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Waived cost-sharing for telehealth services extended through July 31, 2022

Other existing cost share waivers put into place as a response to the coronavirus outbreak will remain in place until further notice.

Coronavirus Information for Providers

Updated March 4, 2022

Geisinger Health Plan (GHP) continues to monitor the pandemic and follow guidance from the Pennsylvania Department of Health and Centers for Disease Control and Prevention. Our goal is to work with healthcare providers to ensure GHP members receive the testing and treatment needed to combat the spread and effects of COVID-19. As we continue to work together in the face of this pandemic, we ask for your continued cooperation and patience.

GHP has taken action

We have taken the following actions to respond to the COVID-19 pandemic:
  • Vaccine:
    Geisinger Health Plan members will have no cost-sharing for the COVID-19 vaccine. Learn more about COVID-19 vaccine administration below.
  • GHP has waived member cost-sharing for testing and treatment of COVID-19: 
    • Members will not pay for a diagnostic 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.

The cost waivers will be in effect until further notice. This is applicable to all Geisinger Health Plan members. Self-insured/TPA groups may opt-out.

Cost-sharing for antibody tests is also waived. See the diagnostic and antibody testing section below.

Members may call their Customer Care Team at the number on their member ID card for more details.

  • PROMISe ID service location requirement: PROMISe ID and related requirements were reinstated for GHP Family and GHP Kids claims with dates of service on or after Sept. 1, 2021. Though we continue to encourage providers to keep their PROMISe ID enrollment up to date for all locations, in accordance with direction from DHS on Oct. 1, 2021, GHP Family and GHP Kids claims will not be denied on grounds of PROMISe ID validation until further notice. More information below.

  • Prior 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.

    *Prior authorization for in-network SNF admissions to be reinstated Apr. 1, 2022.
    In response to last fall’s COVID-19 surge, we temporarily removed the prior authorization requirement for admissions to participating Skilled Nursing Facilities (SNF) for all plans and all diagnoses. That temporary waiver will expire Apr. 1, 2022 and the prior authorization requirement for SNF admissions will be reinstated.

    As of Apr. 1, 2022, prior authorizations for in-network SNF admissions for all members and all diagnoses should be obtained as they were before the temporary waiver.  SNF admissions are still required to meet medical necessity criteria outlined in medical policy MP332

    *Medicaid note: Prior authorization for Medicaid services was suspended in accordance with DHS guidance in 2020. All services that formerly required prior authorization again require prior authorization for dates of service July 1, 2021 and after. Please note that COVID-19 related testing and treatment are still exempt from prior authorization requirements until further notice.
  • Coverage for at-home COVID-19 test kits: The federal government announced that health insurance providers will cover over-the-counter, at-home COVID-19 test kits, beginning Jan. 15, 2022. 

Update on at-home COVID-19 test kits

Geisinger Health Plan now covers over-the-counter, at-home COVID-19 tests for eligible members. Visit our Covid test page to learn more.

  • Prescription refills: We are allowing early refills for 30 or 90-day prescriptions at retail pharmacies. Members are encouraged to ask about and use home delivery when available for their prescriptions. We are also allowing early refills on 90-day prescriptions from our mail order pharmacy, which delivers directly to the member’s home at no extra cost. Early refills are available for controlled substances but will not apply for prescriptions that contain opioids outside of certain conditions.
  • Home prescription delivery: We have relaxed restrictions on home prescription delivery. We’re also encouraging eligible members to use the Geisinger Mail Order Pharmacy.
  • Telehealth: We have waived cost-sharing for telehealth services through July 31, 2022. Learn more on how GHP is addressing telehealth services below.
Vaccine information

The arrival of the COVID-19 vaccine is a milestone in our journey through the pandemic — and one that inspires us to persevere for our communities. It will take some time to get enough people vaccinated to loosen preventive recommendations, but we’ll get there by working together.

What’s the latest?

The Centers for Medicare and Medicaid Services (CMS) has changed the billing process for COVID-19 vaccination administration and monoclonal antibody therapy treatments. If you administer COVID-19 vaccinations and/or monoclonal antibody therapy treatments to Geisinger Gold members on or after Jan. 1, 2022, you’ll need to bill Geisinger Gold. Previously, providers were directed to bill Medicare for COVID-19 vaccination administration and monoclonal antibody therapy treatments.

