06.07.2021 – Updates to cost-sharing and authorization policies, effective for dates of service on or after Aug. 7, 2021.
05.18.2021 — Update to prior authorization for post-acute care section for consistency with Massachusetts mandate.
04.21.2021 — Updated Medicare Advantage sequestration language related to CMS extension of suspension period to Dec. 31, 2021.
04.05.2021 — Updated prior authorization section to confirm that prior authorization requirements were reinstated for inpatient treatment and outpatient scheduled surgeries for Massachusetts commercial products for dates of service on or after April 1, 2021. In addition, prior authorization and notification requirements for hospice services for all lines of business and concurrent review for Massachusetts commercial products were reinstated as of April 1, 2021.
During the public health emergency, we have adapted our policies and business operations to support our members in receiving the care and to aid our provider partners in ensuring that patients can safely access the care they need. As COVID-19 cases continue to fall and states lift emergency orders, Harvard Pilgrim Health Care is returning to many pre-pandemic operations and policies. Please see the information below — which applies to our fully insured, Medicare Advantage, Medicare Enhance, and Medicare Supplement plans, unless otherwise noted — for details on COVID-19 related practices.
Harvard Pilgrim understands the urgency of getting vaccines administered swiftly and effectively and is committed to supporting providers in this important work. We are also conducting education and outreach to our members to educate them about the known safety of COVID-19 vaccines and the importance of getting vaccinated.
Consistent with federal requirements, Harvard Pilgrim is waiving cost-sharing for the administration of COVID-19 vaccines for all members in all states. The federal government has purchased the vaccine and is supplying it to vaccinators. Harvard Pilgrim is reimbursing for administration of the vaccines and services associated with vaccine administration for all fully insured commercial members, while the Centers for Medicare and Medicaid Services (CMS) is reimbursing these costs for Medicare Advantage members.
In order to administer the vaccines, providers must enroll in the federal COVID-19 Vaccination Program coordinated through their jurisdiction’s immunization program and must meet certain requirements, including vaccine documentation and reporting requirements. For information on becoming a vaccinator, please refer to the Centers for Disease Control, CMS, and Advisory Committee on Immunization Practices (ACIP) guidance on the administration of the COVID-19 vaccines. For details, please refer to the CDC’s Interim Jurisdiction COVID-19 Vaccination Playbook and CMS’s provider toolkits.
Harvard Pilgrim is not requiring authorization or referrals in order for members to receive COVID-19 vaccines.
For Medicare Advantage members — As stated in CMS’ Interim Final Rule regarding COVID-19 from Oct. 29, 2020, Original (Fee-for-Service) Medicare will reimburse providers for the vaccine and its administration for all Medicare beneficiaries through the end of 2021, including those enrolled in a Medicare Advantage plan. Therefore, during this time, providers should submit claims for the administration of the vaccine to Harvard Pilgrim StrideSM (HMO) members to the appropriate CMS Medicare Administrative Contractor (MAC) for payment. As noted earlier, the federal government has purchased the initial supply of the COVID-19 vaccines; as a requirement of participating in the COVID-19 Vaccination Program, providers contractually agree to administer a COVID-19 vaccine regardless of an individual’s ability to pay and regardless of their coverage status, and also may not seek any reimbursement, including through balance billing a vaccine recipient.
For commercial members —Providers will receive the vaccines from state and/or federal health agencies and should bill Harvard Pilgrim directly for the administration of the vaccine. Providers should submit claims in the usual manner — electronically or via paper. For details, refer to the Claims Submission Guidelines policy. For accurate reimbursement, please be sure to use the appropriate COVID-19 vaccine administration codes.
While Harvard Pilgrim encourages the use of in-network providers, we will reimburse in- and out-of-network providers for the administration of the vaccine. The reimbursement rate includes vaccine administration, public health reporting, and patient outreach, education, and counseling.
The federal government has purchased the vaccine and is supplying it to vaccinators. As such, please bill Harvard Pilgrim for vaccine administration only using the appropriate vaccine administration coding.Please refer to this COVID-19 Testing, Treatment and Vaccine Coding Grid for details for billing information.
COVID-19 Testing and Treatment
- Harvard Pilgrim Health Plan will pay 100% of the allowed amount for medically necessary testing (including, but not limited to radiology and lab tests). Harvard Pilgrim is waiving member cost share (i.e., no copayments, deductibles or coinsurance) for viral and antibody testing until further notice for commercial and Medicare Advantage members in all states. Providers should not collect a copayment from members.
- Testing for COVID-19 infection is covered when ordered or referred by a physician or appropriately licensed health care provider, or for Maine members when in accordance with the State of Maine regulatory guidelines.
- Tests self-ordered by members, including tests ordered through an online self-completed questionnaire, are not covered for reimbursement.
- At-home COVID-19 PCR tests are not covered unless ordered or referred by a physician or attending provider.
- FDA-authorized antibody testing for COVID-19 is covered only when it has been determined by a provider who has performed an individualized clinical assessment to be medically necessary to make decisions about a member’s care in accordance with current CDC and state public health department guidelines, which are being continuously updated. This applies for Medicare Advantage members, and for commercial members.
- Tests are not covered if conducted solely for return-to-work or return-to-school purposes, for public health surveillance, or for any other purpose not primarily intended for individualized diagnosis or treatment, except for Maine members when in compliance with and required by the State of Maine regulatory guidelines.
- Testing for asymptomatic members, including those with no known or suspected exposure to COVID-19, is covered when being admitted to a health care facility or when it has been determined by a provider who has performed an individualized clinical assessment to be medically necessary to make decisions about a member’s care in accordance with current CDC and state public health department guidelines, which are being continuously updated.
