Provider Coronavirus Information

For all Medicaid and CHIP providers: The U.S. Department of Health and Human Services (HHS) has announced additional distributions from the Provider Relief Fund to eligible providers. Under this Phase 3 General Distribution allocation, providers that have already received Provider Relief Fund payments will be invited to apply for additional funding that considers financial losses and changes in operating expenses caused by the coronavirus. Previously ineligible providers, such as those who began practicing in 2020 are also being invited to apply, along with an expanded group of behavioral health providers.

Applications Due Nov. 6: Providers will have from Oct. 5, 2020 through Nov. 6, 2020 to apply for this Phase 3 General Distribution funding.

Eligibility: Providers eligible to apply for this Phase 3 funding include:

• Providers who previously received, rejected or accepted a General Distribution Provider Relief Fund payment. Providers that have already received payments of approximately 2% of annual revenue from patient care may submit more information to become eligible for an additional payment.
• Behavioral Health providers, including those that previously received funding and new providers such as addiction counseling centers, mental health counselors, and psychiatrists.
• Healthcare providers that began practicing Jan. 1, 2020 through March 31, 2020. This includes Medicare, Medicaid, CHIP, dentists, assisted living facilities and behavioral health providers. 

Payment Methodology: According to HHS, all eligible providers will be considered for payment based on the following criteria:

• All provider submissions will be reviewed to confirm they have received a Provider Relief Fund payment equal to approximately 2% of patient care revenue from prior general distributions. Applicants that have not yet received Relief Fund payments of 2% of patient revenue will receive a payment that, when combined with prior payments (if any), equals 2% of patient care revenue.
• With the remaining balance of the $20 billion budget, HRSA will then calculate an equitable add-on payment that considers the following:
  • A provider’s change in operating revenues from patient care
  • A provider’s change in operating expenses from patient care, including expenses incurred related to coronavirus
  • Payments already received through prior Provider Relief Fund distributions.

Additional information on determining eligibility and how to apply if eligible can be found on the HHS website.

Other terms and conditions (PDF) may apply as specified on the HHS website. 

Learn more about the Provider Relief Program.

Agency COVID-19 Website: As a reminder, the Agency’s COVID-19 alert website ensures providers have all Agency guidance in one centralized location.

On Oct. 5, 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 through Jan. 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 Sunshine Health members through late January, until the PHE is either terminated or extended again.  This extension does not affect Sunshine Health’s additional Medicare coverages that are set to expire on Dec. 31, 2020.

In accordance with this extension, Sunshine Health has updated the General Guidance for COVID-19 Testing, Screening, and Treatment document. 

If you have any questions about this extension or the covered benefits impacted by it, please contact Provider Services at 1-844-477-8313.

The COVID-19 global pandemic has created unprecedented changes to our lives and healthcare systems. While we continue to connect our members to COVID-19 services, we wanted to reach out to our provider partners on how we can work together to better support their care needs.

Primary care physicians (PCPs) are at the heart of our members’ healthcare. They trust and rely on PCPs to help them access appropriate, affordable, coordinated care from the right providers, at the right time. If PCPs refer our members to an out-of-network provider – or send their test specimens to a non-participating laboratory – they could be responsible for the out-of-network charges according to their benefits. These costs can quickly add up, especially for patients who do not have out-of-network benefits.

PCPs can help their patients avoid this and keep members' medical costs down by referring them to providers within their plan network, as denoted on their Member ID card. Understanding it can sometimes be challenging to navigate multiple payor networks to connect patients to appropriate in-network providers and facilities, we want to share two easy methods for PCPs to access this information quickly:

• Search In-Network Providers Online. Our Find a Provider tool offers the current list of our in-network providers. You can also access this tool via our provider portal.
• Contact your Provider Services Representative. They can help you quickly identify in-network specialists and labs.

Thank you for your continued partnership during this time of heightened concern. If you have any questions regarding our networks, please contact Provider Services at 1-844-477-8313.

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

On Sept. 4, 2020, the Agency for Health Care Administration (AHCA) informed Adult Day Care Center providers about a temporary new service, “adult community support services,” that can be delivered in a member’s home.

Providers wishing to render this service should first contact Sunshine Health to discuss service delivery. Providers must obtain approval from Sunshine Health prior to providing adult community support services.