Visit CMS for more information regarding billing for COVID-19 vaccine administration and Monoclonal Antibody Infusion

Visit our COVID-19 vaccine resource page to provide your patients with the latest information and updates. 

Member cost-sharing

There will be no member cost sharing for COVID-19 vaccine for any line of business. TPAs cannot opt out of this waiver.

Vaccine cost

Currently, FDA approved COVID-19 vaccine doses are being paid for with U.S. taxpayer dollars. There is no reimbursement for COVID-19 vaccine doses supplied to provider at no cost.

Vaccine administration and reimbursement

GHP will reimburse CDC COVID-19 vaccination program providers for the administration of FDA approved COVID-19 vaccine administration in accordance with appropriate state and federal agency guidance. Payment for administration is based on contracted rates or CMS published rates, as applicable.


Who to bill

Plan type

Who to bill

Vaccine administration reimbursement

Member cost-sharing

Medicare Advantage – Geisinger Gold

Geisinger Health Plan (as of Jan. 1, 2022)

Medicare COVID-19 Vaccine Shot Payment 

None – no member cost sharing for vaccine or administration whether received in or out of network

Medicaid and CHIP –

GHP Family and GHP Kids

Geisinger Health Plan

Based on your contracted rate and the Medical Assistance Program Fee Schedule for Administration of SARS-CoV-2 Vaccines.

None – no member cost sharing for vaccine or administration whether received in or out of network

Commercial employer and individual plans – Geisinger Health Plan and Geisinger Marketplace

Geisinger Health Plan

In-network based on contracted rates

 

Out-of-network based on CMS rates

None – no member cost sharing for vaccine or administration whether received in or out of network

Self-funded TPA plans

Geisinger Health Plan

In-network based on contracted rates

 

Out-of-network based on CMS rates

None – no member cost sharing for vaccine or administration whether received in or out of network

  

Vaccine resources

Exact time frames for patients and the general public to receive the vaccine continue to evolve, as they depend on many factors. Visit the PA DOH vaccination information page or CDC vaccination page to learn more.

Telehealth services

We understand the important role telehealth services play in keeping both patients and healthcare professionals safe amid the COVID-19 outbreak. Members can receive telehealth services through their in-network provider or through our vendor, Teladoc. We have waived cost-sharing for telehealth services through July 31, 2022.

GHP’s Teladoc service offerings 

We are encouraging members to get care through Teladoc in two convenient ways:

  • Online: Visit Teladoc.com to download the Teladoc smartphone app. Use the app to create an account, fill out a short medical history questionnaire and schedule an online doctor visit. This is the fastest way to get in touch with a doctor. Teladoc will provide an estimate of when a doctor will contact them. 
  • By phone: Call 800-Teladoc to request a call from a doctor. Teladoc will provide an estimate of when a doctor will contact them.

Please note: As the coronavirus outbreak evolves, the need for telehealth care has never been greater. As a result, users may experience extended wait times. The fastest way to connect with a doctor is to use the app or web page.

Learn more about this service at GeisingerHealthPlan.com/Teladoc

In-network provider telehealth services

GHP will cover in-network telehealth and virtual care services that allow members to avoid unnecessary trips to the office. This includes telehealth services for any physical or behavioral health diagnosis, virtual screenings for COVID-19, and other routine medical needs such as cold, flu, allergy, rash, sinus infection, etc.

Our goal is to ensure members get the care they need—through telehealth or otherwise—and we will continue to work with providers to address concerns about coverage and reimbursement.

Telehealth billing advice

  • To bill standard E&M codes or outpatient behavioral health therapy codes as telehealth services, providers should both:
    • Bill the same location code that would be billed for an in-person visit, and
    • Add modifier 95 to indicate telehealth services.
  • In accordance with CMS as of Apr. 1, 2022, location code 02 has been re-designated and location code 10 has been introduced. Location code 02 now refers to telehealth provided other than in a patient's home, and location code 10 to telehealth provided in a patient's home. You can continue to bill telehealth services with location code 02 or 10 as appropriate. Services billed with location code 02 or 10 are generally paid at a lesser rate.
  • For a brief virtual visit, bill code G2012.
  • 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.
Suspension of PROMISe ID requirements

DHS revalidation requirements reinstated

In April 2020, to mitigate the effects of the COVID-19 crisis, the Department of Human Services (DHS) suspended the Affordable Care Act (ACA) requirement to close provider locations for failure to complete the revalidation process (Provider Quick Tip 240).

