3/27/2020
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Posted by Provider Relations
Coronavirus disease 2019 is a new and emerging illness in the United States. The virus causes a disease called COVID-19 that can lead to fever, cough and shortness of breath. There are thousands of confirmed cases in a growing number of countries internationally, and the virus is now spreading in the United States, including New York State. New information, obtained daily, further informs the risk assessment, treatment options, and next steps.
Fidelis Care is closely monitoring the developments across New York State and is following COVID-19 guidance from the New York State Department of Health (SDOH) and Department of Financial Services (DFS) guidance.
New York State has among the highest number of confirmed COVID-19 cases in the country. We are moving quickly to prioritize the health and safety of our employees as we care for the nearly 1.8 million members who rely on us for their health and well-being.
As we respond to this unprecedented and dynamic situation, Fidelis Care’s goals are to continue to serve our members and providers, minimize disruption, and support the health and safety of our employees.
As an important resource for providers, we encourage you to access the information on Fidelis Care’s provider portal at providers.fideliscare.org. On the portal, you can:
• check claim status
• confirm member eligibility and benefits
• submit authorization requests
• check on the status of an authorization
• view provider remittance advice
We also encourage you to use Fidelis Care’s Interactive Voice Response as another way to check claim status and member eligibility.
Using these tools and resources will provide you with the information you need, 24/7, and help to reduce anticipated call volume and wait times for our Provider Call Center.
Emergency Preparedness Plan
Providers should have an emergency preparedness plan in place for their facilities. The latest NYS-specific information can be found on the SDOH website at the following link: https://www.health.ny.gov/diseases/communicable/coronavirus/.
Authorizations: On March 20, 2020 DFS published the following regarding authorizations.
DFS’ guidance letter advises insurers that they should suspend the following requirements for 90 days:
- Pre-authorization review for scheduled surgeries or admissions at hospitals;
- Concurrent review for inpatient hospital services provided;
- Retrospective review for inpatient hospital services and emergency services provided at in-network hospitals;
- Pre-authorization review for home health care services and inpatient rehabilitation services following an inpatient hospital admission;
- To the extent currently required, pre-authorization review for inpatient rehabilitation services following an inpatient hospital admission for mental health and substance use disorders;
- Deadlines for hospitals to submit an internal or external appeal for a medical necessity denial; and
- Non-essential payment audits of hospitals and the timeframe for the insurer to recover overpayments.
Coverage and Copays: Some commercial laboratories and facilities have been granted approval to test for COVID-19. To ensure that cost-sharing is not a barrier to testing, Fidelis Care will cover services including testing for COVID-19 and for physician, clinic, urgent care, and emergency visits without copays, deductibles, or coinsurances for members when the purpose of the visit is testing for COVID-19, consistent with DFS an DOH guidelines.
Effective March 01, 2020, providers are responsible to ensure any copays, coinsurance, or deductible charges are waived for Fidelis Care members at the time of an office visit, urgent care visit, clinic, or emergency room visit when the purpose of that visit is testing for COVID-19. Claims with correct coding will be adjusted to reflect provider payments with $0 member liability upon processing. Providers should follow CDC coding guidelines below when submitting claims to Fidelis Care and ensure accurate diagnosis codes are included with other required elements of a clean claim.
Coding: Fidelis Care is updating claiming systems to be able to receive new codes associated with COVID-19 testing by April 1, 2020. Fidelis Care will add Healthcare Common Procedure Coding System (HCPCS) codes as they become available. In February 2020, CMS developed the first HCPCS code (U0001) to bill for tests and track new cases of the virus. This code is used specifically for CDC testing laboratories to test patients for COVID-19. The New York State Department of Health has communicated that there will be no established New York Medicaid fee for U0001, as it is a code used by CDC labs that are not anticipated to bill insurers. The second HCPCS billing code (U0002) allows laboratories to bill for non-CDC laboratory tests for COVID-19. This second HCPCS code should be used for tests developed by these additional laboratories when submitting claims to Fidelis Care. HCPCS code U0002 will be reimbursed at the New York published rate of $51.31, across Medicaid Fee Schedules, APG, and Medicare Fee schedules in New York.
Providers should use the appropriate CDC coding elements on claims for outpatient services related to COVID-19 testing to ensure $0 member liability upon claims processing, including one of the following diagnosis codes referenced in CDC guidelines:
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Z03.818
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Encounter for observation for suspected exposure to
other biological agents ruled out.
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Z20.828
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Contact with and (suspected) exposure to other viral
communicable diseases
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On March 13, 2020, the American Medical Association Current Procedural Terminology (CPT
® ) Editorial Panel approved a new, specific CPT code to describe laboratory testing for severe acute respiratory syndrome coronavirus 2. Fidelis Care will leverage proxy pricing for CPT code 87635 to mirror established rates for U0002 until additional reimbursement guidance is issued, whereby additional rate updates will be applied as specified in future guidance from New York State Department of Health, CMS, or local administrative contractors responsible for developing rates. The fact sheet for this new code can be accessed at the following link:
https://www.ama-assn.org/system/files/2020-03/cpt-assistant-guide-coronavirus.pdf 87635 Infectious agent detection by nucleic acid (DNA or
RNA); severe acute respiratory syndrome coronavirus
2 (SARS-CoV-2) (Coronavirus disease [COVID-19]),
amplified probe technique
Providers should follow CDC ICD-10-CM Official Coding Guidelines https://www.cdc.gov/nchs/data/icd/ICD-10-CM-Official-Coding-Gudance-Interim-Advice-coronavirus-feb-20-2020.pdf when selecting a diagnosis code to ensure proper reporting.