- Members are encouraged to use participating providers/laboratories for all COVID-19 testing. However, this policy applies to in-network and out-of-network providers.
Please refer to our COVID-19 Testing, Treatment, and Vaccine Coding Grid for guidance on CPT/ICD-10 coding.
Effective for dates of service on or after Aug. 7, 2021, Harvard Pilgrim will resume cost share for COVID-19 treatment for members of our Maine, New Hampshire, and Connecticut commercial, Medicare Advantage, Medicare Supplement, and Medicare Enhance plans products. For members of Massachusetts plans, Harvard Pilgrim will continue to waive cost share for COVID-19 treatment until further notice.
- Monoclonal antibody treatment: These cost-sharing policies apply as well for monoclonal antibody treatment. Harvard Pilgrim covers medically necessary monoclonal antibody treatment in outpatient settings, without prior authorization as per the FDA’s emergency use authorization (EUA) criteria, for the treatment of mild to moderate COVID-19 in adult and pediatric patients with positive COVID-19 test results who are at high risk for progressing to severe COVID-19 and/or hospitalization. Please refer to monoclonal antibody treatment information from the Centers for Medicare and Medicaid Services and Centers for Disease Control for details on limitations of authorized use and instructions for healthcare providers. For commercial members, submit claims to Harvard Pilgrim; for Medicare Advantage members, submit claims to the appropriate Medicare Administrative Contractor (MAC).
- Telemedicine/Telehealth COVID-19 treatment: For COVID-19 treatment via telemedicine/telehealth, Harvard Pilgrim is resuming cost sharing for Maine, New Hampshire, and Connecticut members for dates of service beginning Aug. 7, 2021; for members of Massachusetts products, Harvard Pilgrim is continuing to waive cost-sharing until further notice. For more information on telemedicine/telehealth, please see the section below.
Please refer to our COVID-19 Testing, Treatment and Vaccine Coding Grid for guidance on CPT/ICD-10 coding.
Harvard Pilgrim emphasized telemedicine services for our members during the pandemic. Please refer to our Interim Telemedicine and Telehealth Payment Policy for guidance on telemedicine coverage 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 until further notice and in accordance 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 for conditions other than COVID-19 treatment resumed for commercial members* on Oct. 1, 2020 and Medicare Advantage members on Jan. 1, 2021.
If, however, telemedicine services are being used for COVID-19 treatment, cost-sharing applies as follows:
• For Maine, New Hampshire, and Connecticut members: Harvard Pilgrim is resuming cost sharing for these members for dates of service beginning Aug. 7, 2021.
• For members of Massachusetts products: Harvard Pilgrim is continuing to waive cost-sharing until further notice.
*for fully insured accounts. While most self-insured accounts align with Harvard Pilgrim’s fully-insured cost-sharing policies, some self-insured accounts may elect to to enact cost-sharing policies that differ from those of our fully insured products.
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, for commercial plans, please keep the following in mind:
- Report telemedicine/telehealth services with POS 02 with an appropriate modifier. For details on coding, please refer to our COVID-19 Testing, Treatment and Vaccine Coding Grid.
- Providers may bill for well visits performed via telemedicine
Prior Authorization Policies & Procedures
For diagnoses and treatments related to COVID-19 or for members suspected of contracting COVID-19:
- Members of Maine, New Hampshire and Connecticut plans: Prior authorization requirements will resume, as applicable, for members of Harvard Pilgrim’s commercial, Medicare Advantage, Medicare Supplement, and Medicare Enhance plans products, effective for dates of service on or after Aug. 7, 2021
- Members of Massachusetts plans: Prior authorization requirements will not be required until further notice. Notification will be required within 2 business days of the admission.
These services are never subject to prior authorization. Notification is required within 2 business days after the date of admission.
Effective for dates of service on or after April 1, 2021, Harvard Pilgrim has reinstated review requirements (prior authorization requirements and/or concurrent review, as applicable) for elective inpatient treatment, outpatient scheduled surgeries, or admissions to acute care or mental health hospitals for Massachusetts commercial products. For all other states and products, prior authorization requirements apply. Pre-COVID processes should be followed.
- MA commercial products: Effective for dates of service on or after Aug. 7, 2021, Harvard Pilgrim is resuming prior authorization requirements for post-acute care at non-hospital locations, such as skilled nursing (SNF), long-term acute care (LTAC), inpatient rehab facilities and home care, including following an inpatient hospital admission.
- All other states and Medicare Advantage: Prior authorization was reinstated for dates of service beginning June 30, 2020.
- Acute care and mental health facility admissions: Effective for dates of service on or after April 1,2021, Harvard Pilgrim reinstated concurrent review requirements for Massachusetts commercial products for all inpatient treatment including inpatient hospice services and behavioral health or non-behavioral health admissions at acute care and mental health facilities. Notification is required within 2 days of the admission.
- Rehab and other post-acute admissions: Harvard Pilgrim reinstated concurrent review on SNF, LTAC, inpatient rehab, and home care facilities as of June 30, 2020 in all other markets.
Standard prior authorization requirement for hospice services delivered in outpatient and post-acute care facilities were reinstated for dates of service on or after April 1, 2021 for all lines of business with the exception of Massachusetts members . Effective for dates of service on or after Aug. 7, 2021, prior authorization requirements will apply for Massachusetts members.
For Medicare Advantage, please be aware that CMS has extended the suspension of the sequestration payment reduction through Dec. 31, 2021. Consistent with this CMS requirement, Harvard Pilgrim Health Care has suspended the reimbursement reductions for Medicare Advantage hospital rates and professional rates for acute care hospitals, clinicians, physicians and PCPs, and is processing 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.