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Provider Coronavirus Information

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. 

  • 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:

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

LTC COVERED SERVICES

PROCEDURE CODE

ELIGIBLE LTC PROVIDERS

Adult Companion   

S5135 (1 unit = 15 minutes)

 

  • Adult Day Health Care Center
  • Independent Registered Nurse
  • Licensed Practical Nurse
  • Older Americans Act (OAA) Provider

Attendant Care

           

S5125 (1 unit = 15 minutes)

  • Adult Day Health Care Center
  • Community Care for the Elderly
  • Health Care Service Pool

Behavior Management

H2020 Management (assessment) (1 unit =
15 minutes);

H2019 Management (intervention) (1 unit = 15 minutes)

Nurse Registry

Homemaker

S5130 (1 unit = 15 minutes)

  • Independent Registered Nurse
  • Licensed Practical Nurse

Home Delivered Meals

S5170 (1 unit = 1 meal)

Adult Day Health Care Center

Intermittent and Skilled Nursing

S9123 Intermittent and skilled nursing, RN (per hour)
S9124 Intermittent and skilled nursing, LPN (per hour)

 

 

 

  • Adult Day Health Care Center
  • Center for Independent Living
  • Community Care for the Elderly
  • Health Care Service Pool
  • Independent Registered Nurse
  • Licensed Practical Nurse
  • Nurse Registry

Medical Supplies and Equipment

S5199 Medical Equipment and Supplies, Personal Care

Item Regular Miscellaneous;

E1399 Medical Equipment and Supplies, Specialized

Medical Equipment Regular Miscellaneous;

 

Community Care for the Elderly

Medication Administration

T1502  Medication Administration, administration of oral, intramuscular, and/or subcutaneous medication by a Health Professional (1 unit =
1 visit)

  • Adult Day Health Care Center
  • Participant Direction Option1 (see footnote)

Medication Management

H2010 Medication management, comprehensive medication services (1 unit = 15 minutes)

  • Adult Day Health Care
  • Participant Direction Option2 (see footnote)

Personal Care

T1004 (1 unit = 15 minutes)

  • Adult Day Health Care Center
  • Health Care Service Pool
  • Independent Registered Nurse
  • Licensed Practical Nurse
  • OAA Provider

Respite Care

T1005 (1 unit = 15 minutes)

  • Case Management Agency
  • Health Care Service Pool
  • Participant Direction Option

Transportation Services

T2001 Non-emergency Transportation

  • Community Care for the Elderly
  • Participant Direction Option

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

ON MEDICAID FEE SCHEDULE

NOT ON MEDICAID FEE SCHEDULE

Behavior management   

Adult Companion Care

Intermittent/Skilled Nursing

Attendant Care

Medical Supplies and Equipment (almost all, some ancillary CMS supplies are not)

Homemaker

 

Personal Care

  • Home Delivered Meals
  • Medication Administration
  • Medication Management
  • Respite
  • 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 are increasing the scope and scale of our use of telehealth services for all products for the duration of the COVID-19 emergency.  These coverage expansions will 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.

Effective immediately, the policies we are implementing include:

  • Continuation of zero member liability (copays, cost sharing, etc.) for care delivered via telehealth*
  • Any services that can be delivered virtually will be eligible for telehealth coverage
  • Telehealth services may be delivered by providers with any connection technology to ensure patient access to care**

*Please note: For Health Savings Account (HSA)-Qualified plans, IRS guidance is pending as to deductible application requirements for telehealth/telemedicine related services. 
**Providers should follow state and federal guidelines regarding performance of telehealth services including permitted modalities.

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:

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.

Behavioral Health Services Using Telemedicine

Service

Procedure Code

Required Modifier

Brief individual medical psychotherapy, mental health

H2010 HE

GT

Brief individual medical psychotherapy, substance abuse

H2010 HF

GT

Individual Therapy

H2019 HR

GT

Family Therapy

H2019 HR

GT

Medication Management

T1015

GT

Medication-assisted treatment services

H0020

GT

Targeted Case Management

T1017

T1017 HA

T1017 HK

GT

Therapeutic Behavioral Health Onsite Services (TBOS), therapy

H2019 HO

GT

TBOS, behavior management

H2019 HN

GT

TBOS, therapeutic support

H2019 HM

GT

Psychosocial Rehabilitation (PSR) Services

H2017

GT

Specialized Therapeutic Comprehensive Behavioral Health Assessment Services

H0031 HA

GT

Psychiatric evaluation by a physician

H2000 HP

GT

Psychiatric evaluation by a non-physician

H2000 HO

GT

Brief behavioral health status exam

H2010 HO

GT

Psychiatric review of records

H2000

GT

In-depth assessment, new patient, mental health

H0031 HO

GT

In-depth assessment, established patient, mental health

H0031 TS

GT

In-depth assessment, new patient, substance abuse

H0001 HO

GT

In-depth assessment, established patient, substance abuse

H0001 TS

GT

Bio-psychosocial evaluation, mental health

H0031 HN

GT

Bio-psychosocial evaluation, substance abuse

H0001 HN

GT

Psychological testing

H2019

GT

Limited functional assessment, mental health

H0031

GT

Limited functional assessment, substance abuse

H0001

GT

Behavioral health medical screening, mental health

T1023 HE

GT

Behavioral health medical screening, substance abuse

T1023 HF

GT

Behavioral health-related medical services: verbal interaction, mental health

H0046

GT

Behavioral health-related medical services: verbal interaction, substance abuse

H0047

GT

Behavioral health-related medical services: medical procedures, mental health

T1015 HE

GT

Behavioral health-related medical services: medical procedures, substance abuse

T1015 HF

GT

Brief group medical therapy

H2010 HQ

GT

Group therapy

H2019 HQ

GT

 

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.

