COVID-19 Provider Payment Provisions
Centers for Medicare and Medicaid Services issued a set of blanket waivers that states may utilize in response to COVID-19. The Agency for Health Care Administration has received authority for many of these waivers related to health care facilities and licensure requirements. The Agency is actively working to receive the federal authority needed for many of the items listed in this alert related to the Medicaid program. The Agency will be issuing subsequent guidance related to additional flexibilities or service enhancements that will be enacted to ensure there is no disruption in care for Medicaid recipients in the event of workforce shortages or limitations in recipients seeking care in provider.
At Lighthouse Health Plan we are updating policy and procedures to meet the State guidance and to support our providers. Our website and resources are routinely updated with information available for your review. The following information will help guide you through revised credentialing, administrative, claims and support services policies. We are available to assist you regarding these changes through our Provider Services line at (844) 243-5174 Monday – Friday 7a – 7p CST / 8a - 8p EST. You may also call your provider relations specialist directly or email ProviderRelations@LighthouseHealthPlan.com with any questions. We will continue to update our policies based on evolving events and AHCA guidance.
Provider Enrollment Flexibilities
To ensure adequacy of providers for treatment of members diagnosed with COVID-19 and under the Agency for Health Care Administration’s directive, Lighthouse Health plan will cover medically necessary services provided to recipients diagnosed with COVID-19, regardless of whether the provider is located in-state or out-of-state and is not currently participating in Florida Medicaid. The goal of this process is to minimize the administrative effort required by providers to get paid for services they rendered to Lighthouse members impacted by COVID-19. Non-participating providers will be reimbursed the provider reimbursement rates / reimbursement methodologies published on the Florida Agency for Health Care Administration’s web page for covered services rendered to our members, unless other rates are mutually agreed upon.
To be reimbursed for services rendered to eligible Lighthouse members, providers not already enrolled in Florida Medicaid (out-of-state or in-state) must complete / provide:
- A fully completed provisional (temporary) enrollment application. For the application form, click here.
- A fully completed claim form containing the provider’s active National Provider Identifier (NPI), along with the provider’s SSN/FEIN;
- A copy of the provider’s professional license; and
- Please email the information to ProvisionalEnrollment@LighthouseHealthPlan.com
- Please contact ProviderRelations@LighthouseHealthPlan.com if you have questions about this process.
In the event of workforce shortages in the State, practitioners that are not already enrolled in Florida can seek enrollment following the instructions above.
Prior Authorization and Limits
The Agency for Health Care Administration (Agency) has enacted provider flexibilities to help respond to the 2019 novel coronavirus (COVID-19). As the State commences reopening, we will evaluate each flexibility that was enacted to determine the potential end date.
Prior Authorization Requirements and Waivers
Update Effective June 19, 2020: Consistent with Phase 2 of Governor Ron DeSantis’ Plan for Florida's Recovery, Lighthouse Health Plan will reinstate prior authorization requirements for the following services that were previously waived in response to COVID-19:
- Hospital services (including long-term care hospitals)
- Nursing facility services
- Physician services
- Advanced practice registered nursing services
- Physician assistant services
- Home health services
- Ambulance transportation; and
- Durable medical equipment and supplies.
This change is effective for dates of service on or after June 19, 2020, when prior authorization is required for the service. For additional information, please see AHCA related alert here.
This change does not include Behavioral health services covered under the Medicaid program. Behavioral health services exempt from this change include community behavioral health services, inpatient behavioral health services, and targeted case management services. The AHCA related guidance on Behavioral Health issued on April 21, 2020 and May 5, 2020 is still in place. View related AHCA alerts 2020-24 and 2020-31.
On July 9, the Agency issued alert 2020-39, and updated it on July 14 with alert 2020-41 to facilitate prompt hospital discharges and to ensure adequate inpatient hospital capacity in response to COVID-19. With these changes, Florida Medicaid is waiving service authorization requirements prior to admission for hospital transfers, including:
- inter-facility transfers:
- transfers to a long-term care hospital; and
- transfers to a nursing facility.
This change applies to the fee-for-service and managed care delivery system. The Agency will continue this flexibility until further notice.
Statewide Medicaid Managed Care
- The waiver of prior authorization applies whether the receiving facility is a participating provider or non-participating provider in the health plan’s network.
- Health plans may require the receiving facility to notify the plan of the admission within forty-eight (48) hours of the admission. At that point, the plan may request additional clinical information to begin concurrent/continued stay reviews to facilitate care coordination and discharge planning.
- Fee-for-Service Delivery System
- For inter-facility hospital transfers (hospital to hospital), the receiving hospital facility will need to request a simple, administrative prior authorization through eQHealth Solutions to ensure streamlined reimbursement. Clinical reviews will not take place at this time.
