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Population Health

Telemedicine Guidance by Payer

The Temple Center for Population Health dedicated to providing community physicians with telemedicine updates by payer as we receive new information. Please view the information below to help your practice navigate telemedicine in your offices.  

Please note: We aim to keep this information as up-to-date as possible. Our goal is to update this site as our teams receive new communications from the payers.  Specific questions about these policies should be direct to the payers. 

Aetna

Member Cost Share

Update 10/14/2020:

Place of Service (POS) Update: For commercial members, non-facility telemedicine claims must use POS 02 with the GT or 95 modifier. Fee schedules have been updated so claims with approved telemedicine CPT codes and modifiers with POS 02 will be reimbursed at the same rate as an equal office visit.  For example, a telemedicine service 99213 GT with POS 02 will reimburse the same as a face-to-face in-office visit 99213. Urgent Care Centers should continue to use POS 20. All other facilities should continue to use their respective POS; CPTs and the telemedicine modifiers must be noted on the UB-04 and HCFA 1500 forms as the Rev Code will not be sufficient.

For Medicare members, POS 02 or POS 11, or the POS equal to what it would have been had the service been furnished in-person, along with the 95 modifier indicating that the service rendered was actually performed via telehealth, may be utilized and will reimburse at the same rate.  
 

Effective 9/16/2020:

Aetna extended all member cost-sharing waivers for covered in-network telemedicine visits for outpatient behavioral and mental health counseling services through December 31, 2020. Aetna self-insured plan sponsors offer this waiver at their discretion. 

Cost-share waivers for any in-network covered medical or behavioral health services telemedicine visit for Aetna Student Health plans are extended until September 30, 2020.

For Medicare Advantage plans, Aetna is waiving cost shares for in-network primary care and specialist telehealth visits, including outpatient behavioral and mental health counseling services, through December 31, 2020.

Telemed/Health Billing Requirements

10/8/2020 Update: In most cases, Aetna reimburses providers for telemedicine services, including behavioral health services, at the same rate as in-person visits. For providers with standard fee schedules, telephone-only services 99441 – 99443, when rendered between March 5, 2020 and September 30, 2020, were typically set to equal 99212 – 99214 (e.g. 99441 was set to equate to 99212). This rate change did not apply to all provider contracts (e.g. some non-standard reimbursement arrangements). After September 30, 2020, telephone-only services resumed to pre-March 5, 2020 rates. 

99441-99443 (Modifier GT or 95 not required) Also covered; G2010, G2012 , 98966 - 98968,99421 - 99423.  Non-facility providers should now POS 11 on telemedicine claims.

Update: For commercial members non-facility telemedicine claims must use POS 02 with the GT or 95 modifier. Fee schedules have been updated so claims with approved telemedicine CPT codes and modifiers with POS 02 will be reimbursed at the same rate as an equal office visit. For Medicare members, POS 02 or POS 11, or the POS equal to what it would have been had the service been furnished in-person, along with the 95 modifier indicating that the service rendered was actually performed via telehealth, may be utilized and will reimburse at the same rate. 

Lab Admin Codes for Testing 

U0001 & U0002 or  87635

Swab Collection Codes - Physicians

5/18/2020 Update:
Providers (when not rendering the lab work) should bill for the COVID-19 swab collection using one of these codes:

  • Use code 99001 - Handling and/or conveyance of specimen for transfer from the patient in other than a physician’s office to a laboratory. (distance may be indicated).
  • Use code 99211 - Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional.
  • Use code G2023 - Specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), any specimen source
  • Use code G2024 - Specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), from an individual in a skilled nursing facility or by a laboratory on behalf of a home health agency, any specimen source
  • Use code C9803 - Hospital outpatient clinic visit specimen collection for severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19])

Transition of Care (cpt 99495-99496) and Annual Wellness Visits codes (G0402 and G0438, G0439) permissible to bill under Telehealth policy 

Transition of Care codes are covered however via two-way communication only. Awaiting confirmation from Aetna whether telephonic communication is allowed. Annual Wellness visits - TBD

Update: Aetna will cover appropriate evaluation and management codes with a wellness diagnosis for those aspects of the visit done via telehealth. Preventative visit codes should be reserved for such time when routine in-office visits resume and the remaining parts of the well visit can be completed. Both services will be fully reimbursed, and the patient will not incur a cost-share.

Telehealth Criteria (two-way, telephonic or both)    

Telephonic encounters allowed

7/10/2020 Update- For Commercial plans, Aetna will continue to cover limited minor acute care evaluation and care management services, as well as some behavioral health services rendered via telephone, until December 31, 2020.

Medicare allows telephone-only telemedicine services for a limited number of codes. For other codes announced by CMS, an audiovisual connection is also still required. The policy is available via Navinet or Availity.
 

Reimbursement  

 Per agreement.

Claim Submission    

Standard practice

Pre-Authorization 

Update: Waived for TUHS until 5/31/2020 

PCPs Referrals  

No change to current practice

PCP Capitation    

Codes will be covered in PCP cap

Urgent Care    

TBD

Time period    

10/8/2020 Update:  Through December 31, 2020, Aetna has extended all member cost-sharing waivers for covered in-network telemedicine visits for outpatient behavioral and mental health counseling services for their Commercial plans. Self-insured plans offer this waiver at their own discretion. Cost share waivers for any in-network covered medical or behavioral health services telemedicine visit for Aetna Student Health plans are extended until December 31, 2020.

Through December 31, 2020, Aetna is waiving cost shares for all Medicare Advantage plan members for in-network primary care and specialist telehealth visits, including outpatient behavioral and mental health counseling services. Aetna Medicare Advantage members should continue to use telemedicine as their first line of defense for appropriate symptoms or conditions to limit potential exposure in physician offices. Cost sharing will be waived for all Teladoc® general medical care virtual visits. Cost sharing will also be waived for covered real-time virtual visits offered by in-network providers (live videoconferencing or telephone-only telemedicine services). Medicare Advantage members may use telemedicine for any reason, not just COVID-19 diagnosis.
 

Helpful Links and Resources

Visit the Aetna website.

