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COVID-19 Updates for Providers

Waiver of Network Physician Office Visit Cost-Sharing

For dates of service from May 11, 2020, through Sept. 30, 2020, cost-sharing for all network primary care physician and specialist office visits, as well as network visits for therapy services, is waived for Peoples Health patients.

Electronic Funds Transfer (EFT)

Did you know you can enroll in EFT to receive claims payments from Peoples Health?

Sequestration Adjustments

Sequestration payment adjustments have been suspended for claims with dates of service from May 1, 2020, through Dec. 31, 2020.

Inpatient Claims Reprocessing for Weighted Payments

For patients diagnosed with COVID-19 who are discharged from an inpatient stay during the COVID-19 public health emergency, Peoples Health will automatically reprocess applicable claims for these patients with any increased-weight, diagnosis-related group values once they are released by CMS.

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

Laboratory Testing Codes

Review information on codes for use with high-throughput laboratories.

Billing Guidance for Expanded Telehealth Access

Review update billing information for various telehealth modalities.

The health of our plan members and the safety of those who deliver care are our top priorities. COVID-19 is a rapidly evolving public health emergency, and we’re working closely with national, state and local health organizations.

On this page, we will post COVID-19-related updates to our operational processes, as well as other relevant information that will be pertinent to your provision of care to Peoples Health patients during this time. We’re monitoring the COVID-19 public health emergency closely and updating this site with new information as it’s available. Be sure to check back frequently for updates.

Last updated: 05/15/2020 5:00 p.m.

LATEST COVID-19 NEWS

Waiver of Network Physician Office Visit Cost-Sharing

For dates of service from May 11, 2020, through Sept. 30, 2020, cost-sharing for all network primary care physician and specialist office visits, as well as network visits for therapy services, is waived for Peoples Health patients. The patients are not required to pay a copay for these visits (including those via telehealth) during this time.

This change is part of our ongoing efforts to address COVID-19 challenges by expanding coverage to support the health care system and patients.

The waiver doesn’t require a COVID-19 diagnosis, and it applies 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 includes additional services, such as labs and diagnostic tests, a Peoples Health patient may have cost-sharing based on their plan benefits, unless cost-sharing is already waived because it is for COVID-19-related treatment.

The information below is updated as of 5/8/2020.

The cost-sharing waiver applies to the following services from network providers:

  • Primary care physician office visit
  • Specialist physician office visit
  • Associated physician assistant/nurse practitioner or other health care professional office visit
  • Medicare-covered chiropractic care
  • Medicare-covered podiatry
  • Medicare-covered eye exams
  • Medicare-covered hearing exams
  • Outpatient physical, occupational or speech therapy
  • Cardiac and pulmonary rehabilitation

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

Unless cost-sharing is already waived because it is for COVID-19-related treatment, cost-sharing is 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 is 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

Sequestration Adjustments

Sequestration payment adjustments have been suspended for claims with dates of service from May 1, 2020, through Dec. 31, 2020.

Inpatient Claims Reprocessing for Weighted Payments

For patients diagnosed with COVID-19 who are discharged from an inpatient stay during the COVID-19 public health emergency, Peoples Health will automatically reprocess applicable claims for these patients with any increased-weight, diagnosis-related group values once they are released by CMS. You do not need to resubmit these claims for processing once the new weighting factors are released. For contracted providers, the claims will be processed initially at the contracted rate, and once the updated weighting factors are available, we will automatically reprocess and adjust claims appropriately for any applicable, additional payment. Claims for non-contracted providers will follow Medicare pricing as appropriate. For information on related diagnosis codes and corresponding time frames used for these payment adjustments, refer to this MLN Matters article.

Electronic Funds Transfer (EFT)

Did you know you can enroll in EFT to receive claims payments from Peoples Health? To learn more about enrolling in EFT or to request an EFT enrollment form, email phn.provider@peopleshealth.com or contact your provider representative. Note that to enroll in EFT, you must also be able to receive electronic remittance advice.

