1129725547

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.

Last Updated 11/02/21

important-alert Details about Monoclonal Antibody Infusion Therapy Learn More
important-alert Participating Hospital COVID-19 Reimbursement Learn More

COVID-19 Testing

When COVID-19 Testing is covered

  • For diagnosis of COVID-19: Independent Health covers diagnostic test when a patient or a health care provider decides the individual needs a diagnostic test.
  • For Pre-surgical testing: Independent Health covers COVID-19 testing needed prior to surgery or a medical procedure.
  • Diagnostic tests and pre-surgical testing are covered for commercial, Medicare Advantage and State programs (MediSource, Essential Plan, Child Health Plus) with no cost share.

Self-funded plans may have different coverage; the back of the member ID card indicates “Medical benefits administered by Nova.” For information about how a member’s self-funded plan covers testing, please contact 716-631-8071.

Members of our State products must use participating in-network provider for these services. (These products follow specific coverage guidelines).

Diagnostic Testing Locations: Patients may use government testing sites, urgent care centers, pharmacies and all hospitals which participate with Independent Health.

When Covid-19 Testing is not covered:

Independent Health does not cover Covid-19 testing for screening purposes, such as:

  • Tests required by an employer, such as weekly testing or to return to work;
  • Tests required to attend school (both students and staff);
  • To attend events such as weddings, sports games, camps, concerts and other entertainment, and testing for travel purposes (domestic and international, including Canada).
  • To participate in a sport or team activity;
  • For public health surveillance.

Screening Test locations: Patients should call the New York State COVID-19 Hotline at 1-888-364-3065 or contact their county’s health department for screening tests. Some local pharmacies also conduct testing for screening purposes.

Our members may have questions about their need to get tested, whether they have symptoms, etc., so we advise them to contact their primary care physicians for advice.

Covid-19 Vaccination, Coverage and Reimbursement Summary
 

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, including the booster shot, 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.

Fees are effective for the vaccines which have obtained FDA approval.

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

Vaccine Manufacturer
Administration Code
Facility Rates All LOBs
Office Rates Commercial, Medicare & Self-Funded
Office Rates State Products

Pfizer

0001A (1st Dose)
0002A (2nd Dose)
0003A (3rd Dose)
0004A (Booster)

$40 
$40 
$40 
$40 

$38.81 
$38.81 
$38.81 
$38.81 

$40 
$40 
$40 
$40 

Pfizer (Child 5-11)

0071A (1st Dose)
0072A (2nd Dose)

$40 
$40 

$38.81 
$38.81 

$40 
$40 

Moderna

0011A (1st Dose)
0012A (2nd Dose)
0013A (3rd Dose)
0064A (Booster)

$40 
$40 
$40 
$40 

$38.81 
$38.81 
$38.81 
$38.81 

$40 
$40 
$40 
$40 

Janssen (J&J)

0031A (1st Dose)

0034A (Booster)

$40 

$40 

$38.81

$38.81 

$40 

$40 

Updated Oct. 29, 2021

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.

How does Independent Health cover services for COVID-19?

Independent Health covers all services and treatment for our members with no member cost share, including in-person, telehealth, urgent care center, outpatient hospital or emergency room visits when the primary purpose of the visit is COVID-19 testing, diagnosis and treatment.

This coverage applies until further notice to all fully insured commercial plans (including HSA-qualified high deductible health plans), Medicare Advantage, State Products and Individual plan members.

Self-funded plans may have different coverage; the back of the member ID card indicates “Medical benefits administered by Nova.” For information about how a member’s self-funded plan covers testing please contact 716-631-8071.

How does Independent Health cover testing?

Independent Health covers all laboratory testing and services related to the diagnosis of COVID-19 with no member cost share:

  • For diagnosis of COVID-19: Independent Health covers diagnostic test when a patient or a health care provider decide the individual needs a diagnostic test.
  • For Pre-surgical testing: Independent Health covers COVID-19 testing needed prior to surgery or a medical procedure.

Self-funded plans may have different coverage; the back of the member ID card indicates “Medical benefits administered by Nova.” For information about how a member’s self-funded plan covers testing please contact 716-631-8071.

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).

What types of Covid-19 Testing is not covered?