Additional Coding Guidance

The following codes require an audiovisual connection:                                        

  • G2061, G2062, G2063 - Qualified nonphysician healthcare professional online assessment, for an established patient, for up to seven days, cumulative time during the 7 days; 5-10 minutes; 11 – 20 minutes; or 21 or more minutes
  • H0015 GT or 95 - Alcohol and/or drug services; intensive outpatient (treatment program that operates at least 3 hours/day and at least 3 days/week and is based on an individualized treatment plan), including assessment, counseling; crisis intervention, and activity therapies or education                                        
  • H0035 GT or 95 - Mental health partial hospitalization, treatment, less than 24 hours.                                        
  • H2012 GT or 95 - Behavioral health day treatment, per hour.                                        
  • H2036 GT or 95 - Alcohol and/or other drug treatment program, per diem                                        
  • S9480 GT or 95 - Intensive outpatient psychiatric services, per diem                                        
  • 97151 GT or 95 - Behavior identification assessment, administered by a QHP, face to face with patient and/or guardians administering assessments and discussing findings and recommendations. Includes non-face-to-face analyzing of past data, scoring/interpreting the assessment, and preparing the report/treatment plan.                                        
  • 97155 GT or 95 - Adaptive behavior treatment with protocol modification, administered by QHP, which may include simultaneous direction of a technician working face to face with a patient.                                        
  • 97156 GT or 95 - Family adaptive behavior treatment guidance administered by QHP, with parent/guardian 
  • 97157 GT or 95 - Multiple-family group adaptive behavior treatment guidance, administered by QHP, with multiple sets of parents/guardians                                      
  • 98970, 98971, 98972 - Qualified nonphysician health care professional online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10; 11-20; or 21 or more minutes.               
  • 99421, 99422, 99423 - Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10; 11-20; or 21 or more minutes.                                        

                                        
The following codes require an audiovisual connection or telephone:                                        
                                        

  • G2010 - Remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related e/m service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment.                                        
  • G2012 - Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related e/m service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion.                                        
  • 98966, 98967, 98968 - Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 5-10; 11-20; or 21-30 minutes of medical discussion.                                
  • 99441, 99442, 99443 - Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10; 11-20; or 20-30 minutes of medical discussion.                  
  • 90791, 90792; GT or 95 - Psychiatric diagnostic interview examination                                        
  • 90832, 90833, 90834, 90836, 90837, 90838; GT or 95 - Individual psychotherapy                                        
  • 90839, 90840; GT or 95 - Psychotherapy for crisis; first 60 minutes; or each additional 30 minutes                                      
  • 90845; GT or 95 – Psychoanalysis                                        
  • 90846, 90847, 90853; GT or 95 - Family or group psychotherapy                                        
  • 90863; GT or 95 - Pharmacologic management, including prescription and review of medication, when performed with psychotherapy services                                        
  • 96116; GT or 95 - Neurobehavioral status examination                                        

 

Behavioral Health                                        
                                        
IOP Procedure codes - televideo only                                       
                                      

  • H0015 Alcohol and/or drug services; intensive outpatient (treatment program that operates at least 3 hours/day and at least 3 days/week and is based on an individualized treatment plan), including assessment, counseling; crisis intervention, and activity therapies or education.                                        
  • H2012 Behavioral health day treatment, per hour.                                        
  • S9480 Intensive outpatient psychiatric services, per diem.                                        

                                        
                                        
PHP Procedure codes - televideo only                                        
                                        

  • H0035 Mental health partial hospitalization, treatment, less than 24 hours.                                        
  • H2036 Alcohol and/or other drug treatment program, per diem.                                        
     
Cigna

Member Cost Share  

Waived for COVID-19 Related Services.

Update: As federal guidelines continue to evolve in support of the COVID-19 pandemic, we have extended customer cost-share waivers and other administrative benefits through at least October 31, 2020. We have also extended our interim virtual care and eConsult guidelines through at least December 31, 2020

 

Telemed/Health Billing Requirements  

99441-99443 (Modifier GT or 95 not required) Also covered; G2010, G2012 , 98966 - 98968,99421 - 99423.  Non-facility providers should now POS 11 on telemedicine claims.

Update: For commercial members non-facility telemedicine claims must use POS 02 with the GT or 95 modifier. Fee schedules have been updated so claims with approved telemedicine CPT codes and modifiers with POS 02 will be reimbursed at the same rate as an equal office visit. For Medicare members, POS 02 or POS 11, or the POS equal to what it would have been had the service been furnished in-person, along with the 95 modifier indicating that the service rendered was actually performed via telehealth, may be utilized and will reimburse at the same rate. 
 

Lab Admin Codes for Testing   

86328, 86769, 87635, U001, U0002, U0003 & U0004

Swab collection codes - Physicians      

G2023 & G2024

Transition of Care (cpt 99495-99496) and Annual Wellness Visits codes (G0402 and G0438, G0439) permissible to bill under Telehealth policy     

Cigna will allow providers to bill a standard face-to-face visit for all virtual care services, including those not related to COVID-19.  this means that providers can perform services for commercial Cigna customers in a virtual setting and bill as though the services were performed face-to-face.  Providers should bill using a face-to-face evaluation and management code, append the GQ modifier and use the POS that would be typically billed if the service was delivered face-to-face. 

Telehealth Criteria (two-way, telephonic or both)    

Telephonic encounters allowed.  See Cigna COVID-19 Interim Billing tab

Reimbursement  

Per Agreement; providers will be reimbursed consistent with their typical face-to-face 

Claim Submission    

This billing requirement and associated reimbursement applies to services submitted on CMS1500 or UB04 claim forms and all electronic equivalents

Pre-Authorization 

The guidelines below apply during the emergency declaration period. State and federal mandates may supersede these guidelines.
Referrals: All referrals (if required by customer’s benefit plan) are waived.

Durable Medical Equipment: Documentation of face to face, physician order, and medical necessity is not required to obtain replacements of DME that is lost, destroyed, irreparably damaged or rendered unusable.

Elective Surgeries and Procedures (Outpatient and Inpatient): As more healthcare providers are increasingly being asked to assist with the COVID-19 response, we ask that you consider whether non-essential surgeries and procedures can be delayed so that personal protective equipment (PPE), beds, and ventilators can be preserved. In order to assist providers with this request, routine procedure requests will be extended to six (6) months to allow for rescheduling of needed tests. Eligibility should be confirmed prior to scheduling. Also note that medical necessity review is still required.

Initial Clinical Review. In addition to the modifications listed above, initial clinical review is waived for the following:

  • Home Health Requests
  • SNF Admissions
  • LTAC Admissions
  • Inpatient Rehab Admissions

Admission notification still applies in order for us to concurrently review and provide discharge/transition of care planning support.
Out-of-Network Services (UPDATED 3/31/2020)


The National Emergency Declaration made by the President of the United States will remain effective until further notice. In alignment with the National Emergency Declaration:

  • All referral requirements (if required by customer’s benefit plan) are waived.
  • Authorizations are not required nor will be processed for services requested or delivered by non-contracted providers during this period.

Customer cost-share (if applicable depending on the customer’s benefit plan) for COVID-19 related services provided by out-of-network providers is waived until 5/31/2020. Please continue to inform us of admissions to Inpatient Acute Care, Skilled Nursing Facilities, Acute Inpatient Rehabilitation and Long-Term Acute Care facilities in order for us to assist in customer discharge planning and transitions of care"
   

PCPs Referrals  

No change to current practice. 

PCP Capitation  

Capitation applies to applicable services.  

