COVID-19 Coronavirus Provider Updates

Independent Health has a comprehensive preparedness plan in place to help us deliver coverage and services to our members without interruption.

Have a specific question? View our FAQs

Last Updated 06/09/21

Most Recent Updates

Details about Monoclonal Antibody Infusion Therapy | Learn More

Participating Hospital COVID-19 Reimbursement | Learn More


COVID-19 Testing

Independent Health covers COVID-19 testing with no cost-sharing when a healthcare provider decides that testing is medically appropriate for the purpose of diagnosing or treating an individual Independent Health member.

Based on federal guidance, Independent Health does not cover COVID-19 testing when it is to screen for general workplace health and safety (such as employee “return to work” programs), for public health surveillance, or for any other purpose not intended to diagnose or treat an individual. Our policy is consistent with other plans throughout New York State and across the country.

Free testing is available to the public through the New York State Department of Health and each county’s health department.

Covid-19 Vaccination, Coverage and Reimbursement Summary

COVID-19 vaccinations are well underway in New York. There is no member cost share for the vaccine*.

Visit New York’s COVID-19 Vaccine Information for Providers.

Vaccination Plan
Individuals aged 12 and older are now eligible to be vaccinated, according to the latest vaccination plan. To stay up-to-date on vaccinations in New York, visit the New York State website.

Cost share and coverage criteria
Independent Health members pay no cost share for Covid-19 vaccination for all lines of business:

  • Commercial
  • Medicare Advantage
  • State Programs: (MediSource, Child Health Plus, Essential)
  • Self-funded plans*

Providers must not balance bill or seek reimbursement from immunization recipients for the Covid-19 vaccine.

*Grandfathered plans must also cover Covid-19 vaccine and administration fees with no member cost share while the Federal Government is the sole payer for the vaccine.

Independent Health is complying with applicable regulatory guidance in member eligibility for vaccination.


Reimbursement

Commercial, State Programs

  • Cost of vaccine doses: The cost of the vaccine doses dispensed under federal and state vaccination plans are funded by the federal government. The health plans do not pay for the doses.
  • Administration components: Independent Health reimburses for the administration components of vaccination until otherwise directed by the federal government or New York State.

Providers: Bill Independent Health for the administration code only. Do not submit a code for the vaccine when you obtain it at no charge.


Medicare Advantage

  • Medicare Fee-for-Service is paying for the vaccine and administration components for all Medicare beneficiaries, including those enrolled in Medicare Advantage plans, through calendar year 2021.
  • Providers must submit claims to their applicable Medicare Administrative Contractor (MAC) (National Government Services in Western New York) for reimbursement. Members will not receive Explanation of Benefits (EOB) from Independent Health.

Fee Schedule and Coding
Below are the Independent Health rates for Covid-19 vaccine administration.

UPDATE: Rates have been updates for claims with dates of service on or after March 15, 2021.

Fees are effective for the vaccines which have obtained FDA Emergency Use Authorization.

Visit the CMS site for a comprehensive list of vaccine products, codes and effective dates as the FDA approves them.


Commercial, Self-Funded and Medicare Advantage
Rates for claims with dates of service on or after March 15, 2021

Administration Physician Office Rates Facility Rates
Pfizer and Moderna March 15, 2021 March 15, 2021
Dose 1 $38.81 $40.00
Dose 2 $38.81 $40.00
Janssen (J&J) 2021 2021
Single Dose Shot $38.81 $40.00

Rates for dates of service prior to March 15, 2021

Administration Physician Office Rates Facility Rates
Pfizer and Moderna 2020 2021 2020 2021
Dose 1 $16.35 $16.52 $16.94 $15.50
Dose 2 $27.41 $27.29 $28.39 $25.50
Janssen (J&J) 2020 2021 2020 2021
Single Dose Shot N/A $27.29 N/A $25.50

State Programs (determined by NYS)
Rates for claims with dates of service on or after April 1, 2021

Administration Physician and facility rates
Dose 1 (Pfizer & Moderna) $40.00
Dose 2 (Pfizer & Moderna) $40.00
Single Dose Shot (Janssen J&J) $40.00

Rates for dates of service prior to April 1, 2021

Administration Physician and facility rates
Dose 1 (Pfizer & Moderna) $13.23
Dose 2 (Pfizer & Moderna) $13.23
Single Dose Shot (Janssen J&J) $13.23

Coding

  • The AMA has released CPT® codes for reporting the vaccine and administration.
  • The codes are specific to the manufacturer and dose schedule.

