COVID-19 Guidance

Updated 7/14/2020

As a valued partner, we want to keep you updated with the latest information around the novel coronavirus and its resulting illness COVID-19. We appreciate your partnership during this time of great need as we focus on our shared goal of delivering quality, accessible and affordable healthcare to our members.

Coronavirus disease 2019 (COVID-19) is an emerging illness. Many details about this disease are still unknown, such as treatment options, how the virus works, and the total impact of the illness. New information, obtained daily, will further inform the risk assessment, treatment options and next steps. We always rely on our provider partners to ensure the health of our members, and we want you to be aware of the tools available to help you identify the virus and care for your patients during this time of heightened concern.

General Guidance:

• Know the warning signs of COVID-19. Patients with COVID-19 have reported mild to severe respiratory symptoms. Symptoms include fever, cough, and shortness of breath. Other symptoms include fatigue, sputum production, and muscle aches.  Some individuals have also experienced gastrointestinal symptoms, such as diarrhea and nausea, prior to developing respiratory symptoms.
• However, be aware that infected individuals can be contagious before symptoms arise. Symptoms may appear 2-14 days after exposure.
• Instruct symptomatic patients to wear a surgical or isolation mask and promptly place the patient in a private room with the door closed.
• Health care personnel encountering symptomatic patients should follow contact precautions, airborne with N95 precautions, and wear eye protection and other personal protective equipment.
• Refer to the CDC’s criteria for a patient under investigation for COVID-19.  Notify local and/or state health departments in the event of a patient under investigation for COVID-19. Maintain a log of all health care personnel who provide care to a patient under investigation.
• Monitor and manage ill and exposed healthcare personnel.
• Safely triage and manage patients with respiratory illness, including COVID-19.  Explore alternatives to face-to-face triage and visits as possible, and manage mildly ill COVID-19 cases at home, if possible.

Take Action:

1. Be alert for patients who meet the criteria for persons under investigation and know how to coordinate laboratory testing.
2. Review your infection prevention and control policies and CDC's recommendations for healthcare facilities for COVID-19.
3. Know how to report a potential COVID-19 case or exposure to facility infection control leads and public health officials. Contact your local and/or state health department to notify necessary health officials in the event of a person under investigation for COVID-19.
4. Refer to the Centers for Disease Control and Prevention (CDC) and the World Health Organization for the most up-to-date recommendations about COVID-19, including signs and symptoms, diagnostic testing, and treatment information.
5. Be familiar with the intended scope of available testing and recommendations from the FDA.

We are closely monitoring and following all guidance from the Centers for Medicare and Medicaid (CMS), the Florida Department of Health (DOH), the Agency for Health Care Administration (AHCA), and all other applicable agencies as it is released to ensure we can quickly address and support the prevention, screening and treatment of COVID-19. We will cover all medically necessary services required to facilitate testing and treatment of COVID-19.  This guidance is in response to the current COVID-19 pandemic and may be retired at a future date. For additional information and guidance on COVID-19 billing and coding, please visit the resource centers of the Centers for Medicare and Medicaid (CMS) and the American Medical Association (AMA).

REMINDER: per AHCA policy, providers cannot charge patients for Personal Protective Equipment (PPE) used during the delivery of a Medicaid covered service. Additional information, including balanced billing prohibitions, is located in the Agency’s General Medicaid Policy.

The following guidance can be used to bill for services related to COVID-19 testing. Any specific plan requirements are noted.

COVID-19 Testing Services

Screening Services

• All member cost share (copayment, coinsurance and/or deductible amounts) will be waived for COVID-19 screening visits and if billed alongside a COVID-19 testing code.
• If no testing is performed, providers may still bill for COVID-19 screening visits for suspected contact using the following Z codes:
  • Z20.828: Contact with a (suspected) exposure to other viral communicable diseases
  • Z03.818: Exposure to COVID-19 and the virus is ruled out after evaluation
• This applies to services that occurred as of February 4, 2020.
• Providers billing with these codes will not be limited by provider type.

Treatment Services

• For dates of service from February 4, 2020 through March 31, 2020, providers should use the ICD-10 diagnosis code B97.29: Confirmed Cases – other coronavirus as the cause of diseases classified elsewhere.
• For dates of service of April 1, 2020 and later, providers should use the ICD-10 diagnosis code U07.1: 2019-nCov Confirmed by Lab Testing.
• As a reminder, only those services associated with screening and/or treatment for COVID-19 will be eligible for prior authorization and member liability waivers. For screening or treatment not related to COVID-19 normal copayment, coinsurance, and deductibles will apply.

Additional information:

• Providers should not use U0001-U0004 or 87635 for antibody testing.
• All member cost share (copayment, coinsurance and/or deductible amounts) will be waived across all plans for any claim billed with the new COVID-19 testing codes.
• We have configured our systems to apply $0 member cost share liability for those claims submitted utilizing these new COVID-19 testing codes.
• In addition to cost share, authorization requirements will be waived for any claim that is received with these specified codes.
• Providers billing with these codes will not be limited by provider type and can be both participating and non-participating.
• We will temporarily waive requirements that out-of-state Medicare and Medicaid providers be licensed in the state where they are providing services when they are licensed in another state.