Independent Health does not cover Covid-19 testing for screening purposes, such as:

  • Tests required by an employer, such as weekly testing or to return to work;
  • Tests required to attend school (both students and staff);
  • To attend events such as weddings, sports games, camps, concerts and other entertainment; and testing for travel purposes (domestic and international, including Canada).
  • To participate in a sport or team activity;
  • For public health surveillance.

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.

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 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).

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.

Is Independent Health covering and allowing Telehealth and Telemedicine for insured members?

Independent Health covers telehealth and telemedicine for insured members. As of August 1, 2021, telehealth and telemedicine services not related to COVID-19 will once again have a cost share for commercial and Essential Plan 1 members.

We’ve organized important information in the Telehealth Fee ScheduleCoverage Grid, and Policy.

Providers may render services via non-HIPAA compliant technologies such as FaceTime or Skype as permitted by the Department of Health and Human Services Office for Civil Rights.

Additionally, Independent Health is expanding coverage for Primary Care annual well visits. When both audio and visual contact is possible, and in accordance with the guidelines below, annual preventive visits may be performed via telemedicine during the COVID-19 pandemic for all lines of business. When telephone is the only option (audiovisual is not possible), telephone E/M services can be billed business. Refer to Billing Guidelines for Primary Care Telehealth Preventive Visits for more details.

Important Guidelines for Primary Care Preventive Visits via Telemedicine

  • Providers should reference their specialty society professional recommendations for virtual preventive visits.
  • Providers should only engage in this care delivery when the patient’s conditions and needs can adequately be met, and the service is safe.
  • Billing for the services does not require completion of the physical exam during the state of emergency.
  • Additional, subsequent preventive visits or well visits should not be billed to Independent Health. In the event a member needs to be brought in later for a specific service, such as immunizations, those services would be reportable and reimbursed.
  • Members will not be required to return to the office for a face-to-face visit to “complete” the preventive service done through telemedicine or telephone contact.

Independent Health is reviewing the use of telehealth and telemedicine regularly and will communicate with providers when any adjustments are necessary

*Coverage for self-funded employer plans (see FAQ below), including Nova, varies by employer group.

Is Independent Health covering telehealth and telemedicine for Self-Funded Members?

Self-funded members are administered through Independent Health Self-Funded Services and Nova Healthcare Administrators. Telehealth and telemedicine coverage updates for these members include the following:

  • Independent Health Self-Funded Services members

All employer groups who utilize Independent Health Self-Funded Services to administer health coverage for their employees have elected to cover telehealth services for COVID-19 and non-COVID-19 patient visits with no member liability.

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

    All Western New York clients of Nova, a wholly owned affiliate of Independent Health, have elected to allow telehealth services for all diagnoses under their plans except New York Business Development Corporation .

    While most Nova clients have chosen to apply a member cost share through a standard office visit copay for telehealth services not related to COVID-19, the following clients have waived the member cost share:

    • Jamestown BPU
    • Sheet Metal Workers
    • Uniland

    Nova members are identified by the Nova logo on front of the member ID card. (Lancaster Schools members have an Independent Health Self-Funded Services ID card and the back of the ID card for these members will indicate "administered by Nova" near the top.) These members can call the customer service number on their ID card or call Nova at 716-773-2122 or toll free 1-800-999-5703. or toll free 1-800-999-5703.

What types of visits are covered for Telehealth/Telemedicine?

Most interactions with a patient can be handled through Telehealth/Telemedicine visit for $0 copay or cost-sharing* for members for these services. Providers should only engage in this care delivery when the patient’s conditions and needs can adequately be met, and the service is safe. Some Examples are:

  • COVID-19 related needs
  • Primary Care Annual Well Visits
  • New Patient Visits
  • Neuropsychological Testing
  • Specialist visits
  • Lactation Counseling
  • Transitional Care Management
  • Remote Monitoring (as long as the specified guidelines are satisfied)

Refer to this Coverage Grid for more information.

There are certain services that require in-person interaction (e.g., immunization administration, specimen collection) and therefore are not appropriate for telehealth at this time.

*Medicare Members are responsible for the cost share associated with ancillary services (e.g. dietitians). Coverage for self-funded employer plans varies by employer group.

Who can perform Telehealth/Telemedicine services?