To provide adult community support services to Sunshine Health LTC members, AHCA requires all of the following requirements to be met: 

• The service must be documented in the member’s plan of care and authorized in advance by Sunshine Health.
• The provider must furnish the service at the member’s home.
• The provider must furnish members with the materials and supplies necessary to complete activities at no cost to the member, when appropriate.
• The provider must furnish a daily participant activity schedule to the member/caregiver and Sunshine Health.
• The service must be delivered face-to-face and comply with the Centers for Disease Control and Prevention and Florida Department of Health’s COVID-19 prevention/safety protocols.
• Service delivery must be documented in accordance with current requirements in the Statewide Medicaid Managed Care Long-Term Care Services Coverage Policy and the provider’s contract/agreement with Sunshine Health.

To bill for adult community support services, the provider must be configured to use procedure code S5100 CG.

If you are interested in providing this service, contact Sunshine Health at SunshineProviderRelations@sunshinehealth.com or call us at 1-844-477-8313.

• 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.    

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

The U.S. Department of Health and Human Services (HHS) is offering additional payments from the Provider Relief Fund to eligible providers serving Medicaid and Children’s Health Insurance programs.

To be eligible, providers must not have received payments from the $50 billion Provider Relief Fund General Distribution and must have billed the state Medicaid/CHIP programs or managed care plans for healthcare-related services from Jan. 1, 2018, through May 31, 2020.

Payment to qualifying providers will be at least 2 percent of reported gross revenue from patient care. The final payment will be determined after the data is submitted, including information about the number of Medicaid patients served.*

HHS has posted the following information about this funding:

• A set of instructions for providers (PDF), including a deadline of July 20, 2020, to submit an application.
• The application form (PDF); and
• The enhanced provider relief fund portal to complete the application process.

To learn more, see the FAQs on the HHS website. Please note that the FAQs specific to Medicaid and CHIP providers are near the bottom of the FAQ page under the header, "Medicaid Targeted Distribution."

*Other terms and conditions may apply. Please see the HHS announcement.

To ensure that our Long Term Care members are able to receive all services necessary to maintain their health, safety and welfare during the COVID-19 state of emergency, the Agency for Health Care Administration (AHCA) has temporarily expanded the services that certain LTC Service Providers can perform.

Effective immediately, the following service providers are temporarily eligible to render additional LTC medically necessary services in a member’s home until further notice.

Temporary Expansion of LTC Service Providers

Provider Requirements

• Providers must collaborate with a member’s LTC care coordinator in cases where additional capacity in service delivery is needed.
• Providers must utilize appropriately licensed staff to perform services within the individual’s scope of practice. For example, a home health aide cannot perform a skilled nursing task.
• The needed change in service delivery must be documented in the member’s plan of care.

Guidance on Expanded Services

• This expansion is intended to increase the capacity of the healthcare delivery system during this public health emergency, where shortages and closures may occur.
• Please work with the member’s LTC care coordinator if you have questions, and to ensure our members do not experience any disruption in care. You can also call the Sunshine Health Member Services number at 1-866-796-0530 to ask for a care coordinator.

Billing Guidance

Services on the Medicaid Fee Schedule (listed below) will be paid at 100%. All services not on the Medicaid Fee Schedule will be paid at the average, current participating provider rate based on market parameters.

Billing Guidance

• Find more information on transportation services and reimbursement guidelines.
• Participant Directed Options: Direct Service Workers should submit the member reimbursement form to LogistiCare for reimbursement. Please ensure to include the applicable mileage to be considered for reimbursement.

If you have questions regarding this communication, or are interested in providing or learning more about any of the expanded services, please call Provider Services at 1-844-477-8313.

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 (PDF).

In order to ensure that all of our members have needed access to care, we have increased the scope and scale of our use of telehealth services for all products for the duration of the national COVID-19 public health emergency.  These coverage expansions benefit not only members who have contracted or been exposed to the novel coronavirus, but also those members who need to seek care unrelated to COVID-19 and wish to avoid clinical settings and other public spaces.

