The Ohio Medicaid Managed Care Plans have decided to continue to extend the temporary payment policy allowing for reimbursement to non-VFC providers for both the toxoid and the administration of needed immunizations for children and adolescents ages 0-20 years old. This policy will take effect for dates of service beginning on 01/01/2022 and will continue through 12/31/2022. 

UPDATE:

Effective April 13, 2022, Buckeye is following ODM guidance to rescind the lift of all prior authorizations and/or pre-certifications for all long-term acute care facility (hospital), skilled nursing facility (SNF), and Inpatient Rehabilitation facility (IRF-hospital) admissions that was previously announced in an August 27, 2021, memo. 

Since issuing the August 27th memo, Ohio has seen a decrease in both the number of COVID-19 cases and the number of hospitalizations due to COVID-19. As such, the mandate for MCPs and MCOPs to remove prior authorizations and/or pre-certifications for long-term acute care facilities, inpatient rehabilitation facilities and skilled nursing facility admissions will be rescinded.

August 27, 2021 Memo Lifting All Prior Authorizations for LTC Acute Care, SNFs, and IP Rehab Admissions

Ohio is experiencing another surge in COVID-19 cases, hospitalizations, and ICU admissions across the state. In response, the Ohio Department of Medicaid (ODM) is requiring Medicaid managed care organizations (MCOs) and MyCare Ohio plans (MCOPs) [for services where Medicaid is the primary payer] to lift all prior authorizations and/or pre-certifications for all long-term acute care facility (hospital), skilled nursing facility (SNF), and Inpatient Rehabilitation facility (IRF-hospital) admissions. It is imperative that we respond swiftly to remove barriers to care and reduce administrative burden on hospitals, SNFs, and IRFs.

MCOs and MCOPs shall assist providers with discharge planning activities including:

• Ensuring the member is transferred to the appropriate facility and level of care
• Adding services for the member’s home care needs
• Expediting referrals to participating providers, and
• Ensuring all plans are in place before the member discharges.

Lifting prior authorization requirements for long-term acute care facility (LTACH), SNF, and IRF (hospital) admissions is effective August 27, 2021. Limited authorizations, i.e. three-day authorizations upon notification a SNF admission, are prohibited. MCOs and MCOPs shall continue to determine their members’ level of care upon admission.

MCOs and MCOPs will be notified when this mandate ends. For more information about this directive, contact managedcarepolicy@medicaid.ohio.gov

Latest Provider FAQ's - (PDF)

Ohio Managed Care Plans (MCPs) are extending the member gift card program through June 30th, 2022 and will include all members who are 5 years and older. Any member who receives their first dose of the COVID-19 vaccine will be eligible for the member gift card program.

Additionally, the increased administration fee (any dose for members 5 years and older) will continue to be paid at $100 as part of the provider enhanced reimbursement program for vaccinations for dates of service starting November 1, 2021 through June 30, 2022.

The applicable CPT codes are found below: 

First Dose

• 0001A: Pfizer-BioNTech
• 0011A: Moderna
• 0031A: Johnson & Johnson’s Janssen

Second Dose

• 0002A: Pfizer-BioNTech
• 0012A: Moderna

Third Dose

• 0003A: Pfizer-BioNTech
• 0013A: Moderna

Booster

• 0004A: Pfizer-BioNTech
• 0064A: Moderna
• 0034A: Johnson & Johnson’s Janssen

CPT codes for pediatric billing (children ages 5-11, only).

First Dose

• 0071A: Pfizer-BioNTech

Second Dose

• 0072A: Pfizer-BioNTech

For extensive CPT billing guidelines, access this CMS reference page.

The increase of the administration fee includes all professional claims. Federally qualified health clinics (FQHCs) and rural health clinics (RHCs) are also included in the administration fee increase and will be paid following the same reimbursement process as given in a previous notification. However, it does not apply to the following providers and/or claims:

• Hospitals
• Emergency Rooms
• Hospital Clinics
• Pharmacies
• ASCs
• Dialysis Centers
• EAPG and DRG claims
• SNF claims
• LTAC claims

Payments will be notated by the following CARC and RARC codes:

• CARC code: 144 – incentive adjustment (e.g. preferred product/service)
• RARC code: MA125 – per legislation governing this program, payment constitutes payment in full

Please note that while it is not required, we encourage you to bill the vaccine and the administration code together for reporting purposes. You will need to bill one vaccine code and one administration code per dose of the vaccine administered. At this time, there will be no reimbursement for the vaccine, only the administration fee.

Providers will have until October 1, 2022 to submit claims for administration of the vaccine to receive the bonus payment.

More details and additional materials can be found at COVID Vax on the Spot.  If you have questions, reach out to Provider Services at 866.296.8731.

Providers who administer the vaccine will also receive an administration fee increase through June 30, 2022 date of service. Please provide the member with the Member Incentive Voucher (PDF) after they have received the vaccination.

In early May, Governor DeWine challenged the Medicaid Managed Care Organizations (MCOs) to increase the Medicaid COVID-19 vaccination rate to match the statewide rate. In response to this urgent public health initiative, all 6 Ohio Medicaid MCOs –Aetna, Buckeye Health Plan, CareSource, Molina Healthcare, Paramount Advantage, and UnitedHealthcare – are working collaboratively to ensure Ohioans eligible for the vaccines are able to receive them. Primary efforts focused on Medicaid individuals 18 years of age and older and the providers who serve them. With the number of COVID cases continuing to rise in Ohio, and the growing concerns for Ohio’s children, Ohio Medicaid MCOs’ vaccine initiatives were recently expanded to include individuals 5 years of age and older and extended through December 31, 2021.

