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

• 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

• 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

• 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)

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

• 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 is 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)

• 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

• 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 is 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

• 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

• 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 is still required for any additional visits or services beyond those approved in the initial PA
• Diagnostic radiology: PA is 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 chest 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 is 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

• 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”)

• Standard PA policies remain in place; Express Scripts is monitoring the COVID-19 situation and will update policies if or when the situation changes

• 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