COVID-19 Information and Resources

Harvard Pilgrim is waiving member cost share for viral testing through Dec. 31, 2020 for commercial and Medicare Advantage members in all states.

Viral testing for current COVID-19 infection is covered when ordered by a physician or appropriately licensed health care professional, or for Maine members when in accordance with the State of Maine regulatory guidelines.

Members should always use participating providers/laboratories for all COVID-19 testing. Tests for employment screening, public screening, student screening, and travel screening are not covered benefits, except for Maine members when in compliance with and required by the State of Maine regulatory guidelines.

Please refer to our COVID-19 Testing and Treatment Coding grid for guidance on CPT/ICD-10 coding.

• For commercial members, testing for previous COVID-19 infection is covered only when it is an FDA-authorized test, when ordered by a physician or appropriately licensed health care professional, and when medically necessary for the provider to help make decisions about the member’s treatment for an immediate medical condition (e.g. transplant services).
• Harvard Pilgrim’s commercial COVID-19 Antibody (Serological) Testing Medical Policy, which is effective for dates of service beginning Aug. 15, 2020, outlines the criteria necessary for coverage. If you believe your claim should be considered medically necessary under these criteria, please submit an appeal with appropriate medical documentation.
• Testing for commercial members meeting the above criteria is covered in full with no copayment, deductible, or cost sharing through the COVID-19 emergency period. Members are eligible for two COVID-19 antibody tests (that meet the criteria in the medical policy) per lifetime.

Please refer to our COVID-19 Testing and Treatment Coding grid for guidance on CPT/ICD-10 coding.

Harvard Pilgrim will cover COVID-19 treatment in full without member cost sharing (no copayments, deductibles, or coinsurance) for all our fully insured commercial, Medicare Advantage, Medicare Supplement, and Medicare Enhance plans through Dec. 31, 2020.

Please refer to our COVID-19 Testing and Treatment Coding grid for guidance on CPT/ICD-10 coding.

With flu vaccines more important than ever before, Harvard Pilgrim is conducting outreach to members, employer groups, brokers, and providers to encourage members to get their annual flu shot. In addition to our educational campaign, Harvard Pilgrim has updated our influenza vaccine coverage, now providing coverage for flu vaccines delivered in pharmacies for children age 3 or older. Previously, Harvard Pilgrim reimbursed for influenza vaccines provided in pharmacies for members age 19 or older, with flu vaccines for members age 18 and younger covered when delivered in a doctor’s office.

We’re emphasizing telemedicine services to our members and have expanded the scope of our telemedicine coverage for telephone only, audio/video, and e-visits.

Please refer to our Interim Telemedicine and Telehealth Payment Policy for guidance for our commercial products, and CMS guidelines for Medicare Advantage. We will continue to evaluate market conditions and will inform the network in advance of an end date or any further changes to this interim policy.

Harvard Pilgrim will continue to reimburse for telemedicine, telehealth, and telephone only services consistent with in-person rates through Dec. 31, 2020 or the end of the public health emergency period, whichever is later. Harvard Pilgrim will comply with state regulations.

Telemedicine services may be utilized for any clinically appropriate, medically necessary covered service, provided the service can be administered effectively via telemedicine/telehealth technology.

While this includes services such as PT/OT/ST, lactation services, and home care, providers should carefully evaluate whether certain services are appropriate to provide via telemedicine/telehealth, with care plan, patient need, and ability to effectively deliver remotely all considered. For example, certain home health aide services would not be eligible for telemedicine reimbursement.

For Medicare Advantage members, Harvard Pilgrim reimburses according to CMS guidelines; please refer to CMS information on telemedicine for more information.

Cost sharing for telemedicine services, resumed for commercial members on Oct. 1, 2020 — unless telemedicine is being utilized for COVID treatment, in which case cost sharing is waived through Dec. 31, 2020.

