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Provider Coronavirus Information

Temporary Expansion of LTC Service Providers

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.

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
  • All prior authorization requirements for telehealth services will be lifted for dates of service from March 17, 2020 through June 30, 2020
  • 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.

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.

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 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.

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

  • Providers performing the COVID-19 test can begin billing us for services that occurred after Feb. 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.”

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.

  • All member cost share (copayment, coinsurance and/or deductible amounts) will be waived across all plans for any claim billed with the new COVID-19 testing codes.
  • We have configured our systems to apply $0 member cost share liability for those claims submitted utilizing these new COVID-19 testing codes.
  • In addition to cost share, authorization requirements will be waived for any claim that is received with these specified codes.
  • Providers billing with these codes will not be limited by provider type and can be both participating and non-participating.
  • We will temporarily waive requirements that out-of-state Medicare and Medicaid providers be licensed in the state where they are providing services when they are licensed in another state.
  • Adjudication of claims is currently planned for the first week of April 2020 for Medicare and Marketplace. Medicaid can begin billing these codes effective immediately.
  • Providers should not send patients to any LabCorp or Quest location to have a specimen collected. Instead, specimens are to be collected at healthcare facilities, such as hospitals and physician offices, and sent to Quest or LabCorp using standard procedures.
  • We are complying with the rates published by CMS for Medicare and Medicaid:
    • U0001 = $35.91
    • U0002 = $51.31
    • 87798 = $23.40
    • Please note: Commercial products will reimburse COVID-19 testing 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.

* Last updated 3/24/20

The remaining guidance applies to our Medicaid Providers.

To reduce administrative burden on key providers that are on the frontline serving the populations most impacted by COVID-19, we are waiving initial and ongoing prior authorization requirements for medically necessary hospital services, physician services, advanced practice registered nursing services, physician assistant services, home health services, skilled nursing facilities, long term acute care hospital and durable medical equipment and supplies.

We are waiving prior authorization requirements for all services (except pharmacy services) necessary to appropriately evaluate and treat members diagnosed with COVID-19. Please refer to official diagnosis coding guidelines that have been published by the Centers for Disease Control (CDC).

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.

To ensure providers can focus on serving their patients – and be paid for all medically necessary services rendered – we have initiated our “COVID-19 Payment Exception Process”:

  • Prior to billing for services that require prior authorization, providers should submit an authorization request to document medical necessity.
    • We will not deny claims for services provided during the State of Emergency related to COVID-19 for late notification.
    • We will, however, review the authorization request to confirm medical necessity.
    • In the event any prior authorization requests are sent to us (even though not required), we will review them as per our normal process and if not medically necessary will issue a denial letter (NABD).
  • In the event a provider encounters extenuating circumstances that make it not possible to submit an authorization request, please send signed documentation of the reason for not being able to submit a request using our COVID-19 Temporary Appeal Form, along with any appropriate supporting documentation. In addition, if a provider receives any other claim denials for services rendered during the State of Emergency that they believe to be in error, please also submit those using the COVID-19 Temporary Appeal Form on our web portal.
  • This policy is effective immediately, unless otherwise specified. We reserve the right to update this Exception Process based on continued developments related to the State of Emergency for COVID-19 and/or direction from any applicable regulatory agency.  We will communicate when the Exception Process has ended and normal health plan processes are back in effect.
  • We will reimburse non-network providers at the rates established in the applicable Medicaid fee schedules incorporated by reference in Rule 59G-4.002, F.A.C. and the provider reimbursement rates / reimbursement methodologies published on the Florida Agency for Health Care Administration’s web page for covered services rendered to our members, unless other rates are mutually agreed upon.
  • We will pay for medically necessary services provided to members diagnosed with COVID-19, regardless of whether the provider is located in-state or out-of-state.  Providers that are not already enrolled with Florida Agency For Health Care Administration that render covered services to our members must complete the Agency’s provisional (temporary) enrollment process to obtain a provider identification number in order to be reimbursed for covered services rendered to enrollees who evacuated to other states. The process for provisional provider enrollment is located on the Florida Medicaid Web Portal.
  • If you have questions about the COVID-19 Payment Exception Process, email SunshineProviderRelations@Sunshinehealth.com, call 1-844-477-8313 or fax 1-844-990-1274.

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.