Medicaid MCOs are offering a $100 gift card to all Medicaid Managed Care and MyCare members ages 5 years and older who receive their first dose of the COVID-19 vaccination between now and December 31, 2021. MCOs are also working with pharmacies, providers, and community partners (e.g., local health districts, schools) to increase awareness of the importance of the vaccine, where to receive the vaccine, and the gift card program. Gift cards are available at some pharmacy, provider, and community event vaccination sites; gift cards are also available by contacting the MCO if someone is vaccinated at a place without gift cards on hand. At this time, there are no sign offs required by recipients (parents/caregivers/youth) of the gift cards at pharmacies, physician offices, or community vaccine events.

This is where we need your help! As part of Ohio’s ongoing encouragement of children and youth in custody and their caregivers to receive the COVID-19 vaccine, we ask that you share the gift card opportunity with your youth, their caregivers and primary parents (if applicable), and provider networks. In the event the gift card is not provided at the point of vaccination, but through the MCO’s established process, the gift card will be mailed to the placement address in SACWIS that is contained in the MCO’s enrollment file. Recognizing that youth may have a placement change and miss the gift card in the mail, we request that the previous provider contact the PCSA to know where to forward the card. If you have specific questions about the gift card program, please contact the child’s MCO Member Services number on the back of the health plan ID card or reach out to the appropriate contact on the MCO Contacts for Children in Custody/PCSAs. Lastly, there is a website Vax on the Spot that provides information on vaccine locations, gift cards, transportation assistance, and much more.

At this time, Ohio Managed Care Plans (MCPs) are expanding the member gift card program to include all members who are 5 years and older. Any member who receives their first dose of the COVID-19 vaccine will be eligible for the member gift card program.

Additionally, the increased administration fee (any dose for members ages 5 and older) will be paid at $100 as part of the provider enhanced reimbursement program for vaccinations for dates of service between Nov. 1 and Dec. 31, 2021.

Please see below the pediatric CPT codes for billing (children ages 5-11, only). For extensive CPT billing guidelines, access this CMS reference page.

Pfizer Vaccine

• 91307: Severe acute respiratory syndrome coronavirus 2
• 0071A: Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2
• 0072A: Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2

Please access this Ohio Department of Medicaid (ODM) bulletin to learn more about the authorization of the COVID-19 vaccine for children ages 5-11.

Ohio MCPs will pay the additional $100 for participating and non-participating providers for the first, second, third and booster doses provided between Nov. 1 and Dec. 31, 2021. The increase of the administration fee includes all professional claims. Federally qualified health clinics (FQHCs) and rural health clinics (RHCs) are also included in the administration fee increase and will be paid following the same reimbursement process as given in <a previous notification.> However, it does not apply to the following providers and/or claims:

• Hospitals
• Emergency Rooms
• Hospital Clinics
• Pharmacies
• ASCs
• Dialysis Centers
• EAPG and DRG claims
• SNF claims
• LTAC claims

Payments will be notated by the following CARC and RARC codes:

• CARC code: 144 – incentive adjustment (e.g. preferred product/service)
• RARC code: MA125 – per legislation governing this program, payment constitutes payment in full

Please note that while it is not required, we encourage you to bill the vaccine and the administration code together for reporting purposes. You will need to bill one vaccine code and one administration code per dose of the vaccine administered. At this time, there will be no reimbursement for the vaccine, only the administration fee.

Providers will have until March 1, 2022 to submit claims for administration of the initial vaccination to receive the bonus payment (regardless of FQHC status).

Questions? Please reach out to Provider Services at 866.296.8731.

MCAIDOAHP-VAX-0043

ODM is increasing the rates for at-home vaccine administration for COVID-19 vaccinations. Previously, ODM reimbursed $37.98 for each vaccine administration as well as an add-on payment for M0201 at $33.36 for each dose of COVID-19 vaccine administered in an individual's home.

As of October 1, 2021, ODM will begin reimbursing M0201 with an SY modifier at $62.02 per dose in addition to the $37.98 for COVID-19 vaccine administration. This will result in a total reimbursement of $100 for each COVID-19 vaccine dose administered to an individual in their home. M0201 appended with SY modifier should be reported For the FFS population only. Since MCPs already pay providers $100.00 for COVID vaccine administration, MCPs can continue to pay $33.36 for M0201 and do not need to adopt the SY modifier.

ODM is making this change in order to align with managed care reimbursement rates. This increase will be reflected in the Provider-Administered Pharmaceuticals fee schedule, effective October 1, 2021.

Weekly Update Topics April 23, 2021 (PDF)

• Johnson and Johnson (Janssen) vaccine update
• Best Practices
• Equity Pop-Up Clinics
• Cleveland mass vaccination clinic to offer first doeses
• New PSA's to share
• Talking Points

Weekly Update Topics March 18, 2021 (PDF)

• New groups eligible for vaccination
• New Vaccine Management Solution scheduling
• Mass vaccination sites
• Talking Points

See archive below.

COVID-19 Vaccination Workgroup Handout - March 3, 2021 (PDF)

• Latest on all three vaccines:
  • Pfizer-BioNtech
  • Moderna
  • Johnson and Johnson-Janssen
• How the Janssen vaccine works and key features
• Vaccines at a Glance
• Nusing Home Guidelines

Weekly Update Topics March 11, 2021 (PDF)

• New groups eligible for vaccination
• New Vaccine Management Solution is live
• Mass vaccination sites
• New CDC Guidelines for fully vaccinated individuals
• Talking Points

Weekly Update Topics February 27, 2021 (PDF)

• Possible vaccine shipment delays due to severe weather
• Pfizer vaccine quantities update
• VMS 411 sessions to be held on Wednesdays and Fridays at 3:00 p.m.
• COVID-19 Vaccine Town Halls start Monday, February 22, 2021
• Reminder: medical disorders group began February 15, 2021
• Talking Points

Weekly Update Topics 2-8-21 (PDF)