The policies we have implemented include:

• Continuation of zero member liability (copayments, coinsurance and/or deductible cost sharing) for care delivered via telehealth
• Any services that can be delivered virtually will be eligible for telehealth coverage
• All prior authorization requirements for telehealth services will be lifted for dates of service from March 17, 2020, through Oct. 25, 2020
• Telehealth services may be delivered by providers with any connection technology to ensure patient access to care

Providers who have delivered care via telehealth should reflect it on their claim form by following standard telehealth billing protocols in their state. For further billing and coding guidance for telehealth services, we recommend following what is being published by:

• Centers for Medicare and Medicaid (CMS)
• Department of Health and Human Services (HHS)
• American Medical Association (AMA)

We believe that these measures will help our members maintain access to quality, affordable healthcare while maintaining the CDC’s recommended distance from public spaces and groups of people. 

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

Additional Telehealth Guidance for Medicaid Providers

Payment parity: For telehealth visits that include audio and video, we will pay providers the same rates they would receive for a similar face-to-face visit.  

• CPT codes: 99201-99215 billed with a GT modifier indicate a service was rendered via synchronous telecommunication with audio and video.

Audio Telehealth Services: Licensed physicians, physician extenders, and licensed behavioral health providers can provide telehealth services using only audio. 

• For existing patients, providers should use the CR modifier with one of the following procedure codes: 99441, 99442, 99443, or 99441 CG
• For new patients, providers should use the CR modifier with one of the following procedure codes: 99442 CG or 99443

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

Therapy and Early Intervention Services

During this public health emergency: Therapy Services and Early Intervention Services can be provided via telehealth.

Behavioral Health Services Using Telemedicine

Behavioral health providers can provide and bill for telehealth services listed in the table below. Providers must perform all service components designated for the procedure code billed.

Additional Requirements/Limitations

• TBOS: Florida Medicaid will reimburse for up to two (2) hours of parent training per day, per recipient, for the purposes of caregiver training when services cannot be delivered in the home and the caregiver needs to be supported in the delivery of care. The provider must guide the caregiver in the implementation of certain components of the recipient’s treatment plan to promote carryover of treatment gains.

• PSR: Florida Medicaid will reimburse for up to two (2) hours per day, as detailed in the coverage policy and on the recipient’s treatment plan.

Telephone Communications for Behavioral Health Services – Audio Only

Behavioral health providers can provide and bill for the following services if video capability is not availability and the services can only be provided telephonically. This modality must be used as a last resort, and the provider must document that the enrollee did not have access to audio and video technology necessary for the service to be fully provided via telemedicine.

Additional Requirements for Behavioral Health Providers using Telemedicine/Telehealth

Providers using any modality of telemedicine/telehealth described in this alert must:

• Ensure treatment services are medically necessary and performed in accordance with the corresponding and promulgated service-specific coverage policy and fee schedule.
• Comply with HIPAA regulations related to telemedicine/telehealth communications.
  • See additional guidance provided by the Office of Civil Rights on March 17, 2020, during the state of emergency.
• Supervision requirements within a provider’s scope of practice continue to apply for services provided through telemedicine/telehealth.
• Out-of-state practitioners who are not licensed in Florida may provide telemedicine/telehealth services to Florida Medicaid recipients, when appropriate, during the state of emergency in accordance with the Department of Health’s emergency order (DOH 20 - 002). 
  • These providers must go through the provisional enrollment process, if they are not already enrolled in Florida Medicaid. Apply for provisional enrollment.

Documentation regarding the use of telemedicine/telehealth must be included in the medical record or progress notes for each encounter with a recipient.

During this public health emergency: Therapy Services and Early Intervention Services can be provided via telehealth.

Therapy Services (Audio and Video)

During this public emergency, Therapy Services can be provided via telehealth. This includes speech language pathology, and physical and occupational therapy. Services must be delivered in a manner that is consistent with the standards of care and all service components designated in the American Medical Association’s Current Procedural Terminology code set and the Florida Medicaid coverage policy.

Early Intervention Services (Audio and Video)

During this public emergency, early intervention screenings and evaluations (initial and follow-up) may be provided via telehealth when the service is delivered in accordance with federal and state law requirements (e.g., multidisciplinary team requirements can be met through live, two-way audio and video capabilities). The service must be completed in its entirety, as detailed in the EIS coverage policy and fee schedule.

