that OCR might seek to impose a penalty for noncompliance with the HIPAA rules related to the good faith provision of telehealth during the COVID-19 nationwide public health emergency.
• Providers are encouraged to notify patients that these third-party applications potentially introduce privacy risks, and providers should enable all available encryption and privacy modes when using such applications.

While the 1135 waiver is in force, providers may also use telephones that have audio and video capabilities during the COVID-19 public health emergency.

For more information, see CMS FAQs.

Providers may conduct a telehealth visit from any private, secure location that will support patient privacy.

Referrals are not required for physician visits for any of our plans.

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.

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.

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

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.