The following provider types can perform Telehealth/Telemedicine services:

  • Primary Care Physician (PCP)
  • Specialist Physician
  • Registered Nurse (if performed solely by the RN, must be performed while working with a supervising physician and under general supervision)
  • Non-Physician, independent billing provider (i.e. Audiologist, CSW, Physical Therapist, Psychologist, Dietitian)

The following provider types can NOT perform Telehealth/Telemedicine services:

  • Urgent care center visits are not covered for telehealth/telemedicine at this time. Independent Health encourages member to reach out to their PCP with urgent needs by phone or through telemedicine. Members without PCP's can call Independent Health Member Servicing for available providers.
  • Licensing Practical Nurses (LPNs)

Refer to this Coverage Grid for more information.

What is Teladoc®?

Although Independent Health encourages its members to contact their primary care physician for their medical needs, we realize this isn’t always possible. So, when a member can’t reach their primary care practice, Independent Health’s telemedicine benefit is provided through Teladoc®. Independent Health is waiving the cost share for Teladoc services during the COVID-19 outbreak.

Teladoc is not available to MediSource, MediSource Connect, Essential Plan and Child Health Plus members. Coverage for self-funded employer plans varies by employer group.

Can Medicare Advantage Member obtain care from out-of-network providers?

Due to the emergency declaration, Medicare Advantage members may obtain care from out-of-network providers at the in-network cost sharing. For more information, see the page called “Getting care during a disaster.”

What is the difference between virtual check-ins and phone visit codes?

Telephone services are provided only via telephone. Virtual check-ins can be performed via telephone or other telecommunication means (e.g., audio, secure text, use of patient portal).

Another virtual service is a “store and forward” remote evaluation where the patient submits a recorded video and/or images and the provider evaluates, interprets and provides follow-up with the patient within 24 hours.

Does Independent Health cover home health, home infusion nursing, and hospital outpatient therapies virtually?

Yes, Independent Health is covering the following services delivered virtually for all lines of business effective immediately and through June 22, 2020:

  • Home Health Services
  • Home Infusion Nursing
  • Hospital Outpatient Therapies

To track and appropriately apply member benefits for these services when delivered virtually, Independent Health is requesting providers append the following modifiers to each applicable claim line based on how the service is provided:

  • Telephone: Audio Only Modifier: GQ
  • Synchronous, Two-Way Audio-Visual Technology Modifier: GT or 95
  • In-Person Modifier: n/a

Independent Health is working with providers along with state and federal agencies to determine a possible increase or decrease in the duration of this change, if needed.

Is there any change to current provider reimbursement for home health services, home infusion nursing and hospital outpatient therapies via telephone or two-way audio-visual technology?

No, not at this time.

Should providers continue to submit claims for home health services, home infusion nursing and hospital outpatient therapies?

Yes, beyond the application of the additional modifiers listed above.

Does Independent Health still require concurrent review authorization upon receipt of clinical information for home health services, home infusion nursing and hospital outpatient therapies?

Yes, while notification timeframes are relaxed to ease hospital discharge planning, please continue to notify as close to initiation of care to avoid retrospective denials for medical necessity.

What is the reimbursement rate for Telehealth/Telemedicine visits?

Independent Health has provided a Telehealth Fee Schedule to outline the reimbursement rates for different codes. The same percentage applies to Advanced Practice Practitioners as any other service. Reimbursement for Primary Value providers may be included in the global payment for the applicable lines of business.

If a patient calls in and they are triaged, the billing is based on the cumulative number of minutes performed for that date of service, so it includes the call back from the provider.

The billing is based on the cumulative number of minutes performed for that date of service.

In order to process claims appropriately, the same documentation requirements apply when services are rendered via telemedicine as they are for in-person visits, including:

  • Method of Communication
  • Start and end times (for time-based codes)
  • Patient consent (verbal or electronic), if required
  • Completed SOAP notes must be included in the documentation

What POS should be used when Telehealth/Telemedicine visits are being conducted from the office to the patient’s home?

POS 02 should be used for these visits. Independent Health has adjusted how these claims are processed during the state of emergency to pay at the non-facility rate.

What codes are covered for Telehealth/Telemedicine by Independent Health?

Please refer to our Coverage Grid and Telehealth Fee Schedule which detail the codes and reimbursement rates for Telehealth/Telemedicine.

What are the guidelines I should follow for COVID-19 ICD-10 diagnosis coding of claims?