Services are covered, as described below:  

Early Intervention Sessions

Providers may bill for early intervention sessions via telemedicine when performed by an eligible EIS provider (as defined in the Medicaid coverage policy) to provide family training designed to support the caregiver in the delivery of care. The provider must guide the caregiver in the implementation of certain components of the member’s individualized family support plan to promote carryover of treatment gains. Providers are required to ensure caregivers can perform the tasks. Services are covered, as described below:  

Provider Telemedicine Requirements

Early intervention service providers using telemedicine as a modality to deliver services must also comply with the following:

• Telemedicine services cannot be provided if another EIS provider is in the home on the same date of service.
• Ensure services are medically necessary and performed in accordance with the service specific policy and fee schedule.
• The member (and their legal guardian) must be present for the duration of the service provided using telemedicine.
• Telemedicine should not be used by a provider if it may result in any reduction to the quality of care or if the service delivered through this modality could adversely impact the recipient.
• Documentation regarding the use of telemedicine must be included in the progress notes for each encounter with a member. All other documentation requirements for the service must be met as described in the coverage policy.
• Providers must comply with the Health Insurance Portability and Accountability Act (HIPAA) when providing services; all equipment and means of communication transmission must be HIPAA compliant.
• Providers must assure that the member has compatible equipment and the necessary connectivity in order to send and receive uninterrupted video. Telephone (audio-only) or electronic-based contact  without a video component is not permitted.  

Please note: We do not reimburse for the acquisition, installation, and maintenance of telecommunication devices or systems.

Well-Child Visits Provided via Telemedicine

Well-child visits using telemedicine (live/two-way communication that includes audio and video) is covered during the state of emergency for children older than 24 months through 20 years for the following procedure codes:

• 99382-99385
• 99392-99395

Providers must also include the GT modifier for live, two-way communication.

Although providers may be able to conduct the majority of the well-child visit components via telemedicine, providers must schedule a follow-up visit for the administration of immunizations and other physical components of the exam that could not be delivered using telemedicine.

In accordance with the American Academy of Pediatrics guidance, providers should prioritize in-person newborn care, newborn well-visits, and immunization of infants and young children through 24 months of age. We will not reimburse for well-child visits performed via telemedicine for children 24 months and younger.

We are closely monitoring and following all guidance from the Centers for Medicare and Medicaid as it is released to ensure we can quickly address and support the prevention, screening, and treatment of COVID-19. The following guidance can be used to bill for services related to COVID-19 testing, screening and treatment services. 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).  

COVID-19 Testing Services

• Providers performing the COVID-19 test can bill us for testing services that occurred after February 4, 2020, using the following newly created HCPCS codes:
  • HCPCS U0001 - For CDC developed tests only - 2019-nCoV Real-Time RT-PCR Diagnostic Panel.
  • HCPCS U0002 - For all other commercially available tests - 2019-nCoV Real-Time RT-PCR Diagnostic Panel.
  • CPT 87635 - Effective March 13, 2020 and issued as “the industry standard for reporting of novel coronavirus tests across the nation’s health care system.”
  • PLA 0202U - Effective May 20, 2020. Infectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected.

Please note:  It is not yet clear if CMS will rescind the more general HCPCS Code U0002 for non-CDC laboratory tests that the Medicare claims processing system is scheduled to begin accepting starting April 1, 2020.

• These codes should not be used for serologic tests that detect COVID-19 antibodies.
• All member cost share (copayment, coinsurance and/or deductible amounts) will be waived across all products 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.

COVID-19 Antigen Testing Services

• Providers performing COVID-19 antigen tests can bill us for testing services that occurred after June 25, 2020, using the following HCPCS codes:
  • 87426 - Infectious agent antigen detection by immunoassay technique, qualitative or semiquantitative, multiple-step method; severe acute respiratory syndrome coronavirus (eg SARS-CoV, SARA-CoV-2 (COVID-19).
  • 0223U - Infectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected
  • 0224U - Antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease (COVID-19) includes titer(s), when performed (Do not report 0224U in conjunction with 86769).
• All member cost share (copayment, coinsurance and/or deductible amounts) will be waived across all products for any claim billed with the above COVID-19 antibody testing codes.
• In addition to cost share, authorization requirements will be waived for any claim that is received with these specified codes. This includes non-participating providers.
• Providers billing with these codes will not be limited by provider type and can be both participating and non-participating.
• Reimbursement rates are still pending from CMS and this communication will be updated when available.