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  27, 2020, through June 30, 2020: Include modifier 95
  • 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 testing, including telehealth. RHCs and FQHCs must include the modifier “CS” on the service line for these services.

Claims Processing Update

As part of our ongoing efforts to support you in your operations, Peoples Health will accelerate the timing of payments for your submitted claims starting April 15, 2020, and throughout the COVID-19 public health emergency. Payments will be issued the week immediately following adjudication of a claim.

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. For more information, please visit the CMS website.

Prior Authorization for Drugs
The reduction in prior authorization requirements for certain prescription medications when a provider is not available to help with the authorization includes instances when a doctor is unable to complete a prior authorization request for a patient due to lack of access to the office or the patient’s medical record.
COVID-19 Treatment Cost-Sharing

Peoples Health is waiving patient cost-sharing for any COVID-related treatment provided through May 31, 2020. The waiver applies to all locations of services and from both in-network and out-of-network providers.

Early Prescription Refills

Your Peoples Health patients can fill existing prescriptions early (up to a 90-day refill) through direct pharmacy or mail order. This early-refill option is available through June 15, 2020. To get an early refill, patients can call the pharmacy number on their ID card or speak directly to a pharmacist.

COVID-19 Testing-Related Telehealth Visits

From March 18, 2020, and throughout this public health emergency, we will waive patient cost-sharing for in-network and out-of-network COVID-19 testing related telehealth visits, including both interactive audio/video and audio only.

Expanded Provider Telehealth Access

Peoples Health is waiving the CMS originating site restriction and audio-video requirement for patients from March 18, 2020, until June 18, 2020. Eligible care providers can bill for telehealth services performed using interactive audio/video or audio only, except in the cases where we have explicitly denoted the need for interactive audio/video such as with PT/OT/ST, while a patient is at home.

Pharmacy Updates

Peoples Health is closely monitoring the drug supply chain to determine if any coverage changes are necessary.

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 are effective March 24, 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.
    • Prior authorization is not required for COVID-19 testing and COVID-19 testing-related visits.
  • 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.

And, we may temporarily suspend or relax additional policies in regions where inpatient capacity is most compromised and at risk. Please watch for updates on this page.

Check back often for the latest information.

COVID-19 Testing and Testing-Related Visits

Peoples Health is waiving cost sharing for COVID-19 testing during this public health emergency. We’re also 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, an urgent care center, an emergency department or through a telehealth visit.

COVID-19 Claim Coding

When submitting COVID-19-related claims, follow the coding guidelines outlined below.

Diagnosis

Effective with services on and after April 1, 2020, a confirmed diagnosis of COVID-19 (2019 novel coronavirus disease) should be reported with diagnosis code U07.1, COVID-19. Assignment of this code is applicable to positive COVID-19 test results and presumptive positive COVID-19 test results.

While this list is not comprehensive, here are some additional ICD-10-CM codes that may be helpful for reporting encounters related to possible COVID-19 exposure as described in the ICD-10-CM Official Coding and Reporting Guidelines:

  • Z20.828, contact with and (suspected) exposure to other viral communicable diseases
  • Z03.818, encounter for observation for suspected exposure to other biological agents ruled out
  • Z11.59 (Encounter for screening for other viral diseases)

Additional resources may be available through the Centers for Disease Control and Prevention (CDC). See the links below:

For more information, download the CPT® Assistant Guide, and review the CMS Emergency Preparedness and Response for Current Emergencies for Coronavirus.

Laboratory Testing Codes

More information is available at AMA Resource Center for Physicians, or you can download the CPT Assistant guide.

  • 87635: For lab testing for severe acute respiratory syndrome coronavirus 2 (SARS-2-CoV-2)
    – 
    Via high-throughput laboratories: U0003
  • U0001: For laboratory test developed by the CDC, for COVID-19 testing performed on or after Feb. 4, 2020, as outlined by CMS
  • U0002: For the laboratory test developed by entities other than the CDC, for COVID-19 testing performed on or after Feb. 4, 2020, as outlined by CMS
    – Via high-throughput laboratories: U0004

      High-throughput laboratories allow for increased testing capacity and faster results, as described in CMS-Ruling 2020-1-R.