Urgent Care    

Reimbursed without cost share when one of the diagnosis codes are present Z03.818 or Z20.828: S9083

Time period  

3/2/2020 - 10/31/2020 (cost-share) & 12/31/2020 (interim virtual care/eConsult)

Helpful Links

Visit the Cigna website

Cigna HealthSpring

Member Cost Share  

Customer cost-share (if applicable depending on the customer’s benefit plan). Confirmed COVID-19 Cases - cost share waived for in- and out-of-network providers until 12/31/2020.   Non-Covid-19 related PCP & Specialist Services - cost share is waived for in- and out-of-network physicians until 12/31/2020.  

Telemed/Health Billing Requirements    

E&M with GT or 95 Modifier as appropriate.  Physicians and practitioners who bill for Medicare telehealth services should report the POS code that would have been reported had the service been furnished in person.                                                                                  

All providers may conduct a face-to-face visit virtually and bill as a standard face-to-face visit including those not related to COVID-19. 

Providers should bill using a face-to-face evaluation and management code and use the POS that would be typically billed if the service was delivered face-to-face. 

Allow tele-visits to take place with audio only when patients only have audio capabilities.

Allow reimbursement of select virtual physical, occupational, and speech therapy services when appended with a GQ modifier. These services will be reimbursed consistent with standard rates.

Revised 5/4/2020 -  98966-98968 & 99441-99443, Requirements: Audio Only                                                                                                 

Lab Admin Codes for Testing   

Testing: U0001, U0002, U0003 (3/18 - 7/24/2020), U0004 (3/18 - 7/24/2020), 87635, 86318, 86328, & 86769.  

Swab collection codes - Physicians    

Specimen Collection: G2023, G2024, C9803 (Hospital)

Transition of Care (cpt 99495-99496) and Annual Wellness Visits codes (G0402 and G0438, G0439) permissable to bill under Telehealth policy  

CMS allows 99495, 99496,G0438-G0439, with GT or  95 modifiers, G0402 not allowed (awaiting confirmation from payer)  

Telehealth Criteria (two-way, telephonic or both)    

Telephonic encounters allowed.  

eVisits:  99241, 99422, 99423, G2061, G2062, G2063 a communication between patient and their provider through an online patient portal.  Requirement: Paitient Portal                          

Virtual Check in G2012 & G2010 audio only brief (5-10) minute check-in conversation between customer and provider to determine whether an office or other service is needed.  Requirement: Audio Only. 

Reimbursement  

Per Agreement. Providers will be reimbursed consistent with their typical face-to-face rates. 

Claim Submission    

Standard practice.

Pre-Authorization  

The 2020 authorization requirements can be located here: https://medicareproviders.cigna.com/static/medicareproviders-cigna-com/docs/prior-auth-reqs-2020.pdf

Note that these requirements may change, reference our provider website for the latest information. (https://medicareproviders.cigna.com/).    

Given the COVID-19 circumstances, Cigna is not requiring authorizations for treatment services with a COVID-19 diagnosis code or SARS-CoV-2 testing.  The initial clinical review is waived, however, authorization requirements still apply for these services: Home Health, SNF, LTAC and Inpatient Rehab. 

PCPs Referrals 

Waived   

PCP Capitation    

TBD

Urgent Care    

Must use appropriate diagnosis codes -  see table (view PDF). 

Time period  

December 31, 2020

Helpful Links

Visit the Cigna website.

Community Behavioral Health

Member Cost Share

TBD    

Telemed/Health Billing Requirements    

Starting 4/1 - use POS 99  for telehealth services.  

UPDATE (5/18/2020): Starting 6/15/2020, when services are delivered to a CBH member via telehealth, we ask that your billing department use Place of Service (POS) code 02 instead of 99 on the claim form. Please continue to utilize the 99 POS code on all claims submitted prior to June 15, 2020 to denote any services performed via telehealth before transitioning to 02 POS for telehealth on that date.

Lab Admin Codes for Testing   

TBD

Swab collection codes - Physicians  

 TBD

Transition of Care (cpt 99495-99496) and Annual Wellness Visits codes (G0402 and G0438, G0439) permissible to bill under Telehealth policy     

TBD

Telehealth Criteria (two-way, telephonic or both)    

Telehealth is not on any provider's schedule A.  You will continue to bill services as usual.  Just make sure somewhere in your system you note that these were telehealth services.

Reimbursement    

Per agreement.

Claim Submission  

Standard practice.

Pre-Authorization 

Acute Services (AIP, APHP, CMIS, SAIP, Crisis Residence, Enhanced Staffing, Private Rooms)

  • Contact the PES line or assigned CCM for the initial authorization number
  • Initial review and concurrent review are suspended
  • Providers must remain in contact with the assigned CCM to ensure that authorizations are open and active for individuals who are in treatment in these services
  • Upon discharge review, the assigned CCM will ensure authorization reflects the length of stay
  • Substance Use Services (ASAM 2.5, 3.1, 3.5R, 3.5H, 3.7WM, 4, 4WM, RINT)
  • Contact the PES line or assigned CCM for the initial authorization number
  • Initial review and concurrent review are suspended
  • Providers must remain in contact with the assigned CCM to ensure that authorizations are open and active for individuals who are in treatment at the facility
  • Upon discharge review, the assigned CCM will ensure that authorization reflects the length of stay
  • Residential Treatment Facilities (RTF, RTFA, CRR-HH, EAC, AMHR, LTSR)
  • Prior authorizations will remain; concurrent reviews will be suspended
  • Authorizations will be extended as needed by the CCM to ensure they are open and active for individuals who are in treatment at the facility


Targeted Case Management

  • Prior authorizations will remain; concurrent reviews will be suspended
  • Providers must ensure that authorizations remain open and active for individuals who remain in treatment in these services
  • Community-Based Services (BHRS, IBHS, ABA, FBS, FFT, MST-PSB)
  • Current authorizations will be extended until August 30th, 2020 (all services except initial assessment and treatment); providers wishing to opt-out of the extension must notify their provider representative by May 30, 2020
  • Submit Written Order (BHRS, IBHS, ABA) or Referral Form and Evaluation (FBS) to the CBH secure web server or via fax to obtain an authorization number
  • New written Orders for BHRS and IBHS should only be made for authorizations through the summer, not to exceed the first day of school

Out of Network (OON) Services

  • Remain Fee-for-Service (FFS)
  • Prior authorizations will remain; concurrent reviews will be suspended
  • Providers must remain in contact with the assigned CCM to ensure that authorizations are open and active for individuals who are in treatment at the facility
  • Upon discharge review, the assigned CCM will ensure that authorization reflects the length of stay


PCPs Referrals 

No change to current practice.   

PCP Capitation  

TBD 

Urgent Care    

TBD 

Time period

Update: Telehealth extended to 12/3/2020. 

Helpful Links

Visit the Community Behavioral Health website. 