• Ohio launching new Vaccine Management Solution (VMS)
• Process announced for medical disorders group beginning February 15
• Save the Date: Ohio's COVID-19 Vaccine Town Halls
• Ohio administers more than 1 million doses of COVID-19 vaccine
• Updated Target Population/Occupation Checklists
• Johnson & Johnson has submitted EUA application
• Talking Points

Weekly Update February 4, 2021 PDF

• Where those with disabilities should go to schedule vaccines
• K-12 School Staff Vaccination Program underway
• Do not hold back second doses from first-dose shipments of vaccine
• Acceptable forms of identification
• Talking Points

Weekly Update January 25, 2021 PDF

• CDC has updated clinical guidance
• Resources available for working with patients with disabilities
• New VaxText resource
• Continue proper reporting
• Submit information for statewide Vaccine Provider Location searches
• No vaccine should be wasted
• Correction from last week's update
• Talking Points

Weekly Update January 20, 2021 PDF

• Submit information for statewide Vaccine Provider Location search
• Phase 1B begins
• Vaccinations for those with qualifying medical conditions
• Vaccine allocation
• Expectation to immediately vaccinate
• Vaccinating vaccinators
• Talking  Points

ODH Town Hall Information

Ohio’s COVID-19 Vaccine Town Halls begin Feb. 22 Whether you hear myths on social media, at work, or from friends or family, there is a lot of dangerous misinformation out there about COVID-19 vaccines.

The truth is that COVID-19 vaccines are safe, effective, and rigorously tested. Ohio’s COVID-19 Vaccine Town Halls are designed to help you sift through the myths and learn where you can find reliable, trustworthy information about COVID-19 vaccines.

You’ve got questions, and the upcoming Town Halls will give you answers. Hear from medical experts, community leaders, and public health professionals.

Watch livestreams at the following dates and times:

• Monday, Feb. 22, 6:30 p.m. – African American Ohioans 
• Tuesday, Feb. 23, 6:30 p.m. – Hispanic/Latino Ohioans
• Monday, March 1, 6:30 p.m. – Asian American and Pacific Islander Ohioans
• Tuesday, March 2, 6:30 p.m. – Rural Ohioans 

How to watch: Watch live or on-demand after the event:

• Facebook - OH Department of Health
• YouTube - OH Deptartment of Health
• Online - OH Department of Health
  

Watch later on TV: Watch later on the Ohio Channel. Find the date and time, and your local channel by checking with your PBS station or television provider.

Learn more about Townhalls 

Medicaid Vaccine Resource Links

How to enroll:

• Pandemic Vaccine
• Provider Enrollment Information

Provider Resources:

• Pandemic Vaccine
• Provider Resource Page
• FAQ for Health Providers
• Phase 1B guidance

Pfizer Resources:

• Pfizer-BioNTech
• COVID-19 Vaccine Fact Sheet for Providers

Moderna Resources:

• EUA Fact Sheet for
• Vaccination Providers
• EUA Fact Sheet for
• Recipients and Caregivers

Vaccines Communications Toolkit: This toolkit will be expanded with additional resources but is being provided now to support your immediate needs.

Resources for the Public

• coronavirus.ohio.gov/vaccine
• Ohio's Phased Approach
• Priority Populations Distribution Fact Sheet
• Phase 1B Distribution Graphic and medical conditions
• Myths vs. Facts
• COVID-19 Vaccines FAQ
• Safety and effectiveness of COVID-19 vaccines
• Trust the facts graphic

CDC Resources

• Communications Toolkit for Medical Centers, Clinics and Clinicians
• Vaccinate with Confidence
• Understanding How COVID-19 Vaccines Work
• About V-Safe
• Benefits of Getting a COVID-19 Vaccine
• What to Expect at Your Vaccine Appointment
• Ensuring Safety of Vaccines
• Different Vaccines

Update on February 25: The flexibilities listed below will expire on February 28, 2022 for all Medicare and Ambetter products.

• Inpatient Admissions: We will allow notification of admission up to 5 days post admission date and complete medical necessity reviews when notification is received.
  
  
• Post-Acute Accommodations for rehab hospitals and Long Term Acute Care hospitals (LTACH):
  • We will relax our requirements related to facility transfers including:
  • We will not require discharging acute care facilities to obtain prior authorization for patient transfers to participating post-acute facilities. 
  • We will not require sending facilities to provide notification of transfer to participating providers. 
  • However, we will require receiving facilities to notify the health plan of patient admission.  And we will accept notification up to five days post-transfer.
  • We will continue to conduct medical necessity review
  • Because we will not have visibility prior to transfer, we request that hospitals utilize our in network post-acute facilities
     
• Skilled Nursing Facilities: We will allow post admission notification and authorize up to a 7 day stay before medical necessity continued stay review.

TEMPORARY MEDICARE PLAN WAIVERS EXPIRING FOR APPLICABLE COVID-19 TREATMENT AND TELEHEALTH SERVICES ON JUNE 1, 2021

As we continue to address the COVID-19 pandemic, we want to update you on important changes for our Medicare plans. Last year, we instituted temporary member cost share liability and prior authorization waivers for select services to ensure critical care could be quickly delivered to our members during a time of heightened need. On June 1, 2021, these temporary waivers will expire and our members’ Medicare plan benefits will be reinstated for the following services:

COVID-19 Treatment Related Services

• COVID-19 treatment related services (those billed with a confirmed ICD-10 diagnosis code) will continue to be eligible for coverage at this time, in accordance with the member’s plan benefits.
• Beginning June 1, 2021, prior authorization will be required for COVID-19 treatment related services in accordance with CMS guidance and plan benefits.
• Providers should also resume collecting Medicare member liability at the point of service for applicable treatment related services on June 1, 2021 onward.