Cost sharing will continue to be waived for all telemedicine services (no copays, deductibles, or coinsurance) for Medicare Advantage members through Dec. 31, 2020.

Referral requirements for all telemedicine/telehealth services, not only COVID-19 claims, were reinstated as of Sept. 28, 2020.

For details on Telemedicine/Telehealth, please refer to our Telemedicine/Telehealth Payment Policy (COVID-19 Pandemic) for commercial products and CMS guidance for Medicare Advantage plans. In addition, please keep the following coding guidance in mind.

Coding for commercial plans:

• In addition to standard claim coding, report telemedicine/telehealth services with POS 02 with an appropriate modifier (95, GT, GQ, G0, GP). We reimburse for CPT codes 99421, 99422, 99423; however, we will also accept G2010 and G2012.
• Providers may bill for well visits performed via telemedicine
• The applicable modifier — GT or 95 — is dependent on the codes being billed. The codes eligible for modifier GT are determined by CMS, while the AMA determines the codes eligible for modifier 95.

Coding for Medicare Advantage:

• Expanded telehealth services covered under the 1135 waiver that are provided by synchronous two-way audio-visual technology should be reported with modifier 95 and the place of service that would be reported if the services were provided in person.
• All traditionally covered Medicare telehealth claims should be reported with a place of service 02, in accordance with Medicare billing requirements.
• CMS does not allow for the use of evaluation and management codes for services provided by telephone only. Telephone only services should be billed using CPT codes 99441–99443

MA commercial products: For dates of service through Dec. 31, 2020, Harvard Pilgrim will suspend prior authorization on elective admissions at acute care facilities and acute inpatient admissions at acute care, skilled nursing (SNF), long-term acute care (LTAC), and rehab facilities. Please provide notification within two business days and updates every 5 days to enable Harvard Pilgrim to assist in coordinating care and discharge planning. Hospitals should use their best efforts to transfer members to in-network providers. Refer to this list of Medicare Advantage and commercial in-network IRF/LTAC and SNF facilities  for guidance. Refer to our medical necessity guidelines for more information.

All other states and Medicare Advantage: Prior authorization was reinstated for dates of service beginning June 30, 2020.

Harvard Pilgrim reinstated concurrent review on SNF, LTAC, inpatient rehab, and home care facilities as of June 30, 2020 in all markets.

Where there is a critical need for more clinicians to provide care for COVID-19 patients,   Harvard Pilgrim has developed expedited credentialing and enrollment protocols to help hospitals and other health care facilities quickly meet this demand, in conjunction with HealthCare Administrative Solutions, Inc. (HCAS).

• Under this adapted process, Harvard Pilgrim will fast-track credentialing and enrollment of clinicians (including those coming from out of state) being activated to directly assist with this public health crisis and will provisionally credential them for 180 days.
• This Expedited Credentialing and Enrollment document provides instructions on how to make a request for provisional credentialing, including the information required, submission email address, and other important details.
• Providers already credentialed by Harvard Pilgrim do not need to be recredentialed to practice at a new location. Please refer to the Clinical Credentialing and Recredentialing Policy for details. To update or change a practice location, please complete the Changing Provider Enrollment Information Form in the commercial Provider Manual and follow the instructions on the form for returning it. We will work to expedite changes as quickly as possible.
• For initial inquiries related credentialing/enrollment of out-of-state providers, please provide the following information: number of providers, provider types, and whether those providers would be acting in an inpatient only or other setting.

For Medicare Advantage, please be aware that the CARES Act (Coronavirus Aid, Relief, and Economic Security) temporarily suspends the mandatory payment known as sequestration, effective for claims with dates of service from May 1 through Dec. 31, 2020. Harvard Pilgrim will be processing these claims accordingly.

Harvard Pilgrim has adjusted our policies to reimburse certified registered nurse anesthetists (CRNAs) for providing medically appropriate covered services, including Evaluation and Management and Critical Care services.