Citing a growing volume of overdue revalidations and other COVID-19 mitigation measures being lifted, DHS reinstated this requirement on June 1, 2021 (MA Bulletin 99-21-01). The requirement mandates that providers revalidate enrollment for each service location every 5 years (MA Bulletin 99-16-10).

GHP Family and GHP Kids will reinstate PROMISe ID verification requirements Sept. 1, 2021

*UPDATE* Though we continue to encourage providers to keep their PROMISe ID enrollment up to date for all locations, in accordance with direction from DHS on Oct. 1, 2021, GHP Family and GHP Kids claims will not be denied on grounds of PROMISe ID validation until further notice.

On March 15, 2020, GHP Family (Medical Assistance) and GHP Kids (CHIP) suspended PROMISe ID verification claim edits to offer providers maximum flexibility in fighting the COVID-19 pandemic.

In conjunction with DHS ending many of its COVID-19 emergency measures, GHP Family and GHP Kids put PROMISe ID verification claim edits back into place for dates of service on or after Sept. 1, 2021.

As of Sept. 1, 2021, all facilities, offices, individual providers and other practitioners who render, order, refer or prescribe items or services to GHP Family and GHP Kids members, must be enrolled with DHS — with a valid PROMISe ID specific to each practice location.

ORP provider billing requirement reinstated

The PA Department of Human Services (DHS) has issued a notice reinstating the requirement to include the NPI of ordering, referring and prescribing (ORP) providers on Medical Assistance claims, including your claims for GHP Family members. The ORP requirement was previously relaxed in response to the COVID-19 pandemic. 

Claims for encounters on or after Jan.1, 2021, where the ORP provider is required but do not contain the NPI for the ORP provider, may be affected. A valid NPI is needed for the provider types and specialties listed in the PH and CH ORP Required PT-SP Chart.

The ORP requirement will be applied to GHP Family claims as of Mar. 15, 2021. We will not reprocess GHP Family claims that have already been adjudicated.

COVID-19 diagnosis coding recommendations

The CDC has released recommendations for the diagnoses codes to be used when coding and encounter related to the coronavirus. 
  • Code the reason for encounter and add ICD10 code B97.29: Providers should continue continue to code the reason for the encounter using current ICD10 diagnosis codes for illnesses such as pneumonia or lower respiratory infection, and then code B97.29 (Other coronavirus as the cause of diseases classified elsewhere).
    • If the provider documents “suspected,” “possible” or “probable” COVID-19, providers should not use B97.29. Instead, providers should assign a code explaining the reason for the encounter, such as fever. 
  • ICD10 diagnosis code U07.1: The World Health Organization has created a new ICD10 diagnosis (U07.1) for COVID-19. This code will be effective and acceptable for use as of April 1, 2020.

  • Do not use ICD10 diagnosis code B34.2: Providers should not use diagnosis code B34.2, coronavirus infection, unspecified. The cases have universally been respiratory in nature and the site would not be “unspecified.”
COVID-19 diagnostic and antibody testing

COVID-19 diagnostic testing

Choose the right diagnostic test for your patient

  • Polymerase chain reaction (PCR) test — FDA authorized and the best method to confirm COVID-19 infection
  • Antigen test — FDA authorized but inferior sensitivity to the PCR test
  • Multi pathogen respiratory panels — not recommended for diagnosing COVID-19 

Diagnostic testing codes

CMS released a ruling on April 14, 2020 regarding a payment increase for two new HCPCs codes to encourage COVID-19 testing. The increase in payment reflects the time, enhanced technician training and specialized equipment needed to conduct high-throughput testing. The two new codes created are:

  • U0003: 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, making use of high throughput technologies as described by CMS-2020-01-R.

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

  • U0004: 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC, making use of high throughput technologies as described by CMS-2020-01-R.

    Providers should report U0004 for services that would normally be reported using code U0002.

COVID-19 antibody testing

Serologic assays, or antibody tests, for COVID-19 — granted an emergency use authorization by the U.S. Food and Drug Administration (FDA) — have become widely available. Despite their availability, federal agencies and public health officials recognize the science around COVID-19 antibody testing is rapidly evolving. In late May, the CDC issued interim guidelines on antibody testing.