Telehealth Services

• Any services that can be delivered virtually will continue to be eligible for telehealth coverage at this time.
• Beginning June 1, 2021, prior authorization requirements will be reinstated for applicable services delivered via telehealth.
• Providers should also resume collecting Medicare member liability at the point of service for all telehealth services on June 1, 2021 onward, in accordance with the member’s plan benefits.
• Providers should reflect telehealth care on their claim form by following standard telehealth billing protocols in their state.
• For further coding guidance for telehealth services, we recommend following what is being published by:
  • Department of Health and Human Services (HHS)
  • American Medical Association (AMA)
  • Centers for Commercial/Marketplace and Medicaid (CMS)

Prior authorization requirements and member cost share liability (copayments, coinsurance and/or deductible cost share amounts) will continue to be waived for COVID-19 testing, screening services and vaccinations.

We are working in close partnership with state, local and federal authorities to serve and protect our members and communities during the COVID-19 pandemic, including ensuring that our providers have relevant and up-to-date information. We value your partnership during these unprecedented times.

This guidance is in response to the current COVID-19 pandemic and may be retired at a future date.

THE CENTERS FOR MEDICARE AND MEDICAID (CMS) RELEASE AN Interim Final Rule Addressing COVID-19 Vaccine Coverage

Ambetter from Buckeye Health Plan is closely following advancements in the prevention and treatment of COVID-19, including vaccinations. As a healthcare provider, you will play an integral role as COVID-19 vaccines become available. We want to update you on important new information about vaccine coverage.

To prepare for vaccine administration, the Centers for Medicare and Medicaid (CMS) have begun to publish guidance for providers.  Similar to other COVID-19 services, the vaccines will be offered at no cost to your patients. In addition:

• Ambetter from Buckeye Health Plan will configure its systems to properly adjudicate COVID-19 vaccine-related claims, both for the vaccine and its administration
• Member liability will be $0
• Non-participating provider pre-auth requirements will be waived
• Provider reimbursement rates and emergency use authorizations (EUA) are all still pending and we will update you as that information becomes available

The American Medical Association (AMA) has published updates to the Current Procedural Terminology (CPT®) code set that includes new vaccine-specific codes to report immunizations for the novel coronavirus (SARS-CoV-2). The code set will continue to be updated as additional vaccines receive EUA approval by the U.S. Food & Drug Administration (FDA).

The following codes have been published as of December 21, 2020. However, they will not be billable until the specific vaccine receives official EUA approval.

Payment Allowances and Effective Dates for COVID-19 Vaccines and Treatment during the Public Health Emergency:

Additionally, CMS has also published a set of toolkits to help providers prepare to swiftly administer the vaccine once it is available. If you have any further questions about this upcoming vaccine or the COVID-19 services Ambetter from Buckeye Health Plan covers, please contact Provider Services at 877.687.1189.

UPDATED PROVIDER BILLING GUIDANCE FOR COVID-19 VACCINE, TESTING, SCREENING & TREATMENT SERVICES

We are closely monitoring and following all guidance from the Centers for Medicare and Medicaid as it is released to ensure we can quickly address and support the prevention, screening, and treatment of COVID-19. The following guidance can be used to bill for services related to COVID-19 vaccinations, testing, screening and treatment services. This guidance is in response to the current COVID-19 pandemic and may be retired at a future date. For additional information and guidance on COVID-19 billing and coding, please visit the resource centers of the Centers for Medicare and Medicaid (CMS) and the American Medical Association (AMA).  

COVID-19 Vaccines

• All member cost share (copayment, coinsurance and/or deductible amounts) will be waived for claims billed with the new COVID-19 vaccine codes.
• In addition to cost share, authorization requirements will be waived for any claim that is received with these specified codes. This includes non-participating providers.
• Per CMS guidance, all Medicare claims for the COVID-19 vaccine and its administration must be billed directly to Original Medicare fee-for-service (FFS).
• All Medicare claims related to the COVID-19 vaccine codes will be denied, with direction to submit directly to Medicare FFS for payment.
• The following codes have been published as of February 22, 2021. NOTE: Vaccines will not be billable until the specific vaccine receives official EUA approval. Currently approved vaccines are denoted by their effective date below.

• We will employ the reimbursement rates established by CMS and our state regulators in accordance with provider contract terms for COVID-19 vaccine payments.

COVID-19 Testing Services

• Providers performing the COVID-19 test can bill us for testing services that occurred after February 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.”
  • PLA 0202U - Effective May 20, 2020. Infectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected.

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.

• These codes should not be used for serologic tests that detect COVID-19 antibodies.
• All member cost share (copayment, coinsurance and/or deductible amounts) will be waived across all products 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.
• We will employ the reimbursement rates established by CMS and our state regulators in accordance with provider contract terms for COVID-19 testing services payments.

COVID-19 Antigen Testing Services

• Providers performing COVID-19 antigen tests can bill us for testing services that occurred after June 25, 2020, using the following HCPCS codes:
  • 87426 - Infectious agent antigen detection by immunoassay technique, qualitative or semiquantitative, multiple-step method; severe acute respiratory syndrome coronavirus (eg SARS-CoV, SARA-CoV-2 (COVID-19).
  • 0223U - Infectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected
  • 0224U - Antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease (COVID-19) includes titer(s), when performed (Do not report 0224U in conjunction with 86769).
• All member cost share (copayment, coinsurance and/or deductible amounts) will be waived across all products for any claim billed with the above COVID-19 antibody testing codes.
• In addition to cost share, authorization requirements will be waived for any claim that is received with these specified codes. This includes non-participating providers.
• Providers billing with these codes will not be limited by provider type and can be both participating and non-participating.
• We will employ the reimbursement rates established by CMS and our state regulators in accordance with provider contract terms for COVID-19 antigen testing services payments.