Frequently Asked Questions

With the uncertainty everyone is facing, we know health care providers have many questions. If your practice has questions not answered below, contact our Provider Relations Department by phone at (716) 631-3282 or 1-800-736-5771, or email at providerservice@servicing.independenthealth.com, Monday through Friday from 8 a.m. to 6 p.m.
Has Independent Health changed any requirements around hydroxychloroquine?

Yes, we’ve implemented the following protocols to coincide with Governor Cuomo’s Executive Order around the dispensing of hydroxychloroquine (HCQ) and chloroquine:

  • Members previously prescribed HCQ for FDA-approved indications of Lupus or Rheumatoid Arthritis can continue to fill this medication.
  • Prior authorization is required for any patient new to therapy.
  • The use of HCQ to treat COVID-19 is excluded from coverage for Medicare members.
    • Per CMS guidelines, pharmacies will be able to submit diagnosis codes for Medicare Advantage members with certain documented conditions, allowing HCQ and chloroquine claims to pay. This applies to Medicare members only.
  • If you have any questions around this change in coverage, please all our Pharmacy Help Desk at (716) 631-2927 or 1-800-993-9898, Monday through Sunday from 7 a.m. to 11 p.m.
Is Independent Health allowing members to refill prescriptions early?

Yes, members who are considered to be at higher risk as defined by the CDC guidelines or members who may not have access to a pharmacy will be able to obtain an early refill or an extended supply of their medication if needed. Early refills will be for the day-supply currently allowed, typically a 30-day supply.

For maintenance medications, an early refill for a 90-day supply will be allowed. This early refill policy is in place for all Independent Health members, including those with a Medicare Advantage plan, Commercial plan and MediSource/Child Health Plus.

What should a pharmacy do if early refills are rejected for “refill too soon”?

Independent Health network pharmacies should use a Submission Clarification Code 13 (SCC) to allow an override for the refill too soon (RTS) edit. This SCC applies to all Independent Health lines of business and can be used at any network pharmacy within the United States.

If your claim still rejects after entering the SCC, please contact our Pharmacy Help Desk at (716) 631-2927 or 1-800-993-9898, Monday through Sunday from 7 a.m. to 11 p.m.

How will Independent Health handle drug shortages due to COVID-19?

We will cover alternative medications, including the brand name medication if there is a shortage of the generic.

Is Independent Health extending pharmacy prior authorizations set to expire?

Independent Health is extending certain prior authorizations set to expire before July 31, 2020. These prior authorizations will now expire 90 days from their original expiration date. This applies only to medications treating certain chronic conditions, which were submitted as a pharmacy prior authorization. This change affects all insured lines of business. We will continue to monitor the situation and prolong extensions, if needed.

Can Independent Health members use mail order for maintenance medications?

Independent Health members may have their maintenance medications delivered to their homes through one of the mail-order vendors Independent Health has partnered with, either Wegmans Mail Order Pharmacy Services or Proact Pharmacy Services. Learn more about ordering prescriptions through mail order.

In addition, some pharmacies offer prescription delivery. We encourage our members to contact their preferred pharmacy to see if home delivery is available.

Is Independent Health requiring physical signatures from members for prescription receipt?

No. We are temporarily waiving the requirement for a physical signature from members upon prescription receipt. In addition, we encourage pharmacies to use other means of prescription pick-up, including delivery and mail, to help limit possible exposure to COVID-19.

Is Independent Health changing any authorization or claim review activity because of COVID-19?