Gateway

Member Cost Share  

Waived-Effective March 1, 2020

Gateway Health has identified the following as COVID-19 diagnosis codes:  Dates of Service 3/1/20 – 3/31/20: Z03.818, Z20.828, Z11.59, U07.1 

Dates of Service 4/1/20 to present:  Z03.818, Z20.828, Z11.59, U07.1

When COVID-19 meets the definition of principal diagnosis, code U07.1, COVID-19, should be sequenced first, followed by the appropriate codes for associated manifestations, except in the case of obstetrics patients for COVID-19 in pregnancy, childbirth, and the puerperium.

During pregnancy, childbirth or the puerperium, a patient admitted (or presenting for a health care encounter) because of COVID-19 should receive a principal diagnosis code of O98.5-, Other viral diseases complicating pregnancy, childbirth and the puerperium, followed by code U07.1

View the Covid19 Claim Guidance for additional Claim Submission Details (Download PDF)

Telemed/Health Billing Requirements  

 Criteria:  A brief (5-10) minute check-in via telephone or telecommunication device to decide if an office visit or other service is required. For established patients only.

G2010 & G2012 E&M with GT or  95 Modifier as appropriate and Place of service 02

Lab Admin Codes for Testing

U0001 & U0002 or 87635

Swab collection codes - Physicians    

TBD

Transition of Care (cpt 99495-99496) and Annual Wellness Visits codes (G0402 and G0438, G0439) permissible to bill under Telehealth policy     

99495,99496 and AWV codes (G0438/G0439) w/ POS 02.
 
Code G0402 is for an Initial Preventative Exam which is offered only once when the member initially enrolls in Medicare and is not part of the Annual Wellness benefit; it is not offered thru Telemedicine currently.

Telehealth Criteria (two-way, telephonic or both)    

Telephonic encounters allowed.

Reimbursement    

Per agreement.

Claim Submission    

Standard practice.

Pre-Authorization  

Waived. 

PCPs Referrals    

No change to current practice.

PCP Capitation 

TBD

Urgent Care    

TBD

Time period  

Effective March 1, 2020, cost-sharing (i.e. copays, deductible, or coinsurance) for all inpatient and outpatient medical services related to COVID-19 will be waived for Gateway Health Pennsylvania Medicaid and Part C Services for Medicare Assured lines of business. Confirming effective dates (i.e., expirations, etc) with payer.

Helpful Links

N/A

Geisinger

Member Cost Share 

GHP has waived member cost-sharing for testing and treatment of COVID-19:   

  • Members will not pay for a COVID-19 test. Members will also not pay a visit fee to a PCP, urgent care center, or ER if they are tested for COVID-19.  
  • If a member is hospitalized for COVID-19, all in-network, inpatient treatment costs will be waived.
  • Cost-sharing is also temporarily waived on all telehealth visits with participating providers, for medical or behavioral health needs, whether or not the visit is COVID-19 related,  will be waived through December 31, 2020. 

Telemed/Health Billing Requirements 

Providers will typically bill an E&M service (99213, 99214, etc.) along with location code 02 which is for telehealth services.

  • Virtual check-ins will be billed using HCPCs code G2012. 
  • Online digital E/M codes will be billed using 99421, 99422 or 99423.
  • Codes G2061, G2062 and G2063 will be billed for online patient assessments provided by qualified non-physician health care professionals. 
  • Modifiers (GT, G0, GQ, 95) are to be appended as applicable.

Please note, under standard guidelines, CPT codes 99441-99443 and CPT codes 98966-98968 are bundled in nature and not reimbursed by Medicare.  However, due to the current emergency, we have lifted the bundle denial on these services and have set these codes up to pend for manual review by the Reimbursement Services team. These codes will be cross-walked to standard E&Ms based on the level of service as well as based on if a physician or other qualified non-physician performs the service.

Lab Admin Codes for Testing  

U0001 & U0002  Diagnostic testing codes

Providers should report U0003 for services that would normally be reported using CPT code 87635.

Providers should report U0004 for services that would normally be reported using code U0002.     Codes to use for antibody testing

COVID-19 specific codes:

  • 86328 Single step method (e.g. reagent strip
  • 86769 Multi-step method (e.g. ELISA, etc.)

Swab collection codes - Physicians    

TBD

Transition of Care (cpt 99495-99496) and Annual Wellness Visits codes (G0402 and G0438, G0439) permissible to bill under Telehealth policy     

Medicare has approved the initial Annual Wellness Visit (AWV) code G0438 as a telehealth service. GHP will also accept subsequent AWV code G0439 as a telehealth service for Geisinger Gold members.

Telehealth Criteria (two-way, telephonic or both)

Telephonic encounters allowed.

Reimbursement  

Per agreement. 

Claim Submission    

Standard practice.

Pre-Authorization

Prior authorization will not be a barrier for any COVID-19 related testing or treatment. GHP will not subject COVID-19 related testing or treatment to prior authorization.    

PCPs Referrals  

No change to current practice.

PCP Capitation    

TBD

Urgent Care   

TBD 

Time period 

March 6 -  December 31, 2020

  • 99441, 99442 & 99443 – still awaiting further instruction from CMS – these are not reimbursed by Medicare – GHP will not be adding these codes to fee schedules, however, we will set these codes up to pend for manual pricing so they will not deny. This will also apply to code 98966, 98967, 98968
  • 99421, 99422 & 99423 are on fee schedules – CMP 14
  • Modifiers do not change reimbursement, they are informational
      

Helpful Links

Visit the Geisinger website. 

Additional Guidance

  • Rehab services (PT/OT) – telehealth for these services appears to be included in the temporary CMS guidelines.  Specific coding may be required.  This is being researched further.• If providers don't have capabilities, they should refer to a reputable virtual care company. I.e. Teladoc
  • Edits for tele will be lifted. ex. G codes - temporary
  • Claims may deny or not pay correctly at first due to set up timing but will pay. Configuration is happening daily.
  • The practitioner types that can provide services through telehealth will not be limited to psychiatrists, licensed psychologists, Certified Registered Nurse Practitioners and Physician Assistants certified in mental health; Licensed Clinical Social Workers; Licensed Professional Counselors; and Licensed Marriage and Family Therapists. Other individuals providing necessary behavioral health services will be permitted to utilize telehealth for services that are within their scope of practice.  – this is a temporary lift of regulation restriction "
     
Health Partners Plan

Member Cost Share    

Waived,

Telemed/Health Billing Requirements    

E&M w/appropriate modifier 95 or GT. Will accept POS 11

Lab Admin Codes for Testing   

U0001 & U0002  

Swab collection codes - Physicians  

If the swab collection is performed in the office, use 99000 or 99001 as appropriate.

  •  99000  - Handling and/or conveyance of specimen for transfer from the office to a laboratory
  • 99001 - Handling and/or conveyance of specimen for transfer from the patient in other than an office to a laboratory (distance may be indicated)

 

Transition of Care (cpt 99495-99496) and Annual Wellness Visits codes (G0402 and G0438, G0439) permissable to bill under Telehealth policy

99495, 99496, G0438-G0439, with GT or 95 modifiers as appropriate.  G0402- not allowed.      