High-Throughput Technology Testing Services

• Providers performing high production COVID-19 diagnostic testing via high-throughput technology can bill us for testing services that occurred after February 4, 2020, using the following newly created HCPCS codes:
  • HCPCS U0003 - Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique, making use of high throughput technologies as described by CMS-2020-01-R.
  • Please note: U0003 should identify tests that would otherwise be identified by CPT code 87635 but for being performed with these high throughput technologies.
  • HCPCS U0004 -2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC, making use of high throughput technologies as described by CMS-2020-01-R.
  • Please note: U0004 should identify tests that would otherwise be identified by U0002 but for being performed with these high throughput technologies.
• Neither U0003 nor U0004 should be used for tests that detect COVID-19 antibodies.
• We have configured our systems to apply $0 member cost share liability for those claims submitted utilizing these codes to indicate high production testing.
• Providers billing with these codes will not be limited by provider type and can be both participating and non-participating.
• We will employ the reimbursement rates established by CMS and our state regulators in accordance with provider contract terms for COVID-19 high-throughput technology services payments.

COVID-19 Specimen Transfers

• For specimen transfer related claims, the following codes can be used:
  • G2023 - Spec Clct for SARS-COV-2 COVID 19 ANY SPEC SRC
  • G2024 - SP CLCT SARS-COV2 COVID19 FRM SNF/LAB ANY SPEC
  • C9803 - Hospital outpatient clinic visit specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), any specimen source. This is effective for services provided on or after March 1, 2020.
• Providers billing with these codes will not be limited by provider type and can be both participating and non-participating.
• We will employ the reimbursement rates established by CMS and our state regulators in accordance with provider contract terms for COVID-19 specimen transfer payments.

COVID-19 Screening Services

• All member cost share (copayment, coinsurance and/or deductible amounts) will be waived for COVID-19 screening visits and if billed alongside a COVID-19 testing code.
• If no testing is performed, providers may still bill for COVID-19 screening visits for suspected contact using the following Z codes:
  • Z20.828 – Contact with a (suspected) exposure to other viral communicable diseases
  • Z03.818 – Exposure to COVID-19 and the virus is ruled out after evaluation
• This applies to services that occurred as of February 4, 2020.
• Providers billing with these codes will not be limited by provider type.
• We will employ the reimbursement rates established by CMS and our state regulators in accordance with provider contract terms for COVID-19 screening service payments.

COVID-19 Treatment Services

• For dates of service of April 1, 2020 and later, providers should use the ICD-10 diagnosis code:
  • U07.1 – 2019-nCov Confirmed by Lab Testing
• We will waive member cost sharing for COVID-19 treatment for all members for dates of service through May 31, 2021.
• For dates of service June 1, 2021 and onward, providers should collect Medicare and Marketplace member cost share (copayment, coinsurance and/or deductible amounts) at the point of service.
• Prior authorization requirements will continue to be waived for COVID-19 treatment services.

COVID-19 Monoclonal Antibody Infusion Services

• All Marketplace and Medicaid member cost share (copayment, coinsurance and/or deductible amounts) will be waived for claims billed with the new COVID-19 monoclonal antibody infusion services codes.
• In addition to cost share, authorization requirements will be waived for any claim that is received with these specified codes. This includes non-participating providers.
• Per CMS guidance, all Medicare claims for monoclonal antibody infusion services must be billed directly to Original Medicare fee-for-service (FFS).
• Medicare claims related to the monoclonal antibody infusion codes will be denied, with direction to submit directly to Medicare FFS for payment.
• CMS has identified the following specific code(s) for the monoclonal antibody product and specific administration code(s) for Medicare payment:
  • Eli Lilly and Company’s Antibody Bamlanivimab (LY-CoV555), EUA effective November 9, 2020
    • Q0239 - Injection, bamlanivimab-xxxx, 700 mg
    • M0239 - Intravenous infusion, bamlanivimab-xxxx, includes infusion and post administration monitorin
  • Regeneron’s Antibody Casirvimab and Imdevimab (REGN10933 and REGN10987), EUA effective November 21, 2020
    • Q0243 – Injection, casirvimab and imdevimab, 2400 mg
    • M0243 – Intravenous infusion, casirvimab and imdevimab, includes infusion and post-administration monitoring
• We will employ the reimbursement rates established by CMS and our state regulators in accordance with provider contract terms for COVID-19 monoclonal antibody infusion service payments.

TALKING TO YOUR PATIENTS ABOUT The COVID-19 VACCINE: How you can engage and inform in a meaningful way

As COVID-19 vaccines are approved and distributed, providers will be a key part in its adoption and administration to the American public. Patients look to their healthcare professionals for medical guidance and assurance, and while much is still unknown, you can start laying the groundwork now for when the vaccines are available. As your partners in healthcare, we want to share some tips for effectively setting expectations and addressing questions from your patients.

Start COVID-19 Vaccine Conversations Early

Even before you are able to offer COVID-19 vaccinations, consider including the topic in your conversations with patients. This will give you the opportunity to set expectations about vaccine availability, including if/when you might recommend vaccination for them, and learn about any concerns they have.

Engage in Effective COVID-19 Vaccine Conversations

Effective engagement can occur during an in-person office visit, through messages on your patient portal, or at a telemedicine appointment. Patients trust in their providers to help guide healthcare decisions, and your strong vaccine recommendation is the most important part of the conversation.

Start with empathy and understanding.

• Acknowledge the disruption COVID-19 has caused in all our lives.
• Provide an opportunity to recognize common concerns that can be addressed by a vaccine.

Assume patients will want to be vaccinated but may not know when to expect it.

• Consider providing the following general information to patients about the timeline for COVID-19 vaccines:
• Limited COVID-19 vaccine doses may be available in 2020.
• It is anticipated that vaccine supply will increase substantially in 2021.
• The goal is for everyone to be able to easily get a COVID-19 vaccine as soon as large quantities are available. However, not everyone will be able to get vaccinated right away.
• Encourage patients to continue taking steps to protect themselves from COVID-19 and let them know how you plan to share updates about vaccine availability.