Independent Health is changing certain authorization activities in order allow claims to adjudicate more smoothly during the pandemic. This will be in place between March 24 and June 22. We are working with providers and state and federal agencies and may lengthen or shorten the duration of the suspensions if needed. The changes do not suspend commitments to Medical Necessity.

Changes included are:

  • Suspension of Prior Authorization, Concurrent Review, and Retrospective Reviews for inpatient medical, surgical, and behavioral health (psychiatric and substance abuse) admissions.
  • Suspension of Prior Authorization for post-acute medical rehab admissions, including those to skilled nursing facilities. Concurrent Review for these services continues.
  • Suspension of Prior Authorization for home health care services. Concurrent Review for these services continues.

Review the details surrounding these changes detailed here.

What lines of business does the authorization and claim review activity suspension cover?

These suspensions apply to all fully insured lines of business. While we understand the importance of consistency across lines of business during a pandemic, we are not able to suspend utilization management activities for self-funded lines of business (IH Self-Funded Services and Nova Healthcare Administrators, Inc.) at this time. We ask that facilities continue to follow existing notification and authorization processes for self-funded members.

Review the details surrounding these changes detailed here.

Do the claim suspensions apply to Long-term Services and Support (LTSS) services?

Theses suspensions do not apply to skilled nursing services for nursing home residential members (Medisource Nursing Home and Medicare Institutional Special Needs / Family Choice members) as well as any Personal Care (PCS) or Consumer Directed Personal Assistance Program (CDPAP) services provided to IH State Program members. Long Term Services and Supports (LTSS) continue to require a Physician’s orders, member assessment, and Plan approval before services may begin.

What is the difference between Prior Authorization and Concurrent Review?

The suspensions are designed to lessen constraints to hospital discharge planning, which Prior Authorization can lengthen. While Prior Authorization is suspended for each of the services listed above, IH will still conduct Concurrent Reviews for Medical Necessity for ongoing post-acute services, namely, medical rehabilitation, skilled nursing facility admissions, and home health episodes. Both Prior Authorization and Concurrent Review are suspended for acute hospital admissions.

What about elective surgeries which require Prior Authorization?

Rendering physicians, not hospitals, establish Medical Necessity for elective surgeries which require Prior Authorization. These physician authorization responsibilities continue. However, the corresponding inpatient or outpatient level of care determinations for facility services associated with elective surgeries are suspended within the authorization and concurrent review suspensions for hospital surgical admissions.

Should Providers still notify IH of services?

Yes. Providers should still notify IH in a manner which is as timely as possible with the date of admission or referral. Providers should continue to make clinical information available through existing processes, including the Utilization Management secure phone and fax lines listed in the table below.

What happens if Providers fail to notify and/or provide clinical information?

Providers should make notification and provide clinical information as soon as possible to the date of service. In the event providers submit claims for post-acute services prior to the submission (and review by IH) of clinical information, claims will deny administratively; again, Concurrent Review remains in place for post-acute services.

Upon Provider Inquiry with clinical information, IH will make a Medical Necessity determination retrospectively to the start of services. Impacted claims will then be adjusted.

Will IH review services for Medical Necessity retrospectively once normal business restores?

We may. The scope of any retrospective review relates directly to providers continuing with notification of services and availability of clinical information. IH appreciates that the circumstances may lengthen communication timeframes.

COVID-19 Diagnostic Testing
Does Independent Health cover laboratory testing and services related to the diagnosis of COVID-19?

Independent Health covers with no member cost share laboratory testing for COVID-19 when testing is for diagnosing and treating COVID-19 or other health conditions. Coverage includes COVID-19 testing if ordered by a physician prior to a surgery or procedure.