Telehealth Criteria (two-way, telephonic or both)    

Telephonic encounters allowed.

Reimbursement    

Per agreement.

Claim Submission    

Standard practice.

Pre-Authorization

Waived.    

PCPs Referrals  

TBD  

PCP Capitation  

TBD  

Urgent Care 

Yes   

Time period    

4/9/2020 Update: In effect for the duration of the pandemic.

Horizon

Member Cost Share  

 Waived for COVID-19 Related Services

Telemed/Health Billing Requirements

E&M with GT or 95 Modifier as appropriate and Place of service 02. Horizon BCBSNJ is prepared to accept the following codes for audio-only telehealth services: 

  • 99441
  • 99442
  • 99443

Consistent with previous announcements, Horizon BCBSNJ will continue to accept claims for telemedicine services when modifiers 95 or GT are appended to CPT® or HCPCS codes that ordinarily describe face-to-face services including but not limited to:

  • Professional services related to diagnosis or treatment of COVID-19 
  • Routine care
  • Therapy
  • Mental health care

Lab Admin Codes for Testing     

U0001, U0002 and 87635 for reporting SARS-Co-V-2 testing. Laboratories and providers should submit claims as you currently do today and follow the standard claims processing procedures.

Swab collection codes - Physicians  

Use standard swab collection codes with COVID-19 diagnosis codes.

Transition of Care (cpt 99495-99496) and Annual Wellness Visits codes (G0402 and G0438, G0439) permissible to bill under Telehealth policy     

The following lists of codes is provided as an informational tool only, to help identify some of the applicable CPT® codes/code ranges and HCPCS codes that may be utilized in reporting telemedicine services. The inclusion of a specific code does not indicate eligibility for coverage in all situations.

CPT Codes
90785, 90863, 96116, 90791-90792, 90832-90838, 90839-90840, 90845-90847, 90951-90961, 90963-90966, 90967-90970, 96150-96154, 96160-96161, 97802-97804, 99201-99205, 99211-99215, 99231-99233, 99241-99245, 99251-99255, 99307-99310, 99354-99357, 99406-99407, 99408-99409, 99495-99496, 99497-99498
 

Telehealth Criteria (two-way, telephonic or both)    

Telephonic encounters allowed.

Reimbursement 

Ensuring provider reimbursements are consistent with existing policies.

  • For covered services rendered by common video platforms, providers will be reimbursed at the same rates as if the service was provided in office. 
  • Mental health service professionals are reminded that Horizon BCBSNJ maintains an open network for mental health professionals and these professionals are encouraged to join our network   

Claim Submission    

Standard claims processing procedures.

Pre-Authorization    

Waived.

PCPs Referrals  

TBD  

PCP Capitation    

TBD

Urgent Care    

S9038 with COVID-19 diagnosis codes.

Time period   

March 13 - June 30, 2020  

Update: TeleHealth policy extended to 12/31/2020  ***Update*** Horizon BCBSNJ will continue to waive member cost-sharing for in-network telemedicine and telehealth visits for at least 90 days after the end of the public health emergency and State of Emergency declared by the Governor. This applies to all covered services..member cost-sharing for COVID-19 testing for at least 90 days after the end of the public health emergency and State of Emergency declared by the Governor. Members will pay no deductible, copay or coinsurance for COVID-19 testing for diagnostic purposes determined to be medically appropriate by the individual’s health care provider, in accordance with CDC guidelines. Testing for public health surveillance purposes or for employment purposes is not covered

Helpful Links

Visit the Horizon website.

Independence Blue Cross

Member Cost Share  

Waived for all telemedicine PCP visits; Regular cost-sharing will apply to all specialists and ancillary telemedicine services not related to COVID-19 testing.

For high-deductible health plan (HDHP) members, cost-sharing will be waived for COVID-19 testing and primary care telemedicine visits and will be covered before the deductible.  Self-funded customers can opt-out of waiving PCP cost-sharing for non-COVID related telemedicine visits.

However, for self-funded health plans, coverage of telemedicine services is provided for COVID-19 testing without member cost-sharing consistent with the federal Families First law.

Telemed/Health Billing Requirements    

PCP/Specialist :99201-99205, 99211-99215, 99421-99423 & 99441-99443 (E&M); Behavioral Health: 90785, 90791-90792, 90832-90834, 90837-90840, 90846-90847, 99201-99205, 99211-99215, 99231-99233, 99307-99310, 99354-99357, 97151, 97155-97156, G0406-G0408, G0425-G0427, G0459; Medical Nutrition Therapy: 97802, 97803, G0270; PhysicalOccupational Therapy: 97110, 97112, 97116, 97129, 97130, 97161-97168, 97530, 97533, 97535; Speech Therapy: 92507-92508, 92521-92524, 92907-92609, 97129-97130, G0153, G0161, S9128, S9152; Urgent Care: S9083; w/POS 02. GT or 95 modifier not required.  PCPs will need to submit an encounter claim (837P) in order to be compensated for copayments.  Commercial members: Eligible providers performing telemedicine services must report the appropriate modifier (Modifier GT or 95) and place-of-service (POS) code 02 (Telehealth) to ensure payment of eligible telemedicine services.

Telemedicine services performed through telephone communication only must report the appropriate POS code 02 (Telehealth) to ensure payment. Use of Modifier GT or 95 will not be required.

Medicare Advantage members: Eligible providers performing telemedicine services must report the appropriate POS code 02 (Telehealth) to ensure payment of eligible telemedicine services.                                                          

Additional Billing Requirements:

  • Eligible professional providers performing telemedicine services must report the appropriate modifier (modifiers GT or 95) and place-of-service (POS) code 02 (Telehealth) to ensure payment of eligible telemedicine services.
  • Telemedicine services performed through a telephone or online digital communication must report the appropriate place of service 02 (Telehealth) to ensure payment. Use of modifiers GT or 95 will not be required.
  • Telemedicine evaluation and management reported by facilities billing on a UB-04 claim form, or the equivalent form 837i, should report revenue code 0780 along with an appropriate evaluation and management procedure code appended by the GT or 95 modifier, as needed.
  • Telemedicine ancillary services (e.g. PT/OT/ST) reported by facilities billing on a UB-04 claim form, or the equivalent form 837i, should report the appropriate revenue code (shown below) along with the corresponding procedure code representing the service provided appended by the GT or 95 modifier, as needed.
  • Inclusion of a code in this News Article does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

Lab Admin Codes for Testing

Diagnostic testing U0001 & U0002 after 2/4/20; U0003-U0004 after 4/14/20; 87635 as of 3/13/2020; Antibody testing, 86328 & 86769 as of 4/10/2020; LABORATORY TESTING FOR COVID-19 DIFFERENTIAL DIAGNOSIS 86603, 86710, 86756, 87260, 87275, 87276, 87279, 87280, 87301, 87400, 87420, 87501, 87502, 87503, 87631, 87632, 87633, 87634, 87804, 87807, 87809    

Swab collection codes - Physicians   

HCPCS codes C9803, G2023 and G2024 for collection of SARS-CoV-2 (COVID-19) specimens, including nasopharyngeal swab (NP), oropharyngeal swabs (OP), serum, plasma, or venipuncture whole blood, are effective and must be used for dates of service as of March 1, 2020 and after.  SPECIMEN COLLECTION FOR COVID-19 DIFFERENTIAL DIAGNOSIS LABORATORY TESTING S9529, 36400, 36405, 36406, 36410, 36415, 36425, 36420

See policy Testing for SARS-CoV-2 (Coronavirus Disease 2019 (COVID-19)) - Updated May 13, 2020  for full details. 