Give your strong recommendation.

• Let your patients know if you plan to recommend COVID-19 vaccination for them.
• Share the importance of COVID-19 vaccines to protect patients’ health as well as the health of those around them.
• Talk about your personal plans to get a COVID-19 vaccine.
• Reassure your patients that the vaccine is safe.

Listen to and respond to questions.

• If a patient has concerns or questions, this doesn’t mean they won’t accept a COVID-19 vaccine. Sometimes patients want your answers to their questions.
• Your willingness to listen to their concerns will play a major role in building trust in you and your recommendation. Make it clear that you understand they have questions, and that you want to answer them, so they feel confident in choosing to get vaccinated.
• Seek to understand patient/caregiver concerns and provide information they need in a way they can understand it (see Q&A below).

Keep the conversation open.

• After answering their questions, let your patients know that you are open to continuing the conversation and answering any additional questions they may have.
• Encourage patients to take at least one action like:
• Scheduling another appointment.
• Reading any additional information you provide them about COVID-19 vaccination.
• Encourage others to get their COVID-19 vaccine when available.
• Continue to remind patients about the importance of getting a COVID-19 vaccine during future routine visits.

Answering Patient Questions about the Vaccine

Your patients will likely have a lot of questions about the vaccine, and as their healthcare provider, they will turn to you for answers.

Q: Can I make an appointment with you to be vaccinated? If not, why? Do I have to go to a pharmacy to receive the vaccine?

A: Pharmacies are generally the most convenient locations to individuals and they also have great expertise in administering vaccines. While many providers anticipate to have the vaccine in their office later on, for now we recommend patients visit their local pharmacy. The website www.vaccinefinder.org  can help them locate the closest location with current inventory.

Q: Why are some people getting the vaccine before others? Why can’t I get mine yet?

A: Initially, there will be a limited number of vaccines available.  Because of the limited supply, some groups are recommended to get the vaccine first:

• Phase 1A will include residents and employees of nursing homes and long-term care facilities.  They are recommended to get the vaccine first, as they are deemed highly vulnerable.  Long-term care facilities account for a high percentage of the deaths from COVID-19 (40%).
• Additional phases are being developed by federal and state governments.  This will address first-responders, essential workers, older adults and people more at risk for either contracting the virus or becoming seriously ill with the virus.

Q: How do we really know if COVID-19 vaccines are safe? 

A: The Food and Drug Administration (FDA) carefully reviews all safety data from clinical trials. It only authorizes emergency vaccine use when the expected vaccine benefits outweigh potential risks.

• The Advisory Committee on Immunization Practices (ACIP) reviews all safety data before recommending any COVID-19 vaccine for use.
• FDA and CDC will continue to monitor the safety of COVID-19 vaccines to make sure even very rare side effects are identified.

Q: Is the vaccine that helpful? I heard getting COVID-19 gives you better and longer immunity than the protection a vaccine can give. Can it actually make my illness worse if I do end up getting COVID-19? 

A: Explain the potential serious risk COVID-19 infection poses to them and their loved ones if they get the illness or spread it to others.

• Remind them of the potential for long-term health issues after recovery from COVID-19 disease, especially for those who have chronic conditions, are older, or have weakened immune systems.
• Explain that scientists are still learning more about the virus that causes COVID-19. And it is not known whether getting COVID-19 disease will protect everyone against getting it again, or, if it does, how long that protection might last. Therefore getting a vaccine is a safer choice.
• Some vaccines are more effective than the natural illness; it is not clear whether natural illness or vaccination will provide more effective immunity in this case.
• Early information indicates that COVID-19 vaccination may reduce the severity of illness, as well as the incidence of illness. As we learn more about the efficacy of the vaccine, we will also learn more about potential long-term protection it may bring.
• Describe how the vaccine was tested in large clinical trials and what is currently known about its safety and effectiveness.
• Be transparent that the vaccine is not a perfect fix. Patients will still need to practice other precautions like wearing a mask, social distancing, handwashing and other hygiene measures until public health officials say otherwise.

Q: I heard I need 2 vaccines. Why? I don’t want to come back for a second vaccine.

A: Two vaccines are needed to provide the best protection against COVID-19.

• The first vaccine primes the immune system and helps recognize the virus. The second vaccine strengthens the immune response.
• The two doses are given a few weeks apart (e.g. 21 or 28 days depending on vaccine type). Explain the dosing options available in your office and advise the patient that they can set up an appointment before they leave to come back for a second dose.
• Provide members with a vaccination record card to ensure that they know when they received their first vaccine, what type of vaccine they received, and when they need to come back and receive their second vaccine.
• Direct them to their insurance health plan to set up non-emergency transportation, if applicable.

Q: Will the shot hurt? Can it cause you to get sick? I don’t want to get the vaccine because it will give me COVID.

A: List the most common side effects from vaccination are and how severe they may be (e.g. fever, headache, body aches, cold symptoms). Emphasize that a fever could be a potential side effect and when to seek medical care.

• Symptoms will typically go away on their own within a week. Let them know when they should seek medical care if their symptoms don’t go away.
• Explain that the vaccine cannot give someone COVID-19 as the vaccine does not contain a live coronavirus.
• Explain that side effects are a sign that the immune system is effectively working.

Q: Do I have to pay for my vaccines?

A: No! The vaccine will be at no cost to patients. They will not have to pay for either dose of the COVID-19 vaccine.

Follow Vaccine Updates from Trusted Sources of Truth

The Centers for Disease Control (CDC)

National Institutes of Health (NIH)

The Centers for Medicare and Medicaid (CMS)

The American Medical Association (AMA)

Post- Acute Care Prior Authorization Changes

Update March 5, 2021 for Medicare and Ambetter members.