High-Throughput Technology Testing Services

• Providers performing high production COVID-19 diagnostic testing via high-throughput technology can bill us for testing services that occurred after Feb. 4, 2020, using the following newly created HCPCS codes:
  • HCPCS 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.
  • Please note: U0003 should identify tests that would otherwise be identified by CPT code 87635 but for being performed with these high throughput technologies.
  • HCPCS 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.
  • Please note: U0004 should identify tests that would otherwise be identified by U0002 but for being performed with these high throughput technologies.
• Neither U0003 nor U0004 should be used for tests that detect COVID-19 antibodies.
• We have configured our systems to apply $0 member cost share liability for those claims submitted utilizing these codes to indicate high production testing.
• Providers billing with these codes will not be limited by provider type and can be both participating and non-participating.

COVID-19 Specimen Transfers

• For specimen transfer related claims, the following codes can be used:
  • G2023 - Spec Clct for SARS-COV-2 COVID 19 ANY SPEC SRC
  • G2024 - SP CLCT SARS-COV2 COVID19 FRM SNF/LAB ANY SPEC
  • C9803 - Hospital outpatient clinic visit specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), any specimen source. This is effective for services provided on or after March 1, 2020.
• Providers billing with these codes will not be limited by provider type and can be both participating and non-participating.

COVID-19 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 Feb. 4, 2020.
• Providers billing with these codes will not be limited by provider type.

COVID-19 Treatment Services

• We will waive prior authorization requirements and member cost sharing for COVID-19 treatment for all members.
• For dates of service from Feb. 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.

Reimbursement Rates for COVID-19 Services for All Provider Types

• We are complying with the rates published by CMS for the following codes:
  • U0001 = $35.91
  • U0002 = $51.31
  • U0003 = $100.00
  • U0004 = $100.00
  • G2023 = $23.46
  • G2024 = $25.46
  • NOTE: Commercial products will reimburse COVID-19 services in accordance with our negotiated commercial contract rates.
•  Any additional rates will be determined by further CMS and/or state-specific guidance and communicated when available.
• We will follow these CMS published rates except where state-specific Medicaid rate guidance should supersede.

Service Authorizations for Hospital Transfers Temporarily Suspended

As of July 9, 2020, Sunshine Health 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 the Sunshine Health of the admission within forty-eight (48) hours of the admission. 

June 19, 2020, Update: Prior Authorizations Return

Effective June 19, 2020, Sunshine Health 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 (PDF) of Gov. Ron DeSantis’ Plan for Florida’s Recovery and guidelines from the Agency for Health Care Administration (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 listed in the July 9, 2020, update above)
• 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 by 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.

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.   

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.

AHCA has extended healthcare coverage for all Medicaid members whose coverage was set to expire on March 31, 2020. This order extends coverage for those members through April 30, 2020.

These members already received a letter from the Agency notifying them that their coverage was ended, but they will receive a second letter from the Agency notifying them of this extension.

Please note: These members will not appear in the Department of Children and Families database as eligible because of system configuration challenges, but their coverage will be valid.

The Florida Medicaid Management Information System (FMMIS) is expected to be accurate as of April 1, 2020.  

For more information, please read the communication on Department of Children and Families website.

If you have questions, please contact your Provider Relations representative or call Provider Services toll-free 1-844-477-8313.

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.

We always rely on our provider partners to ensure the health of our members, and we want to ensure your own wellness as you conduct necessary care visits. To that end, we would like to share some guidance and available resources to help you provide any in-home care for your patients during this time of heightened concern.

