Medical Billing Services

Prior authorization (PA) Policy Changes related to COVID-19

The information and guidance provided in this document are believed to be current and accurate at the time of posting this article.

Major medical insurance plans

Plan

Effective Date(s)

Policies

Aetna Check the Aetna COVID-19 Communications Update for state-specific information and detailed requirements 3/25/20 – 5/6/20
  • Transfers: Initial PAs waived in the following scenarios:
    • Admissions to post-acute care facilities (including skilled nursing and extended acute rehabilitation)
      • Facilities must notify Aetna of the admission within 48 hours and send medical records for concurrent review within 3 days
    • Admissions to long-term acute care hospitals
      • Facilities must notify Aetna of the admission within 48 hours
    • Admissions — PA waived for admissions to acute care facilities in certain states
      • Acute care facilities must notify Aetna of the admission within 48 hours
      • Changes will be effective per state declaration for commercial fully insured patients
      • Effective through 5/6/20
    • Lines of business: Commercial and Medicare Advantage
BlueCross BlueShield Association Check with individual BCBS plans for additional information 3/6/20

All 36 BCBS plans

  • COVID-19 screening/testing: PA waived for COVID-19 diagnostic tests
  • COVID-19 treatment: PA waived for “covered services that are medically necessary and consistent with CDC guidance for members if diagnosed with COVID-19”
    • Not clear what constitutes “medically necessary covered services”
  • Lines of business: Fully insured, individual, and Medicare members

Anthem (CA, CO, CT, GA, IN, KT, ME, MO, NH, NV, NY, OH, VA, WI) – additional policy updates Effective 3/27/20:

  • Transfers: PA requirements suspended for certain patient transfers
  • DME: PA requirements suspended on durable medical equipment critical for treating COVID-19

Note: Most Anthem plans have implemented additional policy changes, including suspension or extension of certain PAs. For more information, visit the relevant state-specific provider communications page at https://providernews.anthem.com/state (e.g., https://providernews.anthem.com/georgia)

Health Care Services Corporation (IL, MT, NM, OK, TX) – additional policy updates Effective 4/2/20:

  • Transfers: PA waived for transfers to in-network, alternative post-acute facilities until 4/30/20

Regence (OR, ID, UT, select counties in WA) – additional policy updates Effective 4/1/20:

  • Transfers: PA waived for transfers to post-acute care settings until 5/31/20
    • Applies to transfers that must happen quickly due to the impact of COVID-19
    • Discharging AND receiving facility/provider must notify Regence within 24 hours
  • Extension of elective inpatient PAs: Regence is offering an extension of PAs for elective inpatient admissions
    • Contact Regence for extension; duration not specified
    • PA still required for professional services that occur during inpatient admissions for certain plans
  • Extension of medication PAs: 6-month extension of existing medication PAs set to expire between 3/23/20 and 6/30/20

Effective 4/15/20:

  • Extension of PAs for elective procedures: PAs extended for certain elective procedures; duration of extension not specified (contact Regence)
Centene 3/12/20 (screening, testing); 4/1/20 (treatment)
  • COVID-19 screening/testing/treatment: PA/step therapy not required for medically necessary COVID-19 screening, testing, or treatment services
  • Lines of business: Medicaid, Medicare, and Marketplace members
Cigna 3/17/20 (screening, testing, and treatment); 3/23/20 – 5/31/20 (transfers); 3/25/20 – 5/31/20 (elective outpatient services)
  • COVID-19 screening/testing: PA not required for COVID-19 evaluation/testing
  • COVID-19 treatment: PA not required for “medically necessary treatment” for COVID-19
    • PA for COVID-19 treatment follows the same protocols as any other illness based on place of service and plan coverage; PA generally not required for routine office, urgent care, and emergency visits
  • Non-COVID-19 services: Cigna will not deny claims for other services that require PA for failure to secure authorization if the care was emergent, urgent, or involved extenuating circumstances; delays in the timely filing of claims or the ability to request PA due to COVID-19 will be treated as extenuating circumstances in the same way as during a natural catastrophe (e.g. hurricane, tornado, fires, etc.)
  • Transfers: PA waived for the transfer of non-COVID-19 patients from acute inpatient hospitals to in-network long-term acute care hospitals and other subacute facilities, including skilled nursing facilities and acute rehab centers
    • The notification required on the next business day following the transfer
    • Coverage reviews for appropriate levels of care and medical necessity still apply to these admissions
  • Extension of elective outpatient PAs: Duration of PAs for all elective outpatient services is temporarily increased from 3 months to 6 months
    • Effective 3/25/20 – 5/31/20
    • PA decisions made between 1/1/20 and 3/24/20 will be assessed when the claim is received and will be payable if it is within 6 months of the original authorization
  • Extension of medication PAs: Automatic 90-day extension of existing medication PAs set to expire between 4/1/20 and 6/1/20
  • Lines of business: Commercial and Medicare Advantage plans
Humana 3/23/20; 4/1/20
  • COVID-19 screening/testing/treatment: Effective 3/23/20, PA suspended on services with COVID-related diagnoses, excluding post-acute discharge, for both participating/in-network and non-participating/out-of-network providers
  • Non-COVID-19 services: Effective 4/1/20, “nearly all” PA requirements suspended for participating/in-network providers for non-COVID-19 related services, including inpatient (acute and post-acute) and outpatient treatment and referrals
    • Humana requests notification when the patient is admitted to the hospital, even what PA is not required
    • Non-par/out-of-network providers must continue to follow referral requirements and submit PA requests per Humana’s policy
    • PA still required for transplants and genetic-related services
  • Extension of PAs for elective/nonemergent procedures and services: Previously approved PAs extended to a 90-day approval timeframe, except for home health authorizations, which are extended for 60 days
  • Medications: PA still required for drug/pharmacy-related requests (Commercial, Part D, and Part B)
  • Lines of business: Commercial employer-sponsored (fully insured and select self-funded plans), Medicare Advantage, and Medicaid plans
UnitedHealthCare 3/24/20 – 5/31/20
  • COVID-19 screening/testing: PA is not required for COVID-19 testing and COVID-19 testing-related visits
  • Transfers to the different level of care: Suspension of PA requirements for admissions to post-acute care settings (long-term care acute facilities, acute inpatient rehabilitation, and skilled nursing facilities)
    • Admitting facility must notify UHC within 24 hours for weekday admissions or by 5 p.m. local time on the next business day for weekend and holiday admissions
    • Length of stay reviews still apply, including denials for days that exceed the approved length
    • Discharges to home health will not require PA
  • Transfers to a similar site of care: Suspension of PA when patient transfers to a similar site of care for the same service (e.g., hospital transfers or practice transfers)
    • For inpatient/post-acute admissions, admitting facility must notify UHC within 24 hours for weekday admissions or by 5 p.m. local time on the next business day for weekends/holidays
    • For other transfers, such as outpatient services, contact UHC using the phone number on the back of the member’s ID card to transfer the existing PA
  • Extension of PAs for medical services: 90-day extension of open and approved PAs set to expire between 3/24/20 and 5/31/20
    • Extension based on the original authorization date; does not apply to authorizations issued on or after 4/10/20
    • Applies to in-network and out-of-network medical, behavioral health, and dental services (including many provider-administered drugs)
    • PA still required for any additional visits or services beyond those approved in the initial PA
  • Diagnostic radiology: PA not required for diagnostic radiology (diagnostic imaging) of the chest for COVID-19 patients
    • Notification requested for CPT® codes 71250, 71260, 71270 for Medicaid or commercial members with known/suspected COVID-19 diagnosis
    • PA continues to be required for all other chests CTs
  • DMEPOS: For dates of delivery from 3/31/20 through 5/31/20, PA requirements are adjusted as follows:
    • PA suspended for COVID-19-related orders for a respiratory assist device or a ventilator (codes E0471, E0465, E0466, E0467)
      • Notification is requested, and PA will be required after 5/31/20
    • PA not required for COVID-19-related oxygen requests; exemption from current clinical criteria
    • Changes in face-to-face evaluation requirements for the ordering provider for DMEPOS PAs:
      • New PAs required for services completed before 10/1/19; may be done through telehealth
      • PAs for services completed 10/1/19 or later are extended through 9/30/20
      • For new DMEPOS PAs, face-to-face assessments may be done via telehealth
    • PA not required for DMEPOS repair when the claim uses the repair modifier
  • Site of service reviews: Suspension of reviews for the site of service until 5/31/20 for certain surgical codes
  • Lines of business: Commercial (fully insured), Medicare Advantage, and Medicaid plans
CVS 3/25/20
  • Extension of medication PAs: Extension of existing PAs set to expire before 6/30/20 for “most” medications
    • The presumed 90-day extension (“if a current [PA] is set to expire on May 15, the expiration date will be extended to August 15”)
Express Scripts
  • Standard PA policies remain in place; Express Scripts is monitoring the COVID-19 situation and will update policies if or when the situation changes
OptumRx 3/19/20
  • Extension of medication PAs: One-time, 90-day extension of existing PAs set to expire on or before 5/1/20 for medications taken on a chronic basis
  • Existing PA and renewal requirements remain in place for:
      • Drugs with significant abuse potential
      • Drugs dosed for finite durations or intermittently (e.g., hepatitis or fertility agents)
      • Newly prescribed medications
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