Credentialing and Prior Authorization during COVID-19 (Bulletin 2020-10)
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Directs commercial health insurers and HMOs to expedite credentialing and suspend or modify prior authorization requirements to ensure timely access to COVID-19 testing, treatment, inpatient transfers, home health, and post-acute placement during the public health emergency.
Carriers are expected to suspend prior authorization systems that delay transfers from acute care to lower levels of care (rehabilitation hospitals, skilled nursing facilities, or home health) for the duration of the Governor's Emergency Order.
Carriers shall not require prior approval for COVID-19 testing when a patient's symptoms are consistent with DPH or CDC guidance and must pay for out-of-network testing if in-network providers are unavailable.
Carriers must develop expedited credentialing modifications and clear materials explaining the expedited process for COVID-19 practitioners.
When patients are placed in out-of-network post-acute or home health facilities due to unavailability of in-network providers, Carriers must reimburse at the Medicare rate and facilities may not balance-bill above Carrier reimbursement for the duration of the Emergency Order.
Coverage and Operational Expectations During COVID-19 Emergency
COVID-19 coverage and operational criteria
Coverage and operational expectations during the COVID-19 emergency include the following mandates and allowances.
COVID-19 Testing Codes
| Testing for COVID-19 does not require prior authorization when symptomatic per DPH/CDC guidance; Carriers must pay for out-of-network testing if in-network providers are unavailable. |
Actions Providers and Carriers Must Take
Suspend prior authorization for COVID‑19 testing and cover out‑of‑network testing when needed
Do not require prior approval for COVID-19 testing when a patient's symptoms are consistent with Department of Public Health (DPH) or CDC guidance; if no in‑network provider is available, the Carrier must pay for necessary testing provided by an out‑of‑network provider. Carriers must inform members how to work with their primary care physician or contact websites/consumer hotlines for testing access.
- No prior approval required when symptoms align with DPH/CDC guidance.
- Carrier to pay for out‑of‑network testing if in‑network providers are unavailable.
- Carriers must inform members how to access testing via PCPs, websites, or hotlines.
Suspend prior authorization for inpatient transfers to post‑acute care
Suspend any prior authorization systems that delay transfers from acute care hospitals to rehabilitation hospitals or skilled nursing facilities for the duration of Governor Baker's Emergency Order (Mar 25, 2020); Carriers may perform concurrent or retrospective review after admission, and facilities must notify the Carrier within 48 hours of the patient's admission.
- Suspend prior authorization that delays transfers for the duration of the Emergency Order.
- Carriers may conduct concurrent and retrospective review after patient admission.
- Facility must notify the patient's Carrier within 48 hours of admission.
Suspend prior authorization for home health discharges and require written plan of care
Suspend prior authorization systems that would impede medically necessary home health discharges for the duration of Governor Baker's Emergency Order; a written plan of care approved in writing by a licensed provider is required, Carriers may conduct concurrent or retrospective review, and home health agencies must notify the Carrier within 48 hours of the first visit.
- Suspend prior authorization for COVID‑19 home health services during the Emergency Order.
- Require plan of care established and approved in writing by a licensed provider.
- Home health agencies must notify the Carrier within 48 hours of the first home health visit.
- Carriers may conduct concurrent and retrospective reviews after services begin.
Reimburse out‑of‑network post‑acute and home health at Medicare rate and prohibit balance billing
If patients are placed in out‑of‑network post‑acute (rehabilitation/skilled nursing) or home health facilities because in‑network providers are unavailable, the Carrier must reimburse at the Medicare rate for the duration of Governor Baker's Emergency Order and the facility may not balance‑bill patients for amounts above the Carrier's reimbursement; when care is provided in‑network, reimburse at the contractual rate.
- Reimburse out‑of‑network post‑acute or home health facilities at the Medicare rate during the Emergency Order.
- Prohibit facilities from balance‑billing patients for amounts above the Carrier's reimbursement during the Emergency Order.
- If facility is in‑network, reimburse at the contractual (in‑network) rate.
Definitions and Operational Processes
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