  • Members of our State products (MediSource, Essential Plan, Child Health Plus) must use participating in-network provider for these services. (These products follow specific coverage guidelines).
  • Members of our Medicare Advantage plans do not need an order from their health care provider to get a diagnostic test. However, we strongly encourage our members to contact their primary care doctor to help them decide if they need diagnostic test.
  • Members of our self-funded plans should contact us at (716) 631-2661 or 1-800-257-2753 for specific information about how their plans cover testing. The back of your member ID card indicates “Medical benefits administered by Nova.”
  • However, testing is not covered if ordered or required by a third party, such as: government/public agency to determine community spread, or by an employer for return-to-work or weekly testing, or for school or camp purposes. (Self-funded coverage may vary by plan).
Where should Independent Health patients go for testing?

Certain testing sites may require a prescription or ask for payment in advance and reimbursement for covered services will have to be submitted and processed by Independent Health. To reduce out-of-pocket cost, we encourage members to use one of the county or State testing sites. These county and state testing locations will not take any cost upfront.

Individuals can make appointments at these testing sites by calling the Departments of Health:

  • ECDOH - Call 716-858-2929 to schedule a test (a lab order is not needed). Or visit the County Health Department’s website.
  • NYSDOH - Call 1-888-364-3065 to schedule a test (a lab order is not needed)
  • View additional testing sites in Erie County here.
  • Residents of other counties should call their county health departments
Do individuals need a prescription or doctor’s order to get tested?

Independent Health covers COVID-19 testing with no cost-sharing when a healthcare provider decides that testing is medically appropriate for the purpose of diagnosing or treating an individual Independent Health member.

Are there specific codes my facility should use when billing for COVID-19 laboratory testing?

Yes. CMS and the American Medical Association (AMA) have released updated coding for providers to utilize when billing for COVID-19 laboratory testing services.

What are the rates associated with each code for COVID-19 laboratory testing?
Code Type of Lab Test Commercial, Medicare, & Self-Funded Rate State Products Rate Reimbursement Notes
U0001 CDC $35.91 $0.00 Pursuant to NYS guidance and consistent with NY Medicaid, IH will not be setting a State Products rate for this code.
U0002 Non-CDC $51.31 $51.31 Participating hospitals may use either U0002 or 87635 when billing for non-CDC COVID-19 laboratory testing.
87635 Non-CDC $51.31 $51.31 Participating hospitals may use either U0002 or 87635 when billing for non-CDC COVID-19 laboratory testing.

Will COVID-19 testing be packaged for reimbursement with other services?

Yes. In alignment with current IH methodology, payment for COVID-19 laboratory testing within an emergency room, observation, or inpatient stay is packaged to Independent Health’s reimbursement for the hospital stay.

Independent Health will continue to work with its providers as well as state and federal agencies to determine any changes to this consolidated payment.

How should claims be submitted with testing is performed by and outside laboratory?

Claims should be submitted with Modifier 90 (Reference Laboratory).

How should non-CDC COVID-19 laboratory testing be billed?

Providers may use either U0002 or 87635 but may not bill both codes for the same member and date of service.


COVID-19 Antibody Testing
What if my patient requests an antibody test?

Independent Health encourages our members to contact their primary care physician to determine if they should receive an antibody test and to help decide where to go for the test.

The New York State Department of Health recommends antibody COVID-19 testing only if:

  • A patient has a history of symptoms of COVID-19 (e.g. fever of 100.3, cough, and/or trouble breathing); *Antibodies are unlikely to be present at the time of active symptoms.

Testing for antibodies (serological testing) should not be done until at least 3 weeks after the onset of symptoms, or 2 weeks after the resolution of symptoms.

  • A patient had close (i.e. within six feet) or proximate (very close) contact with a person known to be positive with COVID-19. Testing should happen at least 2 to 3 weeks after that point of contact.
  • A patient requires precautionary or mandatory quarantine.
  • A patient is employed as a health care worker, first responder, or other essential worker who directly interacts with the public while working.

Note: A positive antibody test does not indicate someone is qualified to donate convalescent plasma. For someone to be considered as a donor, they MUST have had a positive COVID diagnostic test (PCR test).

Is COVID-19 antibody testing covered by Independent Health?

