COVID-19 Information and Resources

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 Stride^SM (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.

Harvard Pilgrim is waiving member cost share for viral testing through March 31, 2021 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.

FDA-approved PCR home tests are covered when ordered by a physician or attending provider. Home tests that are self-ordered by members, including over-the-counter tests and/or tests ordered through an online self-completed questionnaire, are not covered for reimbursement.

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

FDA-authorized antibody testing for COVID-19 is covered only when it has been determined medically necessary by a provider who has performed an individualized clinical assessment 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 (effective for commercial for dates of service beginning 2/22/2021).

For coding guidance for commercial members, please refer to our COVID-19 Testing, Treatment, and Vaccine Coding Grid.

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 March 31, 2021.

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

• Monoclonal antibody treatment: Effective for dates of service on or after Nov. 9, 2020, Harvard Pilgrim covers medically necessary monoclonal antibody treatment, 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.

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

If, however, telemedicine services are being used for COVID-19 testing or treatment, cost-sharing is waived for commercial and Medicare Advantage members through March 31, 2021.

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

MA commercial products: Harvard Pilgrim has suspended 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 for dates of service through March 31, 2021. Prior authorization requirements for these services will resume on April 1, 2021. 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.

To support providers with capacity issues and rescheduling needs as COVID-19 cases continue to surge, Harvard Pilgrim is extending date ranges on authorizations for elective inpatient admissions. New and existing authorizations will remain open and valid through March 31, 2021. Any authorizations that are used will be closed. This applies for our commercial and Medicare Advantage members in all markets, as well as authorizations approved by our vendor partner National Imaging Associates, Inc. (NIA).

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 CMS has temporarily suspended the mandatory payment known as sequestration, effective for claims with dates of service from May 1 through March 31, 2021. 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.