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.
03.31.2021 — Updated to reflect that COVID-19 treatment cost-sharing waiver extended until further notice.
03.22.2021 — Updating COVID-19 treatment information for clarification.
03.09.2021 — Updated COVID-19 testing information to note that cost-sharing is waived as noted below until further notice.
03.08.2021 — Updated information the prior authorization section with clarification on authorization, notification, and concurrent review requirements for acute care admissions, post-acute care admissions, COVID-19 and non-COVID-19 admissions, and hospice services. Updated section on monoclonal antibody treatment to specify coverage applies for outpatient settings, here and in COVID-19 Testing,Treatment, and Vaccine Coding Grid.
We’re here to support you, our members, and employers during the COVID-19 public health emergency. We’re continually assessing and adapting our policies and business operations to support our members in receiving the care they need, including any necessary testing and treatment for COVID-19, and to aid our provider partners in ensuring that patients can safely access the care they need. Please review the following information — which applies to our fully insured, Medicare Advantage, Medicare Enhance, and Medicare Supplement plans, unless otherwise noted — to learn more.
With the COVID-19 vaccine given Emergency Use Authorization (EUA), Harvard Pilgrim offers the following guidance for providers on administering the vaccine. 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 state and federal guidelines on availability of the vaccine and populations who should receive vaccinations first).
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.
- The Centers for Disease Control, CMS, and Advisory Committee on Immunization Practices (ACIP) have released guidance on the administration of the COVID-19 vaccines, and we expect states to coordinate vaccine administration efforts, as well.
- 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. Requirements are detailed in the CDC’s Interim Jurisdiction COVID-19 Vaccination Playbook and include:
- Be able to meet the reporting requirements outlined by the CDC, including that providers must report certain data elements for each dose administered into their system of record within 24 hours of administration and into the applicable public health system (state or local) within 72 hours. These records must be made available to any federal, state, local, or territorial public health department to the extent authorized by law.
- Communicate to their patients about the need to get both doses of the same vaccine.
- Be able to comply with CDC requirements for vaccine management such as storage and temperature monitoring and reporting requirements (unused vaccine, spoilage, errors in administration, etc.)
- Provide a completed COVID-19 vaccination record card to every vaccine recipient or parent/legal representative. Information on the card includes vaccine manufacturer, lot number, date of first dose administration, and second dose due date.
- Submit the necessary information for the CDC Covid-19 Vaccination Provider Profile form for each location where the vaccine will be administered (days and hours of operation, setting type, populations service, storage unit capacity and ability to maintain required temperatures, etc.)
- Providers should coordinate with their state health departments to implement CDC and ACIP guidance.
- Please refer to CMS’s provider toolkits for details on how to become a vaccinator.
- To allow the vaccines to be delivered to the population in a widespread, efficient way, the vaccines will likely be administered in a variety of settings — mobile clinics, occupational health settings, mass vaccination sites, pharmacies, doctor’s offices, urgent care clinics, hospitals, etc.
As vaccine supply will be limited initially, federal and state health agencies, such as the CDC, CMS, and state health departments, will provide guidance on the populations for initial focus, such as healthcare personnel, individuals living in long-term care facilities, and adults with high risk medical conditions that may put them at risk for severe COVID-19 illness, among others. Providers should administer vaccines consistent with this guidance.
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.
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 until further notice.
Please refer to our COVID-19 Testing, Treatment , and Vaccine Coding grid for guidance on CPT/ICD-10 coding.
- 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). For coding information, please refer to Harvard Pilgrim’s COVID-19 Testing, Treatment and Vaccine Coding grid.
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 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, 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 testing or treatment, cost-sharing is waived for commercial and Medicare Advantage members 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:
- Prior authorization will not be required (including for transfers to post-acute non-hospital facilities and for home health care for MA members).
- 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: Harvard Pilgrim has reinstated prior authorization on elective admissions for post-acute care at non-hospital locations, including skilled nursing (SNF), long-term acute care (LTAC), and inpatient rehab facilities, for dates of service on or after April 1, 2021, except for COVID-19 diagnosis. 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.
- 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 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 with a COVID-19 diagnosis.
Harvard Pilgrim reserves the right to retroactively review services for medical necessity. For all admissions, Harvard Pilgrim remains available to assist with discharge planning.
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 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.