• Ensure continuity of care to our members while following proper health and safety protocols when making home visits. This includes frequently washing your hands and utilizing sanitation supplies, following contact precautions and wearing personal protective equipment when necessary.
• Be aware of and follow the Centers for Disease Control (CDC) COVID-19 guidance for healthcare providers, including the specific guidance for providing in-home care.
• Be alert for those who meet the criteria for persons under investigation for COVID-19 and know how to coordinate laboratory testing.
• Review your company’s infection prevention and control policies, and ensure you have proper protocols in place in the event of any coronavirus-related exposure or emergencies.
• Ensure your organization has developed action plans that address the following:
  • Actions that will be taken in order to reduce the risk of workforce shortages.
  • How to provide acute and primary medical resources that continue to meet members’ needs.
• Follow any direction and guidance from relevant local and/or state health departments and agencies. Know how to report a potential COVID-19 case or exposure to facility infection control leads and public health officials. Contact your local or state health department healthcare providers in the event of a person under investigation for COVID-19.
• 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.

Resources

1. Centers for Disease Control and Prevention. Interim Guidance for Implementing Home Care of People Not Requiring Hospitalization for 2019 Novel Coronavirus (2019-nCoV). 
2. Centers for Disease Control and Prevention. Interim Guidance for Preventing the Spread of Coronavirus Disease 2019 (COVID-19) in Homes and Residential Communities. 
3. Centers for Disease Control and Prevention. Interim US Guidance for Risk Assessment and Public Health Management of Persons with Potential Coronavirus Disease 2019 (COVID-19) Exposure in Travel-associated or Community Settings. 
4. World Health Organization. Home care for patients with suspected novel coronavirus (nCov) infection presenting with mild symptom and management of contracts.
5. Joint Commission. Managing the Threat of the New Coronavirus Strain.

We realize impact the COVID-19 state of emergency is having on LTC home and community-based service waiver providers. In response, and in accordance with AHCA guidelines, we are issuing retainer payments to eligible Adult Day Care (ADC) providers serving LTC enrollees.

To be eligible, stand-alone ADCs serving Sunshine Health LTCs enrollees must be experiencing the financial hardships below and attest to certain criteria during the state of emergency:

• The location where services are normally rendered is closed due to COVID-19 and the provider is unable or only able to partially render services in an alternative setting; or
• The location remains open, but they are unable to serve all enrollees at this time due to enrollees who are quarantined, hospitalized, or refusing to receive services.

To request payment, please fill out the request form that you can find by going to the AHCA COVID-19 Medicaid Information page and scrolling down to “SMMC LTC Adult Day Care Provider Retainer Payment Request” near the bottom of the page. Completed forms should be returned to LTC_SSHP_member_info_request@centene.com or faxed to 1-855-469-3306.

Retainer Payment Limitations

The Centers for Medicare and Medicaid Services has issued guidance limiting provider retainer payments to no more than three 30-day periods.

This means that eligible home and community-based providers offering services through the iBudget waiver and Long Term Care program cannot receive retainer payments for more than three months. If providers have already received a retainer payment for three months, Sunshine Health will not make retainer payments in subsequent months. If qualified providers have previously received approval to receive a retainer payment and have not exceeded the three-month limitation – and have not exceeded the three-month limitation – Sunshine Health will continue to make the payments until the three-month limit is reached.

Once you are no longer receiving a retainer payment, you may begin submitting claims based on care plan authorization and member’s utilization of services. For example, if you received retainer payments for May, June and July, starting Aug. 1, you may begin submitting claims to provide adult day care services based on the member’s individual care plan and the member’s use of services.

We understand the difficulty that this may cause for providers. The federal government has other potential funding opportunities:

•  The U.S. Department of Health and Human Services (HHS) announced additional distributions from the Provider Relief Fund. The deadline to submit an application has been extended through Aug. 3, 2020. Visit the HHS website for more information.
  • Frequently Asked Questions: HHS has posted updated FAQs to address questions submitted during the previous webinars.
  • AHCA has created a fact sheet (PDF) with key information for providers. Again, the deadline has been extended to Aug. 3, 2020.
• The U.S. Small Business Administration (SBA) launched the Paycheck Protection Program (PPP) to provide a direct incentive for small businesses to keep their workers on the payroll. The SBA will forgive loans if all employee retention criteria are met, and the funds are used for eligible expenses. The new deadline to apply for a PPP loan is Aug. 8, 2020. Visit the SBA website for more information on the PPP program.

For more information, please see the July 17, 2020, alert issued by the Agency for Health Care Administration (AHCA).