At this time, antibody testing is covered with no cost-share if the test is determined to be medically appropriate by the healthcare provider (see CDC’s Evaluation and Testing Persons for Coronavirus COVID-19 Disease) You may also visit coronavirus.health.ny.gov/covid-19-testing.

The test is covered for Medicare Advantage members with no cost share. Members of self-funded plans should check with their employer to determine if their group is covering testing.

Members of state products must receive services through in-network providers, which will help ensure they are not billed in error by providers that do not participate with Independent Health.

What if COVID-19 or antibody testing is a requirement for going or returning to work?

It is the employer’s responsibility to pay for services they require for their employees, such as the COVID-19 virus or antibody testing.

Where should a primary care physician send a patient for an antibody test?

Independent Health encourages primary care physicians to recommend their patients receive an antibody test at a lab as opposed to an urgent care center or emergency room, unless the patient requires urgent medical attention.

Labs provide antibody testing effectively and more efficiently for patients.

What should patients know about the antibody test?

The CDC has advised that antibody tests should not be used to diagnose an active COVID-19 infection. An antibody test may not indicate current infection, because it could take several weeks to make antibodies after symptoms occur.

The CDC has also advised that we do not know yet if having antibodies to the virus can protect someone from getting infected with the virus again, or how long that protection might last. For these reasons, it is important that patients discuss with their primary care provider the value of antibody testing. If the primary care provider orders antibody testing, the patient should follow up with your practice to discuss the test results and what they may mean.

The lab that conducts the test is required to tell individuals:

  • If the test has not been reviewed by the Food and Drug Administration.
  • False negative results can occur. Someone could have infection not detected by the test.
  • False positive results can occur. Positive results may be due to past or present infection with non-COVID-19 coronavirus strains such as the common “cold.”
  • Results from antibody testing should not be used as the sole basis to diagnose or exclude COVID-19 infection, or to inform infection status.
What are members told about testing for both the virus and antibody at the same time?

The test to diagnose COVID-19 checks for the virus that causes the illness. The virus is most likely to be detected at the time of active illness/symptoms.

After the virus is present, the body will start to develop an immune response which will serve to fight the virus. This happens through the development of antibodies. The antibodies can take weeks to develop (as few as 2 weeks, but in some cases more than 6 weeks), so testing for active viral infection and antibodies at the same time is not advised.

It is appropriate to wait at least 3 weeks after symptoms started, or 2 weeks after symptoms have cleared up to test for antibodies. If you’ve had a positive diagnostic test, you should wait at least 3 weeks from the time of the positive test to test for antibodies. If you’ve never had symptoms, but think you might have been exposed or been asymptomatic case, you should wait at least 3 weeks from the time of that potential exposure.

How do I know if a member is Self-Funded?

Self-funded members are administered through Independent Health Self-Funded Services and Nova.

Self-funded members are identified on the member ID card. The back of the ID card for these members indicates "administered by Nova" near the top. Self-Funded members should contact customer service at 716-631-2661 or 1-800-257-2753 for more information.

Nova members are identified on the member ID card. The back of the ID card for these members indicates "administered by Nova" near the top. Nova Members can call the customer service number on their ID card or call Independent Health/Nova at 716-773-2122 or toll free 1-800-999-5703.

The logos are:

IH SFS logo
Nova logo
Nova logo
How do we contact IH?

Existing methods remain in place:

Department / Purpose Fully Insured Plans Self-Funded Plans
Utilization Management (P) 716-631-3425
(F) 716-631-5329
(P) 716-504-3254
(F) 716-250-7170
Provider Relations (P) 716-631-3282
(F) 716-250-7133
(P) 716-631-3282
(F) 716-250-7133

You can also use our Provider Inquiry Form to contact us.

Support for your Patients

We know that things are challenging and uncertain with the COVID-19 Coronavirus. Independent Health has identified resources to help support your practice’s efforts for your patients during this health crisis.

Questions?

Contact our Provider Relations Department by phone at (716) 631-3282 or 1-800-736-5771, or email at providerservice@servicing.independenthealth.com, Monday through Friday from 8 a.m. to 6 p.m.