Transition of Care (cpt 99495-99496) and Annual Wellness Visits codes (G0402 and G0438, G0439) permissable to bill under Telehealth policy  

These codes are valid for telehealth on CMS, awaiting confirmation of payer-specific rules.   New public health emergency telehealth incentive:

  • This new incentive is effective April 15, 2020, and will continue throughout the duration of the national public health emergency, plus an additional 30 days.
  • Earn $150 when you submit a claim/encounter for a telehealth visit. The telehealth visit must be completed with both audio and visual features. During the visit, providers should review current conditions and symptoms, medications, test results, chronic conditions, and overall health status. The codes that qualify are:
    • G0438: Annual Wellness Visit, initial visit
    • G0439: Annual Wellness Visit, subsequent visit

 Remember, the telehealth claim/encounter must report the appropriate place-of-service code 02 (Telehealth).

  • Only Medicare Advantage members on your panel are eligible for this new incentive.
  • Only one incentive payment of $150 will be paid per member.
  •  Payments will be issued on a monthly basis after the claim is processed.  Existing ePASS® incentive:
  • Earn an additional $175 when you submit an initial electronic SOAP (Subjective, Objective, Assessment, Plan) Progress Note after either a face-to-face or telehealth audio and visual encounter.


ePASS® is still available for you to submit SOAP Progress Notes and is now also accepting telehealth encounters. It is important to document the member’s current and chronic conditions in the assessment and to perform a complete assessment, albeit without the benefit of in-person vital signs. System reviews, current and chronic conditions, new symptoms, test results, and medication reviews should all be part of the telehealth encounter.

  • The ePASS® visit must be conducted with both audio and video features to be eligible for payment.
  • One ePASS® incentive will be paid per member.   

Telehealth Criteria (two-way, telephonic or both)    

Telephonic encounters allowed - View IBC Telemedicine Delivery (PDF Download)

Reimbursement 

Reimbursement will be at the same level as the current applicable contracted office fee schedule for a standard in-office visit including up to level 5 evaluation and management.   

Claim Submission   

Standard practice  

Pre-Authorization

6 monts see details on the Utilization Review Guidline COVID 19 grid (PDF Download)   

PCPs Referrals    

TBD

PCP Capitation    

For products with capitation arrangements, services delivered through telemedicine are considered included in capitation with the exception of those services identified in applicable policies identifying fee for service reimbursement.

Urgent Care   

S9083 - audiovisual only 

Time period    

3/6/2020 - 12/31/2020: Medicare Advantage extended through the duration of the public health emergency   

Helpful Links

View the IBC Medical Policies Website information.

View the IBC Provider News Center.

Keystone First

Member Cost Share    

Cost-sharing does not apply to COVID-19 related services.

Telemed/Health Billing Requirements  

Place of service 02 and modifier GT must be appended to the E&M codes listed: 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214 & 99215

Lab Admin Codes for Testing    

U0001, U0002, U0003, U0004

Swab collection codes - Physicians   

TBD

Transition of Care (cpt 99495-99496) and Annual Wellness Visits codes (G0402 and G0438, G0439) permissible to bill under Telehealth policy

Per Keystone First, awaiting further guidance from leadership.    

Telehealth Criteria (two-way, telephonic or both) 

Telephonic encounters allowed  

Reimbursement    

Per agreement.

Claim Submission  

 Standard practice. 

Pre-Authorization    

Waived.

PCPs Referrals    

No change to current process.

PCP Capitation    

Payment not billable above capitation

Urgent Care

TBD    

Time period    

90 days beginning March 6, 2020--- coverage will continue while a valid disaster declaration by the Governor related to the COVID19 virus remains in effect.

Helpful Links

View the Keystone First Fast Facts memo (Download PDF)

Keystone First VIP

Member Cost Share   

Cost-sharing does not apply for Part B COVID-19 testing-related services, which are medical visits that: are furnished between March 18, 2020 and the end of the COVID-19 Public Health Emergency (PHE); that result in an order for or administration of a COVID-19 test; are related to furnishing or administering such a test or to the evaluation of an individual for purposes of determining the need for such a test, and are in any of the following categories of HCPCS evaluation and management codes:

  • Office and other outpatient services
  • Hospital observation services
  • Emergency department services
  • Urgent care centers
  • Nursing facility services
  • Domiciliary, rest home, or custodial care services
  • Home services
  •  Online digital evaluation and management services
  • Telehealth visits

Providers should use the CS modifier on applicable claim lines to identify the service as subject to the
cost-sharing waiver for COVID-19 testing-related services.

Telemed/Health Billing Requirements

As of March 6, 2020 Keystone First VIP Choice has expanded telehealth in compliance with new CMS guidance, to include coverage in all areas (not just rural), in all settings, the use of popular video chat applications, and the increase of allowed services. Please note, when billing professional claims for non-traditional telehealth services bill with the Place of Service (POS) equal to
what it would have been in the absence of the COVID-19 Public Health Emergency (PHE), along with a modifier 95, which indicates the service rendered was actually performed via telehealth. There are also options for Virtual Check-ins and E-Service. 

Lab Admin Codes for Testing     

Use of CPT code 87635 or HCPCS code U0002 for the non- CDC diagnostic lab test, depending on the method used or HCPCS code U0001 for the CDC diagnostic lab test. For tests performed with high throughput technologies, use HCPCS code U0003 for infectious agent detected by nucleic acid, amplified technique or HCPCS code U0004 any technique, multiple types, non-
CDC. Labs, physician offices, hospitals and other settings can bill for tests ordered that they perform.

Swab collection codes - Physicians    

For specimen collection use HCPCS codes G2023 or G2024 (for an individual in a skilled nursing facility or a lab on behalf of a home health agency).

Transition of Care (cpt 99495-99496) and Annual Wellness Visits codes (G0402 and G0438, G0439) permissible to bill under Telehealth policy   

See CMS codes effective 3-30-20 (Download PDF).