      Please note: U0003 and U0004 are not for detecting antibodies.

      Expanded Telehealth Access

      In response to the COVID-19 public health emergency, Peoples Health is expanding its telehealth policies effective immediately. We’re closely monitoring national and local updates from the CDC, CMS and other outlets to adjust our policies as needed.

      Peoples Health will reimburse telehealth services delivered to patients in the home for eligible patients until June 18, 2020.

      Telehealth services do not require prior authorization.

      For all Peoples Health plans, including Dual Eligible Special Needs Plans, any originating site or audio-video requirements that may apply under Original Medicare are waived, so that telehealth services provided via a real-time audio-video or audio only communication system can be billed for patients at home or another location. 

      Additionally, Peoples Health already reimburses appropriate claims for several technology-based communication services, including virtual check-ins, which may be done by audio or video device, and e-visits for new and established patients.

      See the following chart for a summary of descriptions, coding and additional information for specific service types. Please note, billing guidance in the chart below follows Medicare guidelines as of 4/22/2020:

      Type of ServiceWhat Is The ServiceHCPCS/CPT CodeAdditional InformationBilling Guidance
      Medicare Telehealth VisitsA visit with a provider that uses telecommunication systems between a provider and a patient.Common telehealth codes include:

      99201-99215

      G0425-G0427

      G0406-G0408
      Patients may be either a new or established patient.

      The patient may be located in any geographic location (not just those designated as rural), in any health care facility, or in their home.

      During the PHE, clinicians can use popular applications that allow for video chat such as Apple FaceTime and Skype, thanks in part to enforcement discretion by the HHS Office of Civil Rights.

      For medical and outpatient behavioral telehealth visits, providers can utilize both interactive audio/video and audio-only. For PT/OT/ST provider visits, interactive audio/video technology must be used.

      For a complete list of expanded telehealth codes, visit CMS.gov

      Place of service/location billed should align with the place of service that would have been billed if telehealth technology was not used

      Visits related to COVID-19 (test ordered):
      Appropriate modifiers for telehealth services: 95, CS

      Visits not related to COVID-19:
      Appropriate modifiers for telehealth services: 95

      Visits for PT/OT/ST:
      Appropriate modifiers for telehealth services: 95, GT, GQ, GO
      Audio-Only VisitsIn cases where two-way audio and video technology required to furnish a Medicare telehealth service might not be available, there are circumstances where prolonged, audio-only communication between the practitioner and the patient could be clinically appropriate yet not fully replace a face-to-face visit.Reimbursable codes are based on CMS guidance listed here.For the duration of the PHE, Medicare will make separate payment for audio-only visits described by CPT codes 98966-98968 and CPT codes 99441-99443 as outlined on page 125 in the Interim Final Rule with Comment.Place of service/location billed should align with the place of service that would have been billed if telehealth technology was not used

      Appropriate modifiers for telehealth services: 95, CS
      Virtual Check-InNew or established Medicare patients may have a brief communication service with practitioners from wherever they are located, including in their home, via a number of communication technology modalities including synchronous or real-time discussion over a telephone or exchange of information through video or image. We expect that these virtual services will be initiated by the patient; however, practitioners may need to educate patients on the availability of the service prior to patient initiation.G2012

      G2010
      This is NOT limited to only rural settings or certain locations, during the PHE or otherwise.Place of service/location billed should align with the place of service that would have been billed if telehealth technology was not used
      E-VisitsThese visits use an online patient portal. In all types of locations including the patient’s home, and in all areas (not just rural), new or established Medicare patients may have non-face-to-face patient-initiated communications with their doctors or other practitioners. These services are not a substitute for an in-person visit, but are exchanges with a practitioner online through a patient portal. While individual services need to be initiated by the patient, practitioners may educate patients on the availability of the service prior to patient initiation.99421 - 99423

      G2061-G2063, as applicable
      This is not limited to only rural settings. There are no geographic or location restrictions for these visits.