We will waive limits on services (specifically related to frequency, duration, and scope) that need to be exceeded in order to maintain the health and safety of recipients diagnosed with COVID-19 or when it is necessary to maintain a recipient safely in their home.
Specifically, this accommodation allows for providers to:
- Exceed service limits to maintain the health and safety of recipients diagnosed with COVID-19 or when it is necessary to maintain a recipient safely in their home (inpatient, home health, etc.)
- Add coverage of the COVID-19 lab test codes
- Allow early refills of maintenance medication (excluding controlled substances)
- Eliminate restrictions on the use of mail order delivery of maintenance medications
- Allow patients to request a 90-day supply of medications when that quantity is available at the pharmacy; patients can also request a 90-day supply of their medications be delivered through mail order.
In addition, we will waive limits on Medicaid services, including but not limited to 45-day in-patient hospital stays, home health services, and durable medical equipment. Medical records may be requested for medical necessity review. During this time Lighthouse Health Plan will allow enrollees more time to request a fair hearing or health plan appeals.
Preadmission Screening and Resident Review (PASRR) processes may be postponed until further notice. Retro screenings and reviews must document the reason for the delay.
Non-urgent and Non-emergent Services
Providers must delay services that are considered non-urgent/non-emergent and will not place the enrollee's health at risk. The executive order directing this decision can be found here.
For prior authorizations that were previously obtained and approved, but where delays in completing the procedures occurred as a result of the response to COVID-19, Florida Medicaid and Lighthouse will extend the approval period for affected authorizations for at least six months.
Lighthouse Health Plan waives all co-payments, including co-payments for COVID-19 related services.
Early Prescription Refills
Lighthouse Health Plan has lifted all limits on early prescription refills during the state of emergency for maintenance medications, except for controlled substances. For additional information, please contact member services. Recipients may request a 90-day supply of medications when that quantity is available at the pharmacy; recipients can also request a 90-day supply of their medications be delivered through mail order.
Members may have more time to request a fair hearing and appeals.
Claim Submission Requirements
Claim submission requirements remain largely the same with added diagnosis and laboratory testing codes available for COVID-19 related care as well as modifiers for telemedicine. Please check this website for updates on additional information as the situation develops.
COVID-19 Diagnosis Codes
When submitting COVID-19 related claims, follow the appropriate CDC guidance on diagnosis coding for the date of service. The CDC has provided interim coding guidance on which ICD-10 diagnosis codes to report until a new code becomes effective April 1, 2020.
Interim code guidelines:
- ICD-10-CM Official Coding Guidelines – Supplement: Coding encounters related to COVID-19 Coronavirus Outbreak
New ICD-10-CM diagnosis code, effective April 1, 2020:
- New ICD-10-CM Code for the 2019 Novel Coronavirus (COVID-19): New ICD Code for Coronavirus 2-20-2020
Lab providers should use the newly created HCPCS codes when billing for COVID-19 testing.
- Click here for the April 27, 2020 AHCA Alert: Coverage of Coronavirus Laboratory Testing Update New Procedure Codes and Rapid Testing
- Click here for the April 27, 2020 Statewide Medicaid Managed Care (SMMC) Policy Transmittal: 2020-26
- Click here for the June 12, 2020 Additional Guidance on Antibody Testing Alert
This coding information is from the AHCA alert issued on 3/18/2020: Telemedicine Guidance for Medical and Behavioral Health Providers and 3/20/2020 - Telemedicine Guidance for Therapy Services and Early Intervention Services.
Practitioners: The Agency covers physician, physician extenders (advanced practice registered nurses and physician assistants), and clinic providers (county health departments, federally qualified health centers, and rural health clinics) through telemedicine. Covered medical services include evaluation, diagnostic, and treatment recommendations for services included on the Agency’s practitioner fee schedule to the extent telemedicine is designated in the American Medical Association’s Current Procedural Terminology (i.e., national coding standards). All service components included in the procedure code must be completed in order to be reimbursed. The Agency reimburses services using telemedicine at the same rate detailed on the practitioner fee schedule. Providers must append the GT modifier to the procedure code in the fee-for-service delivery system.
AHCA Fee Schedule: Link to AHCA fee schedule For certain evaluation and management services provided during the state of emergency period, the Agency is expanding telehealth to include store-and-forward and remote patient monitoring modalities rendered by licensed physicians and physician extenders (including those operating within a clinic) functioning within their scope of practice. The Agency will reimburse each service once per day per recipient, as medically necessary.
