In an effort to keep you up-to-date during this time, the Alliance is publishing a COVID-19 e-newsletter every Monday for our providers.
Submitting claims for repeat appointments
With the increased social distancing efforts in response to COVID-19,
providers have likely had to pivot from primarily face-to-face interactions
to a greater reliance on telehealth by phone or video chat.
One challenge you may be facing is how to submit claims for patients seen twice on the same date of service. This
situation might occur if you’ve triaged a patient over a telehealth
appointment and determined that they need to be seen in the office.
In order to ensure the claim is processed and avoid a denial for the second
appointment, you will need to submit additional documentation with the
claim, outlining the medical justification for two services rendered to the
same provider, for the same patient, on the same date of service. This can
be done by
adding a note in the remarks section of the claim that indicates the
separate times the member was seen
or otherwise indicating the claim is not a duplicate bill.
If you have questions about this process, please direct billing questions
to Claims support staff at 800-700-3874, ext. 5503
New billing codes for testing
As our members continue to be affected by the COVID-19 pandemic, you are
likely busy screening patients and prescribing COVID-19 laboratory testing.
We want you to know that
the Alliance covers both laboratory testing and screening for COVID-19.
To ensure you receive appropriate reimbursement,
you must submit COVID-19 related claims using the procedure codes
outlined in the table below.
Note that these are base rates only. Contracted providers
will be paid in accordance with the fee schedule outlined in their contract. Refer to your Alliance
Provider Agreement to determine specific contracted rates.
The Alliance would like to extend our continued gratitude to all of our
provider offices for the important work you’re doing to keep our community
safe and well.
We encourage you to contact a Provider Relations Representative,
800-700-3874, ext. 5504, with any questions about COVID-19 procedure
codes and reimbursements.
Authorization updates and changes
In order to expedite services to our members during the pandemic, we have implemented authorization updates and changes:
- Authorizations for approvals are extended to the end of 2020.
- Out of Area (OOA) Authorized Referrals (AR) are approved.
- Face-to-face authorization for durable medical equipment (DME) and the Medical Therapy Program (MTP) are waived.
- Face-to-face certifications are not required for any authorizations that typically require them.
- Bipap and Respiratory Assist Devices (RADs) are automatically approved: Sleep tests for RAD/PAP are waived.
- Home sleep center testing is approved.
- Home oxygen requests are automatically approved: Oximetry for home O2 is waived.
- Home ventilators are automatically approved: Ventilator medical necessity documentation is waived.
- Prothrombin time and international normalized ratio (PT/INR) monitoring is automatically approved.
- Manual BP monitors for home monitoring are approved.
- Telehealth requests are approved, and providers may use previously approved authorization requests for telehealth services.
- Home health care (HHC) post-service approval: No authorizations are required to start services.
Reminder on new telehealth guidance
The Department of Health Care Services (DHCS) and the Department of Managed Health Care (DMHC) have issued new guidance regarding the provision of telehealth services during the COVID-19 pandemic. In order to support social distancing and ensure the safety of members and providers, Alliance providers must take steps to allow members to obtain health care via telehealth when medically appropriate to do so.
Telephonic or video visits: Any clinician eligible to bill for office visits may conduct a telephone or video visit with a patient in lieu of an office visit by way of a HIPAA-compliant platform that supports provider to patient communication for patient care. Such visits must last at least five minutes, must be documented in the patient’s medical record and are subject to oral or written consent by the patient. Per DHCS guidance, FQHCs and RHCs may count video visits and telephone visits the same as in-office visits for the purpose of prospective payment.
Required Codes for Telehealth Services:
- Existing face-to-face codes apply when a Medi-Cal provider/clinician is billing the Alliance for video/telephonic visits. Example codes for the PCP Setting: 99201-99204, 99212-99214
- The CPT or HCPCS code(s) must be billed using:
- Place of Service Code “02”
- Use appropriate telehealth modifiers
- Synchronous, interactive audio and telecommunications systems: Modifier 95
- Asynchronous store and forward telecommunications systems: Modifier GQ
Please note: Not all services are appropriate for telehealth (for example, benefits or services that require direct visualization or instrumentation of bodily structures). The Alliance will communicate any new or additional guidance to allowable telehealth services as it becomes available.
Alliance Provider Services and Claims staff are available to assist with questions. Speak to a Provider Relations Representative by calling 800-700-3874, ext. 5504.