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Revised Private Payer Policies during COVID-19 Pandemic


Article - Revised Private Payer Policies during COVID-19 Pandemic

Medical Billers and Coders (MBC) is closely monitoring private payer policies regarding the COVID-19 pandemic. The following policy details are based on information from each payer’s respective website. Policies are changing rapidly. Your local provider representatives may have updated information. While many payers have provided flexibilities and waivers, much remains unclear. We are in frequent contact with payers to better understand their policies and to continue advocating for additional flexibilities for our members. Areas of advocacy include:

  • Payment of all telehealth services for in-network providers, regardless of existing contract restrictions.
  • Coverage and waiving of out-of-pocket costs for telephone evaluation and management services (CPT 99441-99443).
  • Payment of all telehealth services at the same rate as in-person visits (i.e., parity).
  • Alignment with Medicare’s policy to waive geographic and originating site restrictions.
  • Coverage of all telehealth services, regardless of diagnosis.
  • Waiving out-of-pocket costs for all in-person visits related to COVID-19.
  • Coverage and waiving of out-of-pocket costs for digital services.

    Note: Digital services include online digital evaluation and management services (e-visits [CPT 99421-99423, HCPCS G2061-G2063]) and brief communication technology-based services (virtual check-in [HCPCS G2012 and G2010]).

COVID-19 Private Payer Policies

Coverage for COVID-19 testing

Aetna: Aetna is waiving co-pays and applying no cost-sharing for all diagnostic testing related to COVID-19. The policy covers the cost of the physician-ordered test and the physician visit that results in the ordering or administration of the COVID-19 test. This policy applies for all Commercial, Medicare, and Medicaid lines of business.

Anthem: Anthem affiliated health plans will waive cost shares for full-insured employer, individual, Medicare, and Medicaid plan members. This includes co-pays, coinsurance, and deductibles for COVID-19 tests and visits associated with the COVID-19 test, including visits to determine if testing is needed.

Cigna: Cigna is waiving out-of-pocket costs for COVID-19 FDA-approved testing and diagnostic COVID-19 related laboratory tests (other than the COVID-19 test). Physicians should use diagnosis code Z03.818, Encounter for observation exposure to other biological agents ruled out; or Z20.828, Contact with and (suspected) exposure to other viral communicable diseases. The CR modifier should be used on CMS1500 claims.

Humana: Humana is covering with no out-of-pocket costs COVID-19-related testing, including the COVID-19 test and viral panels that rule out COVID-19. The cost-share waivers also apply to physician office visits or emergency department visits that result in the ordering or administration of the test. For office visits related to COVID-19, physicians should include the modifier CS and the appropriate ICD-10-CM diagnosis code.

United Health Care (UHC): UHC is waiving cost-sharing for COVID-19 testing and costsharing for COVID-19 testing related visits, 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. This policy applies to Medicare Advantage, Medicaid, and employer-sponsored plans.

Out-of-pocket costs for telemedicine visit

Aetna: Aetna is waiving member cost-sharing for a covered telemedicine visit (general medicine, behavioral health, and dermatology), regardless of diagnosis. This policy applies to in-network providers.

Anthem: Anthem’s Affiliated health plans will waive member cost shares for telehealth visits, including visits for mental health or substance use disorders, for fully insured employer plans, individual plans, Medicare plans, and Medicaid plans, where permissible.

Cigna: Cigna is waiving out-of-pocket costs for telehealth screenings for COVID-19. This policy is effective through May 31, 2020. Physicians should use the usual face-to-face E/M code and use diagnosis code Z03.818, Encounter for observation exposure to other biological agents ruled out; or Z20.828, Contact with and (suspected) exposure to other viral communicable diseases. Physicians must use the CS modifier for Cigna to waive cost-sharing. The GQ, GT, or 95 modifier should be used for telehealth claims. Normal cost-sharing applies to telehealth visits not related to COVID-19.

Humana: Humana is waiving out-of-pocket costs for telemedicine visits. Humana will waive member cost-sharing for telehealth services, regardless of whether they are related to COVID-19, if the services are rendered by an in-network provider. Services provided by out-of-network providers for non-COVID-19 visits are subject to member cost-sharing.

UHC: UHC is waiving member cost-sharing for COVID-19 testing-related visits.

Coverage for digital services

Aetna: Aetna has added several CPT and HCPCS codes to its list of covered telehealth services, including online digital evaluation and management services (e-visits [CPT 99421-99423, HCPCS G2061-G2063]) and brief communication technology-based services (virtual check-in [HCPCS G2012 and G2010]). Cost-sharing is waived for a covered telemedicine visit, regardless of diagnosis.

Anthem: The AAFP is seeking more information on Anthem’s digital services policy.

Cigna: Cigna will cover virtual check-ins (HCPCS G2012) and e-visits (CPT 99241). Cigna will waive cost-sharing for virtual check-ins for all visits, including non-COVID-19- related services. For cases where there is concern about a possible exposure to COVID19, it would be appropriate to assign ICD-10 Z03.818 (Encounter for observation for suspected exposure to other biological agents ruled out). When there has been exposure to a confirmed case of COVID-19, it would be appropriate to assign ICD-10 Z20.828 (Contact with and [suspected] exposure to other viral communicable diseases).

Humana: Humana pays for virtual check-ins (HCPCS G2012 and G2010) and e-visits (CPT 99421-99423 and HCPCS G2061-G2063). Humana will cover in- and out-ofnetwork telehealth services related to COVID-19, including virtual check-ins and Medicare e-visits. For telehealth services related to COVID-19, Humana will waive member cost share for the services, regardless of the provider’s network status. Member cost-share waivers will also apply to all in-network telehealth claims not related to COVID-19. Cost-share waivers do not apply to non-COVID-related out-of-network claims, which will be processed in accordance with the plan’s out-of-network benefit.