Since issuing the November 2020 memo, Ohio has seen a decrease in both the number of COVID-19 cases and the number of hospitalizations due to COVID-19. As such, we are resuming prior authorizations and/or pre-certifications for long-term acute care facilities, inpatient rehabilitation facilities and skilled nursing facility admissions effective April 1, 2021.  

Updated November 18, 2020 for Medicare and Ambetter members.

To reduce barriers to care and reduce administrative burden for providers caring for our Medicare and Ambetter members, we have made the following changes to our prior authorization policies:

1. Prior authorization requirements for long term acute care facilities (LTAC), skilled nursing facilities (SNF) and inpatient rehabilitation facilities (IRF hospital) are being waived.  Upon admission to your facility, please contact Buckeye Health Plan as you do today to allow for determination of appropriate level of care and to continue concurrent stay review to assist with discharge planning activities to ensure safe transitions to next the level of care including:
   • Ensuring member are transferred to appropriate level of care
   • Adding services for member home care needs
   • Expediting referrals to participating providers
   • Ensuring all plans are in place before the member discharge
      
2. We will extend authorizations for elective hospital services and surgical procedures for up to six months when treatments, procedures or services have been postponed.

Contact by phone:  866-246-4359

Fax: SN/Rehab/LTAC requests 866-529-0291 / Elective and /or scheduled admits 866-529-0290

On October 5, 2020, HHS Secretary Alex Azar renewed the COVID-19 Public Health Emergency. This extends flexibilities and funding tied to the public health emergency (PHE) to continue through January 21, 2021.

With this renewal the various testing, screening, billing, and telehealth coverages that were implemented in response to the COVID-19 Public Health Emergency earlier this year will be extended to Buckeye Health Plan members through late January, until the PHE is either terminated or extended again.  This extension does not affect coverages that had already been made effective through December 31, 2020.

In accordance with this extension, Buckeye Health Plan has updated the General Guidance for COVID-19 Testing, Screening, and Treatment document, as well as the COVID-19 Telehealth Guidance for Providers documents posted on our website.

If you have any questions about this extension or the covered benefits impacted by it, please contact Provider Services at 866-296-8731.

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 indefinitely for dates of service beginning March 9, 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. 

Please refer to ODM's website for the full Telehealth Billing Guidelines During COVID-19 State of Emergency (PDF). This document was updated on July 17, 2020. 

Buckeye Health Plan is working to quickly address and support screening, testing and treatment for COVID-19, and is closely following guidance from the Centers for Medicare and Medicaid Services (CMS). As of April 1, 2020, the following guidance can be used to bill for services related to the screening and treatment of COVID-19.

COVID-19 Screening Services

• All member cost share (copayment, coinsurance and/or deductible amounts) will be waived for COVID-19 screening visits and if billed alongside a COVID-19 testing code.
• This applies to services that occurred as of February 4, 2020.

As a reminder, only those services associated with screening and/or treatment for COVID-19 will be eligible for prior authorization and member liability waivers.  For screening or treatment not related to COVID-19 normal copayment, coinsurance, and deductibles will apply.

CMS has new COVID-19 ICD-10 procedure codes that will be effective date on 8/1/2020. Please refer to the ICD-10 MS-DRGs Version 37.2 (PDF).

We are closely monitoring and following all guidance from the Centers for Medicare and Medicaid (CMS) as it is released to ensure we can quickly address and support the prevention, screening, and treatment of COVID-19. Coding and modifier information for the expansion of telehealth benefits are available in the ODM Billing Guidance document. Access to this and other key documents around COVID-19 can be found on ODM's website.    

In addition, below is specific Buckeye Health Plan guidance.

COVID-19 Testing Services

• All member cost share (copayment, coinsurance and/or deductible amounts) will be waived across all products 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.

Medicare Reimbursement Rates for COVID-19 Testing Services for All Provider Types*

We are complying with the rates published on 3/12/20 by CMS:

• U0001 = $35.91
• U0002 = $51.31

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.

Buckeye Health Plan can assist FQHC providers with receiving PPE (mask, gloves, gowns, hand sanitizer).

Tara Bires - TBires@centene.com is the facilitator of these request and can assist you with getting supplies to the FQHCs.

To assist our providers in accessing the multiple funding streams available, the Business Development team is developing a page on the Centene website that will:

• Provide access  to the SBA loan application
• Help providers understand available funding opportunities (SBA and grant funding)
• Connect them with a member of the Business Development team that can assist in completing required applications.
  

You will find more details around the CARES Act (financial assistance and relief) and the EIDL and PPP loans available on our Centene site.

Buckeye’s Pharmacy team is working to increase member access to medications where appropriate for COVID-19.

1. Increase member access to medications where appropriate for COVID-19:
   • Refill too soon over rides
   • Quality limit over rides
   • Prior authorization over rides
   • Exception: Refill too soon override NOT allowed for opioids.
2. Over-the-counter (OTC) medications may be covered through the Medicaid pharmacy benefit without a prescription.
3. 90-day supply for medications along with HIV and Transplant medications
   • Maintenance Drug Pharmacy Program (PDF)
4. Delivery of medications with no additional charge to member. Below is a list of some of the major chains that participate in this effort:
   • CVS
   • Walgreens
   • Exactcare Pharmacy

The Centers for Medicare & Medicaid Services (CMS) have released guidance for implementing several provisions included in the Coronavirus Aid, Relief, and Economic Security (CARES) Act. Buckeye Health Plan will be following this guidance as we adjudicate Medicare claims for applicable COVID-19 inpatient treatment services.