Telehealth Criteria (two-way, telephonic or both)    

Telephonic encounters allowed.

Reimbursement

Per agreement; sequestration does not apply 5/1/2020-12/31/2020.

Claim Submission   

Standard practice.  

Pre-Authorization    

No prior authorization is needed for our members to see out of network providers during the COVID-19 PHE. Please note however, prior authorization is still required for services that typically require authorization, such as inpatient admissions, certain DME, and MRIs.

PCPs Referrals    

No change to current process.

PCP Capitation 

Capitation applies to applicable services.   

Urgent Care

TBD    

Time period 

March 6, 2020:  Coverage will continue while a valid disaster declaration by the Governor related to the COVID19 virus remains in effect.   

Helpful Links

View the Keystone First Fast Facts (PDF Download).

View the CMS Provider Toolkit (PDF Download).

PA Health and Wellness

Member Cost Share 

Waived.  

Telemed/Health Billing Requirements 

E&M with GT / 95 Modifier and standard POS 11; 99201-99215, G0425-G0427, and G0406-G0408 for Medicare Telehealth Visits; G2010 or G2012 for virtual check-in w/ telephone; 99231-99233 and HCPCS codes G2061-G2063 for E-Check-In. 

Lab Admin Codes for Testing     

U0001 & U0002

Swab collection codes - Physicians    

TBD

Transition of Care (cpt 99495-99496) and Annual Wellness Visits codes (G0402 and G0438, G0439) permissible to bill under Telehealth policy   

CMS allows 99495, 99496,G0438-G0439, with GT and 95 modifiers, G0402 not allowed (awaiting confirmation from payer); need to check MA guidelines; PHW will follow Medicare guidance.

Telehealth Criteria (two-way, telephonic or both)    

Telephonic encounters allowed.

Reimbursement    

Per agreement.

Claim Submission    

Standard practice.

Pre-Authorization    

Waived.

PCPs Referrals 

No change to current process.   

PCP Capitation    

TBD

Urgent Care   

TBD 

Time period    

10/12/2020 Update:  HHS Secretary Alex Azar renewed the COVID-19 Public Health Emergency. This extends flexibilities and funding tied to the public health emergency (PHE) to continue through January 21, 2021. With this renewal, the various testing, screening, billing, and telehealth coverages that were implemented in response to the COVID-19 Public Health Emergency earlier this year will be extended to PA Health & Wellness members through late January, until the PHE is either terminated or extended again. This extension does not affect PA Health & Wellness’s additional Medicare coverages that are set to expire on December 31, 2020.

8/3/2020 Update: On July 23, 2020, HHS Secretary Alex Azar renewed the COVID-19 Public Health Emergency.  This extends flexibilities and funding tied to the public health emergency (PHE) to continue for another 90 days.

With this renewal the various testing, screening, billing, and telehealth coverages that were implemented in response to the COVID-19 Public Health Emergency earlier this year will be extended to PA Health & Wellness members through late October, until the PHE is either terminated or extended again. This extension does not affect coverages that had already been made effective through December 31, 2020. 

United Healthcare

Member Cost Share 

10/7/2020 Update: For Covid-19 Diagnostic Testing, Anitbody Testing and Testing Related Visits (Individual and Group Market fully insured health plans): From Feb. 4, 2020 (April 10, 2020 for Antibody Testing), through the national public health emergency period, currently scheduled to end Jan. 20 , 2021.

Covid-19 Treatment  (Individual and Group Market fully insured health plans): 

  • From Feb. 4, 2020 through Oct. 22, 2020, UnitedHealthcare is waiving cost sharing for in-network and out-of-network visits.
  • From Oct. 23, 2020 through Dec. 31, 2020, UnitedHealthcare is waiving cost sharing for in-network visits.
  • Starting Oct. 23, 2020, out-of-network coverage will be determined by the member’s benefit plan.
  • State regulations apply to Medicaid.

See detailed guidance effective 10/1/2020 (Download PDF).

7/24/2020 Update: Cost share for Covid-19 treatment services will be waived until 10/22/2020                      Applicable to in-network telehealth services for COVID-19 and non-COVID-19-related visits for medical, outpatient behavioral and PT/OT/ST services from 3/31/2020 through 10/22/2020

Update Individual/Group Market Plan: For COVID-19 related visits, cost sharing will be waived for
in-network telehealth services from March 31, 2020 through 10/22/20  For non-COVID-19 visits, cost
sharing will be waived for in-network telehealth services from March 31, 2020 through 10/22/20.                   Medicaid plans - waived through 10/22/20 

Cost sharing will be waived for testing and testing-related services when billed with diagnosis codes Z03.818 or Z20.828, Covid-19 specific specimen collection and specimen collection, along with appropriate ICD-10 code Z03.818 or Z20.828, if not billed with separate E&M charges.

Telemed/Health Billing Requirements    

11-18-2020 Update: 
Standard E&M Code.  

  • Bill with appropriate E&M code.
  • Use ICD-10 diagnosis code Z03.818 for suspected exposure to COVID-19, or
  • Use ICD-10 diagnosis code Z20.828 for exposure to a confirmed case of COVID-19.

99201-99205, 99212-99215, 99231-99233, 99354 -99355, 99406-99409 (E&Ms) with GT, GQ or 95 Modifier as appropriate.  Use the place of service that would have been reported had the service been furnished in person (11, 20, 22, 23)-see "Covid 19 guidance from UHC tab"  for various scenarios. 

See detailed guidance effective 10/1/2020 (Download PDF).

Lab Admin Codes for Testing     

11/18/2020 Update:

Testing Related Services: ICD-10 Code: Z03.818, Z20.828

  • Cost share will be waived for testing-related serviceswhen billed with diagnosis codes Z03.818 or Z20.828. Place of Service: (23)Emergency room, (20)Urgent care, (11)Office visits/telehealth, (02)Telehealth as of Jan. 1, 2021

Billing:

  • Z03.818 for suspected exposure to COVID-19, 
  • Z20.828 for exposure to a confirmed case of COVID-19.

Specimen Collection Update: Same as below, also note C9803 for Outpatient Hospital Facility only.

Covid-19 Lab Testing Update:
Virus Detection Tests: HCPCS/CPT Codes: U0001, U0002, U0003, U0004, 87635. In order to bill these codes, the laboratory must use a test that is developed and administered in accordance with the specifications outlined by the U.S. Food and Drug Administration (FDA) or through state regulatory approval. In addition:

  • U0001, U0002 or 87635: Laboratories must have a valid CLIA ID.
  • U0003 and U0004: Laboratories must have a valid CLIA ID, as well as CLIA Accreditation, Compliance or Registration certification level.

• Use ICD-10 diagnosis code Z11.59 for billing COVID-19 testing for asymptomatic patients prior to inpatient admissions, planned outpatient procedures and immunosuppressant therapies.