      Patients communicate with their doctors without going to the doctor’s office by using online
      Place of service/location billed should align with the place of service that would have been billed if telehealth technology was not used

      Visits related to COVID-19 (test ordered):
      Appropriate modifiers for telehealth services: 95, CS

      Visits not related to COVID-19:
      Appropriate modifiers for telehealth services: 95

      Visits for PT/OT/ST:
      Appropriate modifiers for telehealth services: 95, GT, GQ, GO

      COVID-19 Physical, Occupational and Speech Therapy Telehealth

      Peoples Health will reimburse physical, occupational and speech therapy telehealth services provided by qualified health care professionals when rendered using interactive audio/video technology. State laws and regulations apply. Benefits will be processed in accordance with the patient’s plan.

      This change is effective immediately for dates of service March 18, 2020, through June 18, 2020.

      Reimbursable codes are based on CMS guidance listed here.

      Below is a short summary of reimbursable CPT codes for physical, occupational and speech therapy telehealth services that are included as part of the temporary expansion of telehealth services as a result of the COVID-19 public health emergency:

      CPT CodeShort Descriptor
      92507Speech/hearing therapy
      92521Evaluation of speech fluenc
      92522Evaluation speech production
      92523Speech sound lang comprehen
      97110Therapeutic exercises
      97112Neuromusulcar reeducation
      97116Gait training therapy
      97161PT Eval low complex 20 min
      97162PT Eval mod complex 30 min
      97163PT Eval high complex 45 min
      97164PT re-eval est plan care
      97165OT eval low complex 30 min
      97166OT eval mod complen 45 min
      97167OT eval high complex 60 min
      97168OT re-eval est plan care
      97535Self care mngment training

      CMS TELEHEALTH TOOLKIT CMS

      For your reference, CMS created a telehealth and telemedicine toolkit for general providers, as well as versions specific to nursing homes and ESRD providers. The toolkit contains links to reliable information regarding telehealth and telemedicine. Most of the information is directed towards providers who may want to establish a permanent telemedicine program. There are specific documents identified that will be useful in choosing telemedicine vendors, initiating a telemedicine program, monitoring patients remotely, and developing documentation tools. However, there is also information that will be useful for providers who wish to care for patients through the virtual services that may be temporarily used during the COVID-19 situation.

      Visit the CMS website for the most up-to-date toolkits.

      TELEHEALTH REIMBURSEMENT

      Peoples Health reimburses telehealth services according to CMS billing guidelines.

      According to the terms of applicable patient benefit plans, Peoples Health will reimburse both participating and non-participating providers who submit appropriate telehealth claims.

      Telehealth Frequently Asked Questions

      These FAQs answer common questions about the expansion of our telehealth policies. Information is being added frequently.

      What changes has Peoples Health made to its telehealth reimbursement policies as a result of the COVID-19 public health emergency?

      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.

      Expanded Provider Telehealth Access

      Peoples Health is waiving the CMS originating site restriction and audio-video requirement for patients from March 18, 2020, until June 18, 2020. Eligible providers can bill for telehealth services performed using interactive audio/video or audio only, except in the cases where we have explicitly denoted the need for interactive audio/video such as with PT/OT/ST, 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.

      Which types of providers do the telehealth changes apply to?

      As of March 19, 2020, 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
      Will Peoples Health reimburse me for audio-only services billed with E/M codes?

      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.

      What technology is needed to use for telehealth services? Does it need to be HIPAA compliant?

      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.

      Are there any limitations on the location of the provider who is conducting a telehealth visit? Will services be reimbursed if the care provider is not in the office?

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

      Does a provider need a referral for a telehealth visit, if the patient has a benefit plans with referral requirements?

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

      Last updated: 05/15/2020 5:00 p.m.

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