The CARES Act provides for a 20% increase to the inpatient prospective payment system (IPPS) Diagnosis Related Group (DRG) rate for COVID-19 patients for the duration of the public health emergency. The increase will be applied to claims that include the applicable COVID-19 ICD-10-CM diagnosis code and meet the date of service requirements, as follows:

• Discharges occurring on or after January 27 and on or before March 31:
  • B97.29 – Other coronavirus as the cause of diseases classified elsewhere
  • CDC coding guidance for cases discharging on March 31 and prior (PDF)
• Discharges occurring on or after April 1:
  • U07.1 – COVID-19
  • CDC coding guidance for cases discharging on April 1 and after (PDF)

For discharges with the diagnosis codes above, [HEALTH PLAN] will follow the Medicare billing guidance published by CMS (PDF). Inpatient claims for these COVID-19 discharges that have already been received will be automatically reprocessed to reflect the payment increase.

This guidance is in response to the COVID-19 pandemic and may be retired at a future date.

Sources:

The Centers for Medicare and Medicaid (CMS)

• New Waivers for Inpatient Prospective Payment System (IPPS) Hospitals, Long-Term Care Hospitals (LTCHs), and Inpatient Rehabilitation Facilities (IRFs) (PDF)
  
• July 2020 Quarterly Update to the Inpatient Prospective Payment System (IPPS) Fiscal Year (FY) 2020 Pricer (PDF)
  

The Centers for Disease Control (CDC)

• ICD-10-CM Official Coding and Reporting Guidelines (PDF)
  
• ICD-10-CM Official Coding Guidelines - Supplement Coding encounters related to COVID-19 Coronavirus Outbreak (PDF)

Allwell from Buckeye Health Plan EXTENDS $0 MEMBER LIABILITY FOR Primary Care, Behavioral Health, and Telehealth SERVICES for Remainder of 2020

Since March, Allwell from Buckeye Health Plan has waived pre-authorizations, co-pays, and other costs related to COVID-19 testing, screening and medically necessary treatment. We also have waived prescription refill limits, and members are able to refill prescriptions prior to their refill date during this crisis.

As seniors face increased social and economic barriers to care amid the pandemic, we are now offering a number of expanded benefits to help our eligible Medicare Advantage members address issues such as out-of-pocket medical costs, food insecurity, and medication assistance.

Effective July 1, 2020, expanded benefits will include:

• $0 Member Liability Extension: We are waiving in-network member costs for all primary care visits for the rest of 2020. We are also waiving member costs for outpatient, non-facility-based behavioral health visits and are extending telehealth cost share waivers for all telehealth visits—primary care, specialty, and behavioral health—for in-network providers for the remainder of 2020. This does not include inpatient hospital, behavioral health facility, or urgent care visits. Medicare members with state benefits will continue to receive support through coordination with their states.
• Extended Meal Benefits – Members eligible for meal benefits due to a chronic condition or recent discharge may receive an additional 14 meals delivered to their home at no cost.
• Increased Annual Wellness Visit Incentives – Members may be eligible for an increased incentive for completing their Annual Wellness Visits, a benefit offered at no cost to the member.
• Additional Over-The-Counter (OTC) Benefits – Plans with an OTC benefit may now receive additional allowance dollars in monthly or quarterly increments, adding up to as much as $150 for the remainder of 2020, depending on plan.
• Access to WellCare’s Community Connections Help Line – The Community Connections Help Line – a toll-free line provided by our partners at WellCare and available to anyone in need – is staffed by peer coaches and support specialists who can refer individuals and caregivers in need to a database of more than half a million social services in local communities across the country. By calling the line at 1-866-775-2192, members can also receive help coordinating of the expanded meal program benefits, OTC allowances, and annual wellness visit incentives via the line.

Beginning July 1, 2020, providers should waive the member liability for the eligible primary and behavioral health care claims at the point of service, and forego the collection of the member cost share. This is a benefit change for our members and our claims system will be configured to administer these adjusted benefits. We recognize that providers have different reimbursement/accounting arrangements with us, and the costs associated with this benefit change will follow the accounting processes as outlined in the provider’s contract with Allwell from Buckeye Health Plan. For services rendered to Medicare members with state benefits, providers should continue to collect that member cost share from their State Medicaid Agency as per usual.

The COVID-19 global pandemic has created unprecedented changes to our lives and healthcare systems. While we continue to connect our members to COVID-19 services, we wanted to reach out to our provider partners on how we can work together to better support their care needs.

As a primary care physician (PCP), you are at the heart of our members’ healthcare. They trust and rely on you to help them access appropriate, affordable, coordinated care from the right providers, at the right time. If you refer our members to an out-of-network provider – or send their test specimens to a non-participating laboratory – they could be responsible for the out-of-network charges according to their benefits. These costs can quickly add up, especially for patients who do not have out-of-network benefits.

You can help your patients avoid this and keep their medical costs down by referring them to providers within their Buckeye Health Plan network, as denoted on their Member ID card. Understanding it can sometimes be challenging to navigate multiple payor networks to connect patients to appropriate in-network providers and facilities, we want to share two easy methods for you to access this information quickly:

• Search In-Network Providers Online (PDF). Our provider directory offers the current list of our in-network providers. You can also access this tool via our provider portal.
• Call to your Provider Services Representative at 1-866-296-8731. They can help you quickly identify in-network specialists and labs.

Thank you for your continued partnership during this time of heightened concern. If you have any questions regarding our networks, please contact Provider Services at 1-866-296-8731.

This guidance is in response to the current COVID-19 pandemic and may be retired at a future date.

There are many additional resources for information around COVID-19, coding for expanded telehealth services and other Ohio-specific information from the Ohio Department of Medicaid:

ODM links

• Telehealth FAQ (PDF)
• MITS BITS Newsletter (PDF)

OAC rules for OhioMHAS and ODM

• OhioMHAS Details
• ODM Rule (PDF)
• OhioMHAS Telecom Policies (PDF)

CMS (Medicare) links

CMS Telehealth Guidelines for Medicare