Reimbursement Rates for COVID-19 Testing Services for All Provider Types*

• We are complying with the rates published on 3/12/20 by CMS for Medicare and Medicaid:
  • U0001 = $35.91
  • U0002 = $51.31
  • U0003 = $100.00
  • U0004 = $100.00
  • G2023 = $23.46
  • G2024 = $25.46
  • 87798 = $23.40
• We will follow these CMS published rates except where state-specific Medicaid rate guidance should supersede.
• Any additional rates will be determined by further CMS and/or state-specific guidance and communicated when available.

The remaining guidance applies to our Medicaid Providers

Prior Authorization

Service Authorizations for Hospital Transfers Temporarily Suspended

As of July 9, 2020, we will no longer require service authorizations for hospital transfers for Medicaid patients, including:

• inter-facility transfers
• transfers to a long-term care hospital
• transfers to a nursing facility

This applies when the receiving facility is a participating provider or non-participating provider. The receiving facility must notify us of the admission within forty-eight (48) hours of the admission.

Effective June 19, 2020, we will require a prior authorization for the following Medicaid services where prior authorizations had been temporarily waived due to COVID-19. These changes are consistent with Phase 2 of Governor Ron DeSantis’ Plan for Florida’s Recovery and guidelines from AHCA.

The following Medicaid services require prior authorization for dates of service on or after June 19, 2020:

• Hospital services (including long-term care hospitals)
• Nursing facility services
• Physician services
• Advanced practice registered nursing services
• Physician assistant services
• Home health services
• Ambulance transportation (except when related to transfers prior to admission, as noted above in the July 9, 2020 update)
• Durable medical equipment and supplies

Behavioral Health Exception

We will continue to waive prior authorization requirements and service limits for behavioral health services covered under the Medicaid program. This includes community behavioral health services, inpatient behavioral health services and targeted case management services. Prior authorizations on these services were waived effective May 5, 2020.

As the state continues reopening, we will continue to evaluate our policies to follow AHCA guidelines.

Please note: We will not expand services beyond those services already covered by the health plan. Any uncovered services will be denied. In addition, any services related to an elective procedure will be denied in accordance with the governor’s order to delay such services to ensure maximum capacity in our healthcare delivery systems for the critically ill.

For elective procedures where prior authorization was already received be the health plan, those authorizations will be extended six months from the last date in the approval window.

Fraud, Waste and Abuse

We will deny payment for any service provided by a provider who is prohibited from participation as a managed care plan provider. We may delay payment and require proof of medical necessity when:

• There is a compelling suspicion of fraudulent activity
• A provider was previously placed on pre-payment review due to aberrant billing activity
• Durable medical equipment requires customization

Limits on Services

We are waiving limits on medically necessary services (specifically related to frequency, duration and scope) that need to be exceeded in order to maintain the health and safety of members diagnosed with COVID-19 or when it is necessary to maintain a member safely in their home. Examples of services include: the 45-day hospital inpatient limit, home health services, durable medical equipment, in-home physician visits, $1,500 outpatient limit, etc.

When service limits have been exceeded for members receiving services, providers must submit medical necessity through our standard authorization process.

Pharmacy

We have lifted “refill too soon” edits on prescriptions to provide early refills on maintenance medications (excludes controlled substances).  We will reimburse for a 90-day supply of maintenance prescriptions. The member must request that the pharmacy dispense a 90-day supply. We are also allowing mail order delivery of maintenance prescriptions during the state of emergency and we will pay for a 90-day supply of maintenance prescriptions through mail order delivery.

Preadmission Screening and Resident Reviews (PASRR)

During the state of emergency, all PASRR processes are postponed until further notice provided by the Agency for Health Care Administration. During the state of emergency and until otherwise advised, we will not deny payment based upon the lack of completion of PASRR requirements for new admissions to a nursing facility.

Telemedicine

We are encouraging providers to use telemedicine services, as appropriate and allowable with the provider’s scope of practice, to be responsive to workforce shortages or to meet the needs of enrollees who are homebound or are being monitored in the home. For additional information on telehealth services, please refer to the separate COVID-19 Telehealth Bulletin on our web portal.

Questions?

If you have questions, please contact your Provider Relations representative or call Provider Services toll-free, Monday – Friday, 8 a.m. to 7 p.m.:

• Staywell Health Plan: 1-866-334-7927 (TTY 711)
• CMS Health Plan: 1-866-799-5321 (TTY 711)

Providers may also email Provider Relations at FloridaProviderRelations@wellcare.com.

Providers may experience higher than normal wait times when calling Provider Services so we encourage providers to use the web portal for eligibility, claims submission, etc.

We reserve the right to update this information and related processes based on continued developments related to the state of emergency for COVID-19 and/or direction from any applicable regulatory agency.

This guidance is in response to the current COVID-19 pandemic and may be retired at a future date.