Pharmacy: Fidelis Care covers a 90-day supply for most prescription and over-the-counter (OTC) maintenance medications. Practitioners and pharmacists should consider ordering 90-day supplies of long-term maintenance medications for individuals in quarantine. Providers can find additional important updates regarding pharmacy changes in the context of the emergency declaration available here.
Telehealth: Fidelis Care will continue to support, promote, and align with rapidly evolving New York State guidance to providers on allowable parameters to render telehealth and telephonic services to our members.
Fidelis Care expanded coverage of telehealth services in 2019 and strongly encourages providers to deliver their services via the telehealth modality wherever reasonably possible in order to support current social distancing and containment strategies. To the extent it is practical, Fidelis Care encourages the use of telehealth to provide COVID-19 related services to members and offers reimbursement for these services across all products.
New York State Department of Financial services issued additional information and answered frequent questions regarding Telehealth on March 23, 2020. The full posting of frequently asked questions and answers can be found here: https://www.dfs.ny.gov/industry_guidance/coronavirus/telehealth_ins_prov_info
Effective March 1, 2020, Fidelis Care is in the process of updating systems to ensure our members can use telehealth services from participating providers with cost sharing waived (in products that have member cost sharing). Providers rendering care via telehealth are responsible to ensure any copays, coinsurance, or deductible charges are waived for Fidelis Care members at the time of telehealth services, and claims will be adjusted to reflect provider payments with $0 member liability upon processing. Providers are required to use Place of Service 02 for telehealth, in combination with the appropriate modifier aligned with the service. More information on the current telehealth policy can be found in the Provider Manual here, Section 26.
On March 21, 2020 New York State Medicaid issued additional comprehensive updates available here: https://www.health.ny.gov/health_care/medicaid/program/update/2020/index.htm providing clarified and broadened definitions related to telehealth, authorizing telephonic services for reimbursement, and specifying additional reimbursement and coding details specific to NYS Medicaid Fee-for-Service. While Fidelis Care is aligned with coverage described in this update, including aligning with expanded definitions and parameters related to telehealth, the coding and reimbursement referenced is not relevant to our claims processing requirements. Providers should continue to submit telehealth claims to Fidelis Care using their existing procedure codes and ensure Place of Service 02 and appropriate modifiers are included consistent with guidelines described in Section 26 of the provider manual. Providers existing contract defining services and rates continue to prevail for the same services rendered through the telehealth modality. Dental providers should contact Dentaquest at 888.308.2508 for specific tele-dental coding guidance. Dentaquest guidance can be found using this link: https://success.ada.org/~/media/CPS/Files/COVID/ADA_COVID_Coding_and_Billing_Guidance.pdf
Fidelis Care’s telehealth coverage and reimbursement approach described throughout also applies to our network of participating behavioral health providers, including individual practitioners (licensed clinical social workers, psychologists, licensed mental health counselors) as well as facilities delivering OMH and OASAS licensed programs. Additional telehealth information for OMH programs regarding recent changes to telehealth regulations can be found in these guidance, self-attestation, and supplemental guidance documents. Additional information for OASAS licensed programs can be found here, including the self-attestation and supplemental guidance.
As guidance continues to evolve over time, OMH licensed or funded programs should continue to monitor updates available here: https://omh.ny.gov/omhweb/guidance/ as well as referencing recently published guidance here: https://omh.ny.gov/omhweb/guidance/omh-covid-19-disaster-emergency-faqs.pdf . OASAS licensed or funded programs should continue to monitor updates available here: https://oasas.ny.gov/keywords/coronavirus . Providers must follow continued guidance from their respective licensing authorities, and any questions on these forms or waiver approvals should be directed to the respective OMH and OASAS contacts indicated on the forms. Fidelis Care does not require the submission of any additional documentation, contracting documents, or forms from OMH or OASAS providers in order to reimburse for telehealth claims. Fidelis Care is not requesting and will not be able to accept any OMH or OASAS self attestation forms, and providers should ensure the submission of these requests are directed to the contacts indicated on the guidance.
Fidelis Care will continue to monitor changes in state and federal regulations related to any expansion of, additional approval, or change in regulation regarding telehealth services.
COVID-19 Background
Treatment: Currently there is no available antiviral to treat COVID-19, though some international clinical trials are underway.
Vaccine: At this point, there is no vaccine for COVID-19.
Identification and Testing of Persons Under Investigation (PUI): As of March 13, 2020, COVID-19 tests are being conducted at the CDC, the NYS Wadsworth Center, and the New York City Public Health Laboratory. Tests performed for suspected individuals at these current public health sites are provided at no cost. Additionally, some hospitals and commercial laboratories are now authorized to perform COVID-19 testing. Providers should follow CDC guidance for evaluating members with suspected illness. This information can be found on the CDC website at the following links: https://www.cdc.gov/coronavirus/2019-nCoV/hcp/clinical-criteria.html and https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html.
When a test is ordered and referred to a public health lab, it is critical that the order form included with the test sample is legible and completed in its entirety.
Healthcare providers should regularly check the SDOH website for the latest guidance on reporting of suspected cases of COVID-19 as the outbreak evolves.
https://www.health.ny.gov/diseases/communicable/coronavirus/providers.htm%20
Prevention: COVID-19 can be spread from infected individuals to others through close personal contact and through the air by coughing and sneezing. Providers should encourage their patients to practice good hand washing, avoid touching their faces as much as possible, and avoid unnecessary contact with individuals who are ill.
Additional guidance can be found on the CDC website: https://www.cdc.gov/coronavirus/2019-ncov/index.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2Findex.html
https://www.cdc.gov/coronavirus/2019-ncov/specific-groups/high-risk-complications.html
https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/summary.html