Telephone Communications for Behavioral Health Services – Audio Only

Service

Procedure Code

Required Modifier

Brief individual medical psychotherapy, mental health

H2010 HE

CR

Brief individual medical psychotherapy, substance abuse

H2010 HF

CR

Individual Therapy

H2019 HR

CR

Family Therapy

H2019 HR

CR

Medication Management

T1015

CR

Medication-assisted treatment services

H0020

CR

Targeted Case Management

T1017

T1017 HA

T1017 HK

CR

Psychosocial Rehabilitation (PSR) Services

H2017

CR

Specialized Therapeutic Comprehensive Behavioral Health Assessment Services

H0031 HA

CR

Psychiatric evaluation by a physician

H2000 HP

CR

Psychiatric evaluation by a non-physician

H2000 HO

CR

Brief behavioral health status exam

H2010 HO

CR

In-depth assessment, new patient, mental health

H0031 HO

CR

In-depth assessment, established patient, mental health

H0031 TS

CR

In-depth assessment, new patient, substance abuse

H0001 HO

CR

In-depth assessment, established patient, substance abuse

H0001 TS

CR

Bio-psychosocial evaluation, mental health

H0031 HN

CR

Bio-psychosocial evaluation, substance abuse

H0001 HN

CR

Psychological testing

H2019

CR

Limited functional assessment, mental health

H0031

CR

Limited functional assessment, substance abuse

H0001

CR

Behavioral health medical screening, mental health

T1023 HE

CR

Behavioral health-related medical services: medical procedures, mental health

T1015 HE

CR

Behavioral health-related medical services: medical procedures, substance abuse

T1015 HF

CR

Behavioral health medical screening, substance abuse

T1023 HF

CR

Behavioral health-related medical services: verbal interaction, mental health

H0046

CR

Behavioral health-related medical services: verbal interaction, substance abuse

H0047

CR

Brief group medical therapy

H2010 HQ

CR

Group therapy

H2019 HQ

CR

 

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.
  • 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). 

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 Services (Audio and Video)

 Service

Procedure Code

Required Modifier

Early Intervention Screening

T1027

GT

Initial Interdisciplinary Psychosocial and Developmental Evaluation rendered by a Physical Therapist

T1024 GP UK

GT

Initial Interdisciplinary Psychosocial and Developmental Evaluation rendered by a Speech Therapist

T1024 GN UK

GT

Initial Interdisciplinary Psychosocial and Developmental Evaluation rendered by an Occupational Therapist

T1024 GO UK

GT

Initial Interdisciplinary Psychosocial and Developmental Evaluation rendered by a Licensed Early Intervention Professional

T1024 TL

GT

Initial Interdisciplinary Psychosocial and Developmental Evaluation rendered by an ITDS

T1024 HN UK

GT

Follow-up Psychosocial and Developmental Evaluation rendered by a Physical Therapist

T1024 GP TS

GT

Follow-up Psychosocial and Developmental Evaluation rendered by a Speech Therapist

T1024 GN TS

GT

Follow-up Psychosocial and Developmental Evaluation rendered by an Occupational Therapist

T1024 GO TS

GT

Follow-up Psychosocial and Developmental Evaluation rendered by a licensed Early Intervention professional

T1024 TL TS

GT

Follow-up Psychosocial and Developmental Evaluation rendered by an ITDS

T1024 TS

GT

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:  

Early Intervention Sessions

 Service

Procedure Code

Required Modifier

Limits

Early Intervention Individual Session: Family Training

T1027 SC

GT

Four 15-minute units per day

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.

COVID-19 Testing and Services (Updated 05/28/2020)

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).  

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
Test      Detection Method Procedure Code Effective Date
CDC testing CDC testing U0001 2/4/20
Non-CDC testing
  • Any technique
  • Infectious agent detection by nucleic acid (DNA or RNA)

 

  • U0002
  • 87635*

* 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.

 

  • 2/4/20
  • 3/13/20
Rapid testing using high throughput technologies, as described by CMS
  • Infectious agent detection by nucleic acid (DNA or RNA)
  • Any technique
  • U0003 (Should identify tests that would otherwise be identified by CPT code 87635 but for being performed with these high throughput technologies)
  • U0004 (Should identify tests that would otherwise be identified by U0002 but for being performed with these high throughput technologies.)
4/14/20
Specimen transfers For specimen transfer related claims
  • 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.

3/1/2020
Other rapid testing Antibody testing
  • 86328
  • 86769
4/10/20

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 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.
  • We are complying with the rates published by CMS for Medicare and Medicaid:
    • U0001 = $35.91
    • U0002 = $51.31
    • U0003 = $100.00
    • U0004 = $100.00
    • G2023 = $23.46
    • G2024 = $25.46
    • 87635 = $23.40
  • Commercial products will reimburse COVID-19 testing services in accordance with our negotiated commercial contract rates.
  • 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.

* Last updated 07/09/2020

Additional guidance for our Medicaid Providers. (Updated 06/16/2020)

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).