Antibody Tests:  CPT Codes: 86328 or 86769. FDA-authorized tests include FDA-approved tests and tests used in an office or lab that are developed and administered in accordance with FDA specifications or through state regulatory approval.

Antigen Tests: CPT Code: 87426. Use code 87426 for infectious agent antigen detection by immunoassay technique.
 

U0001 & U0002 or 87635 

6/25/2020 Update: U0001,U0002,U0003,U0004 or 87635. Antibody Tests: 86328 or 86769. (Specimen Collection): G2023 and G2024. CPT code 99001.

Swab collection codes - Physicians    

If the specimen is collected somewhere other than a physician office, bill CPT code 99001

Transition of Care (cpt 99495-99496) and Annual Wellness Visits codes (G0402 and G0438, G0439) permissable to bill under Telehealth policy     

99495 and 99496 w/ Modifier 95; AWVs - G0402, G0438, G0439.

Telehealth Criteria (two-way, telephonic or both)    

Telephonic encounters allowed.

Reimbursement    

Per agreement.

Claim Submission    

Per UHC, Hold claims until April 1, 2020.

Pre-Authorization

Waived.    

PCPs Referrals 

No change to current process.  

PCP Capitation  

Paid as bill above capitation. 

Urgent Care  

TBD  

Time period   

COVID-19 Testing

From Feb. 4, 2020 through the national public health emergency period, currently scheduled to end Jan. 20, 2021, UnitedHealthcare is waiving cost sharing for in-network and out-of-network testing-related telehealth visits.

COVID-19 Treatment

From Feb. 4, 2020 through Dec. 31, 2020, UnitedHealthcare is waiving cost sharing for in-network telehealth treatment visits.

Out-of-network cost-share waivers will end Oct. 22, 2020. Starting Oct. 23, 2020, coverage for out-of-network services will be determined by the member’s benefit plan. Implementation for self-funded customers may vary.

Non-Covid
For in-network providers, UnitedHealthcare extended the cost share waiver for telehealth services through Sept. 30, 2020. For out-of-network providers, the cost share waiver for telehealth services does not apply.
As of Oct. 1, 2020, benefits will be adjudicated in accordance with the member’s benefit plan.

State regulations apply for Medicaid. If no state guidance was provided, the cost share waiver ended June 18, 2020.

Helpful Links

See detailed guidance effective 10/1/2020 (Download PDF).

UPMC

Member Cost Share   

Waived

Update: UPMC will waive all member cost sharing—including deductibles and copayments— for virtual health care visits with in-network providers until December 31, 2020

See AMA COVID 19 Guidance from UPMC (PDF Download).

UPMC will waive all member cost sharing—including deductibles and copayments— for virtual health care visits with in-network providers until September 30, 2020

Telemed/Health Billing Requirements    

G2012 with POS 02  - Per payer use these guidelines during 90-day no cost-share benefit period for COVID-19

See AMA COVID 19 Guidance from UPMC (PDF Download) for various scenarios. 

Lab Admin Codes for Testing    

U0002 or 87635 only  

Swab collection codes - Physicians   

If the specimen will be prepared by the office and sent to an outside lab, use code 99000.

Transition of Care (cpt 99495-99496) and Annual Wellness Visits codes (G0402 and G0438, G0439) permissible to bill under Telehealth policy

9495, 99496,G0438-G0439, with GO, GQ, GT or 95 modifiers, G0402 not allowed.

Telehealth Criteria (two-way, telephonic or both)    

Telephonic encounters allowed.

Reimbursement   

Per agreement.

Claim Submission   

Standard practice. 

Pre-Authorization   

Waived. 

PCPs Referrals 

No change to current process.

PCP Capitation  

TBD  

Urgent Care   

TBD

Time period   

Current: December 31, 2020 or as outlined in the  AMA COVID 19 Guidance from UPMC (PDF Download).

Additional Guidance

UPMC Health Plan is waiving all deductibles, coinsurance, and copayments for in-network, inpatient COVID-19 treatment for members enrolled in a fully insured group, ACA, and Medicare Advantage plans. This policy change will stay in effect through June 15, 2020

See AMA COVID 19 Guidance from UPMC (PDF Download).

Medicare FFC

Member Cost Share  

Waived.  

Telemed/Health Billing Requirements    

10-14-2020 Update:  CMS is adding 11 new services to the Medicare telehealth services list since the publication of the May 1, 2020, COVID-19 Interim Final Rule with comment period (IFC). Medicare will begin paying eligible practitioners who furnish these newly added telehealth services effective immediately, and for the duration of the PHE. These new telehealth services include certain neurostimulator analysis and programming services, and cardiac and pulmonary rehabilitation services. 

View these newly added services.

E/M w/ POS 11,  Modifier 95 - recent change per CMS

Lab Admin Codes for Testing    

U0001 & U0002

Swab collection codes - Physicians    

(2020-06-18-MLNC) 

Physicians and Non-Physician Practitioners (NPPs): Here are several reminders related to billing for COVID-19 symptom and exposure assessment and specimen collection performed on and after March 1, 2020:

  • Use CPT code 99211 to bill for assessment and collection provided by clinical staff (such as pharmacists) incident to your services, unless you are reporting another Evaluation and Management (E/M) code for concurrent services. This applies to all patients, not just established patients.
  • Submit the CS modifier with 99211 (or other E/M code for assessment and collection) to waive cost-sharing.
  • Contact your Medicare Administrative Contractor if you did not include the CS modifier when you submitted 99211 so they can reopen and reprocess the claim.
  • We will automatically reprocess claims billed for 99211 that we denied due to place of service editing.

Transition of Care (cpt 99495-99496) and Annual Wellness Visits codes (G0402 and G0438, G0439) permissible to bill under Telehealth policy     

 99495, 99496,G0438-G0439, with modifier 95. G0402 not allowed.

Telehealth Criteria (two-way, telephonic or both)  

Telephonic encounters allowed 

Reimbursement    

Paid at the same rate as if the service was rendered face-to-face.

Claim Submission 

Standard practice.   

Pre-Authorization    

Waived.

Medicaid FFC

Member Cost Share    

Waived. 

Telemed/Health Billing Requirements   

E/M w/ GT & POS 11 as appropriate. POS 02 not allowed. Providers must document in the beneficiary’s record the service was rendered via telemedicine. 

Lab Admin Codes for Testing     

U0001 & U0002

Swab collection codes - Physicians  

TBD  

Transition of Care (cpt 99495-99496) and Annual Wellness Visits codes (G0402 and G0438, G0439) permissible to bill under Telehealth policy  

TBD 

Telehealth Criteria (two-way, telephonic or both)  

Telephonic encounters allowed 

Reimbursement  

Paid at the same rate as if the service was rendered face to face at an enrolled location.  

Claim Submission

Standard practice.    

Pre-Authorization   

Waived.