Updated Telemedicine Services and Codes:
|Service||Procedure Code||Modifier Required|
|Telephone Communications –
Therapy Services: Florida Medicaid will reimburse for evaluation, diagnostic, and treatment recommendations for services included on the respective therapy services fee schedule to the extent services can be delivered in a manner that is consistent with the standard of care and all service components designated in the American Medical Association’s Current Procedural Terminology and the Florida Medicaid coverage policy is provided. Providers must append the GT modifier to the procedure code in the fee-for-service delivery system.
Early Intervention Services: Florida Medicaid will reimburse for the delivery of early intervention sessions via telemedicine when performed by an eligible EIS provider (as defined in the Medicaid coverage policy) to provide family training designed to support the caregiver in the delivery of care. The provider must guide the caregiver in the implementation of certain components of the recipient’s individualized family support plan to promote carryover of treatment gains. Providers are required to ensure caregivers can perform the tasks. Services are covered, as described below:
|Service||Procedure Code||Modifier Required||Limits|
|T1027 SC||GT||Four 15 minute
units per day
Provider Telemedicine Requirements (Applies to Therapy and EIS Providers): Providers using telemedicine as a modality to deliver services must comply with the following:
- Ensure services are medically necessary and performed in accordance with the service specific policy and fee schedule.
- The recipient (and their legal guardian) must be present for the duration of the service provided using telemedicine.
- Telemedicine should not be used by a provider if it may result in any reduction to the quality of care or if the service delivered through this modality could adversely impact the recipient.
- Documentation regarding the use of telemedicine must be included in the progress notes for each encounter with a recipient. All other documentation requirements for the service must be met as described in the coverage policy.
- Providers must comply with the Health Insurance Portability and Accountability Act (HIPAA) when providing services; all equipment and means of communication transmission must be HIPAA compliant.
- Providers must assure that the recipient has compatible equipment and the necessary connectivity in order to send and receive uninterrupted video. Telephone or electronic-based contact with a Florida Medicaid recipient without a video component is not permitted.
Additional EIS Provider Telemedicine Requirements: Early intervention service providers using telemedicine as a modality to deliver services must also comply with the following:
- Providers may only utilize telemedicine for existing recipients receiving EIS.
- Telemedicine services cannot be provided if another EIS provider is in the home on the same date of service.
Well Child Visits
The Agency is allowing limited use of telemedicine to accomplish well child visits where safe to do so. This information is from AHCA Alert sent out on 5/29/2020- Well-Child Visits Provided Via Telemedicine During the COVID-19 State of Emergency.
Telemedicine Well-Child Visits for Children Older than 24 Months Through 20 Years:
The Agency understands that well-child visits are just as important as sick visits to ensure children receive quality care at their medical home. Florida Medicaid reimburses for well-child visits in accordance with the recommended schedule developed by the American Academy of Pediatrics. To promote health and wellness through preventive care during the COVID-19 state of emergency, the Agency is expanding telemedicine to include well-child visits.
Providers may render a well-child visit using telemedicine (live/two-way communication that includes audio and video) during the state of emergency for children older than 24 months through 20 years for the following procedure codes:
Providers must append the GT modifier for live, two-way communication. The Agency and the Medicaid health plans will reimburse the same rate as if the service was delivered face-to-face.
Though it may be necessary to conduct a well-child via telemedicine, it is the Agency’s expectation that providers actively work to schedule a follow-up visit to administer immunizations and other physical components of the exam that could not be delivered using telemedicine. Immunizations are critical to reducing and eliminating preventable diseases. Immunizations should be scheduled as soon as possible to ensure children can remain on schedule for these important services. The follow-up visit will eligible for Medicaid reimbursement. Additional guidance will be forthcoming regarding the follow-up visit to render the remaining components of the well-child visit (i.e., a comprehensive physical exam and/or immunizations) .
Well-Child Visits for Children 24 Months and Younger:
In accordance with the American Academy of Pediatrics guidance, providers should prioritize in-person newborn care, newborn well-visits, and immunization of infants and young children through 24 months of age. Therefore, Florida Medicaid will not reimburse for well-child visits performed via telemedicine for children ages 24 months and younger.
We are available to assist you regarding these changes through our Provider Services line at (844) 243-5174 available Monday – Friday 7a – 7p CST / 8a - 8p EST. You may also call your provider relations specialist directly or email ProviderRelations@LighthouseHealthPlan.com with any questions.
COVID-19 Provider Links
Florida Medicaid Web Portal - COVID-19 Information for Providers on the Florida Medicaid Web Portal, which includes the process for provisional provider enrollment
FLMMS Portal - Sign up for Provider Alerts directly from AHCA and access Provider Alert archives
AHCA Alert Website - View the Agency for Healthcare Administration COVID-19 Alert Website