CDC guidelines acknowledge limitations of antibody testing

  • The CDC does not recommend the use of antibody tests to diagnose a suspected COVID-19 infection. Antibody tests do not conclusively indicate current or previous infections and should not be used as a basis for decisions on grouping, PPE or returning to work. 
  • Positive antibody test results do not indicate immunity. Currently, there is no correlation between the presence of antibodies and immunity to COVID-19. 
  • The reliability of some antibody tests on the market remains in question. Some tests exhibit cross reactivity with other coronaviruses leading to false positives. The FDA continues to review tests and assess current emergency use authorizations.

The CDC recommends these antibody testing strategies

  • Choose high-specificity tests.
  • Test those with a high likelihood of COVID-19 exposure or previous infection. 
  • Use 2 independent tests in sequence when the first test is positive but the positive predictive value is low.
  • The CDC does not recommend the use of IgA.

What your patients should understand about antibody testing

 Although the public interest in COVID-19 antibody testing has grown, it’s important to remember your patients may not fully understand the intent of these tests; or their limitations. When ordering an antibody test, be sure your patients know what their results really mean.

  • What a positive COVID-19 antibody test result can tell you: 
    • At some point in time, you had COVID-19 — but it can’t tell you when you were or if you’re currently infected.
    • You have antibodies against COVID-19 — but you’re not necessarily immune to COVID-19. 
    • You were exposed to someone with COVID-19 — but it can’t tell you who or when; or whether you’ve exposed others.
  • What a negative result can tell you: 
    • No antibodies were found — but that does NOT mean you’ve never had a COVID-19 infection.

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.)

Coverage for COVID-19 antibody testing

Geisinger Health Plan covers COVID-19 antibody testing for members with the following indications:

  • A member with symptoms consistent with COVID19 infection and multiple negative PCR tests to COVID-19; or
  • A member who has recovered from a documented COVID19 infection and is now considering plasma donation; or
  • A child with suspected multisystem inflammatory syndrome in children (MIS-C)

Antibody tests for members must be ordered by a treating clinician. Member cost-sharing for antibody tests is also waived.

Ordering oxygen and respiratory equipment

CMS has relaxed some coverage requirements (L33797) regarding the use of oxygen and respiratory equipment during the COVID-19 public health emergency.

Services being provided must be reasonable and necessary for the condition documented in the patient’s medical record. However, the medical record no longer needs to meet traditional face-to-face requirements. 

The indication of a qualified need for the service must still be documented. Need for oxygen is currently qualified by a positive COVID-19 diagnosis or hypoxia-related symptoms.

As of Jan. 1, 2021, all DME orders for your GHP patients should be placed through Tomorrow Health.

Allocation of hydroxychloroquine and albuterol

Therapeutic protocols for COVID-19 may include the use of albuterol and a combination of hydroxychloroquine and anti-viral therapy in some cases. We remind prescribers that these medications should be used judiciously. Supplies are limited and it is imperative that reserves are maintained for those patients already on these pharmaceuticals for chronic conditions or those who may benefit from its use.

By recommendation of the Pennsylvania Department of Human Services (DHS), new starts of hydroxychloroquine for GHP Family members will be limited to a quantity of 4 tablets per day for up to a 10-day supply. GHP has extended these limits to GHP Marketplace and commercial members as well. Existing prescriptions of hydroxychloroquine and albuterol are limited to a 30-day supply at this time. These limits do not apply to Geisinger Gold.

Providers should also be vigilant about potential fraud, waste and abuse related to these medications. If fraud, waste or abuse is suspected, you can call GHP’s Fraud and Abuse Hotline at 800-292-1627 (calls may be made anonymously).

Resources

  • View the CMS COVID-19 vaccine toolkit for healthcare providers for details on vaccine administration and billing.

  • If you have any questions or concerns about COVID-19, please visit the CDC website at cdc.gov/coronavirus for current news, testing information and prevention guidelines.

  • The Pennsylvania Department of Health website also offers a robust supply of printable and shareable fact sheets, covering just about every topic that COVID-19 may impact.

  • Geisinger has produced a podcast series featuring Stanley Martin, MD, director of Infectious Diseases at Geisinger, where he discusses coronavirus facts, symptoms, testing and home isolation. These short and informative videos are appropriate for providers, staff and patients. Watch the series.

  • As we continue to respond to the COVID-19 crisis, we recognize the need extends well beyond the healthcare setting. Neighborly is a resource page that helps individuals and families find free or reduced-cost services in their communities. They can search for local resources to access food, housing, childcare, transportation, utility assistance, healthcare, financial assistance and other needs. Visit Neighborly.