UHC: UHC pays for virtual check-ins (HCPCS G2012 and G2010) and e-visits (CPT 99421-99423 and HCPCS G2061-G2063) for its commercial, Medicare Advantage, and Medicaid plans.

Coverage for audio-only or telephone-only visits

Aetna: Aetna will cover telephone evaluation and management services (CPT 99441- 99443). Aetna will also cover acute evaluation and management services rendered via telephone – a visual connection is not required. General medicine and behavioral health visits still require a synchronous (real-time) audio-visual connection. Cost sharing is waived for a covered telemedicine visit, regardless of diagnosis.

Anthem: The AAFP is seeking additional information regarding Anthem’s coverage of audio-only encounters.

Cigna: The AAFP is seeking additional information regarding Cigna’s coverage of audioonly encounters.

Humana: Humana will temporarily accept audio-only visits. These visits should be submitted as a telehealth visit and will be paid as a telehealth visit. Cost-sharing is waived for all telehealth services for in-network providers. Humana also covers telephone E/M services (CPT 99441-99443).

UHC: UHC is waiving the audio-video requirement for telehealth services. Physicians can bill for telehealth services using audio-video or audio-only communication. Physicians should bill the appropriate office visit E/M and use the place of service that would have been used if the service had been provided in-person and append modifier - 95.

Telehealth services payment rates

Aetna: Aetna will pay visits delivered via telehealth at the same rate as in-person visits.

Anthem: Where required by state law, Anthem pays evaluation and management (E/M) services delivered via telemedicine at the same rate as in-person visits. A list of states with payment parity laws can be found here.

Cigna: Physicians will be paid consistent with their typical face-to-face rate. Physicians should bill using the face-to-face evaluation and management code and append the GQ, GT, or 95 modifier for telehealth visits. Physicians must use the CS modifier for Cigna to waive cost-sharing for COVID-19-related visits. . The place of service should the code they would use if the service was provided face-to-face. Normal cost-sharing applies to telehealth visits not related to COVID-19. Note: Cigna telehealth services billed with a Place of Service (POS) 02 may result in reduced payment or denied claims. Billing the typical POS will ensure physicians receive the same payment as they typically would for a face-to-face service.

Humana: Humana will temporarily reimburse for telehealth visits with in-network providers at the same rate as in-office visits. Humana recommends submitting charges for telehealth services using the Place of Service (POS) that would have been used if the service had been provided in-person and append modifier -95. Claims previously submitted with the POS 02 – Telehealth do not need to be resubmitted. Humana will apply waivers and calculate payment according to this policy to those claims.

UHC: Audio/video visits are paid at the physician’s contracted rate. For most physicians, that is equal to the in-person visit rate. However, physicians should review their individual contracts and fee schedules to verify. Physicians should bill the appropriate office visit E/M and use the place of service that would have been used if the service had been provided in-person and append modifier -95.

Contractual obligation for telehealth services

Aetna: Any in-network physician can provide telehealth services.

Anthem: All contracted physicians can provide telehealth and telephonic services, as clinically appropriate.

Cigna: In-network physicians

Humana: Any in-network physician can bill for telehealth services.

UHC: Telehealth claims will be paid for in-network and out-of-network providers.

Prior Authorization

Aetna: Aetna is providing flexibilities in its prior authorization protocols for inpatient admissions. Details are available here.

Anthem: Beginning March 16, 2020, Anthem is removing prior authorization requirements for skilled nursing facilities (SNF) for the next 90 days. SNFs providers should continue to notify Anthem of admission. Anthem is also extending the time a prior authorization is in effect for elective inpatient and outpatient procedures to 90 days. These policies apply across all lines of business. Anthem has suspended prior authorization requirements for patient transfers and for the use of medical equipment critical to COVID-19 treatment.

Cigna: Prior authorizations are not required for evaluation, testing, or treatment for services related to COVID-19. Prior authorizations for treatment follow the same protocols as any other illness based on place of service. Generally, routine office visits, urgent care, and emergency visits do not require prior authorizations.

Humana: Prior authorizations requirements are waived for Medicare Advantage and commercial Humana members with COVID-19-related diagnosis code(s). For acute inpatient services, Humana recommends notification to facilitate discharge planning. Medicaid waivers are handled at the state-level. Medicare Part D prior authorization requirements have not changed.

UHC: Prior authorizations are not required for COVID-19 testing or COVID-19 testingrelated visits. Effective March 24, 2020, through May 31, 2020, UHC is waiving prior authorizations for admissions to long-term acute care facilities, acute inpatient rehabilitation, and skilled nursing facilities. Admitting providers must still notify UHC within 46 hours of transfer. Length of stay reviews also remain in place.

Advance payments or financial support to practices

Following Medicare’s recent announcement of accelerated and advance payments to provide emergency funding to address cash-flow issues, commercial payers have also started to offer financial assistance programs. On April 7, the nation’s largest private payer, UnitedHealth Group, announced that it would accelerate payments and other financial support to health care providers to address the short-term financial pressure caused by the COVID-19 emergency. Similarly, two Blue Cross Blue Shield plans have announced related policies to physicians affected by the pandemic.

Medical Billers and Coders (MBC) is closely monitoring private payer policies regarding the COVID-19 pandemic. Above private payer policy details are based on information from each payer’s respective website. Policies are changing rapidly. Your local provider representatives may have updated information. You can stay connected with us for more updated payer policy information during COVID-19 Pandemic.

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