Follow ICD-10 CM Diagnosis Coding guidelines published by CDC to report claims for COVID-19 related services on or after January 1, 2021. There are new diagnosis codes for COVID-19 infections. The updated CDC guidance further outlines the appropriate use of the new diagnosis code. Complete guidance for dates of service on or after January 1, 2021 can be found through ICD-10 diagnosis coding guidance. If the CDC makes additional recommendations in the future, please adhere to updated guidance.

What are the changes there for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) due to COVID-19?

  • We are waiving the requirement for a face-to-face visit in order for a member to receive replacement DMEPOS (Durable Medical Equipment, Prosthetics, Orthotics and Supplies) equipment and a telehealth visit with the ordering provider is acceptable.
  • We are waiving sleep study requirements for CPAP supplies (e.g., when a member needs an updated sleep study and order from the physician to obtain a new mask for existing equipment)
  • We will cover respiratory services for acute treatment of COVID-19.
  • We are waiving signature and proof of delivery requirements for Durable Medical Equipment when a signature cannot be obtained due to COVID-19. Suppliers should document in the medical record the appropriate date of delivery and that a signature was not able to be obtained because of COVID-19.
  • Delivery receipts will not be exempt from future post payment review
  • Independent Health requires an expiration date on any orders and will not extend that for recurring medical supply orders (e.g., oxygen, CPAP supplies).

Is Independent Health still requiring authorizations for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS)?

Yes. Independent Health is still requiring authorizations for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) at this time.

Has Independent Health considered waiving all place of service edits that would normally result in a claim denial for Infusion, Respiratory Therapy and DME while a patient is placed in an in-patient facility related to COVID-19?

Independent Health is not making this change at this time.

May I charge my patients for the cost of personal protective equipment our practice is using?

No, health care providers must not charge health plan members for the providers’ use of PPE during in-person visits. Any provider that has charged their patients fees to cover the cost of PPE must refund those patients in full.

Can I temporarily consolidate my practice?

Please email networkoperations@independenthealth.com for requests for any type of temporary practice consolidation or changes.

Is there an impact to my contract if I temporarily close my office?

Please email the Credentialing Department at credentialing@independenthealth.com to discuss options.

Will Independent Health extend the timely filing requirements?

Independent Health is complying with all regulatory guidance about timely filing requirements. Providers may submit claims to be considered for timely filing due to COVID-19, and we will consider reprocessing claims based on the current legislation regarding the National Emergency declaration. The Federal Government will announce when the National Emergency declaration is over, which will change the timely filing requirements. The Federal Government has helpful information here.

How can I submit practice data changes and credentialing requests to Independent Health?

Since many provider offices have support staff working from home and may not have access to a fax machine to submit data changes, your practice may also notify Independent Health of any changes that may occur within your practice by email at networkoperations@independenthealth.com. Your practice may also continue to submit data changes by fax.

To check on the status of new provider application or if you would like to credential a new provider for participation, you can email those requests to credentialing@independenthealth.com

Will Independent Health suspend all audits for at least 6 months to allow us to focus more effectively on emergency activities?

Audit activities are currently being reviewed, but changes have not been communicated at that time.

Will Independent Health extend the appeal deadlines beyond current requirements?

Independent Health will continue to follow regulatory requirements. At this time, there are no federal or state changes issued to the timing of this requirement.

Will Independent Health require providers to add their home address as a practice location to each of their profile? Or, will there be any other requirements?

No, this is not required.

What should I do if I am having trouble obtaining personal protective equipment for my practice?

The NYS DOH has developed guidance for county health departments to uniformly be able to dispense PPE. If your practice is having trouble obtaining this equipment from your normal sources, please see the attached guidance. Please be considerate in your requests for these scarce items by only ordering when you are in need and requesting stock appropriately.

All local county health departments have requested that your practice contact them directly for assistance as follows:

Please note: Here is a previous related notification from Howard A. Zucker, MD, JD, Commissioner of Health, NYSDOH, with additional information.

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.

Independent Health covers all laboratory testing and services related to the diagnosis of COVID-19 with no member cost share:

  • For diagnosis of COVID-19: Independent Health covers diagnostic test when a patient or a health care provider decide the individual needs a diagnostic test.
  • For Pre-surgical testing: Independent Health covers COVID-19 testing needed prior to surgery or a medical procedure.

Self-funded plans may have different coverage; the back of the member ID card indicates “Medical benefits administered by Nova.” For information about how a member’s self-funded plan covers testing please contact 716-631-8071.

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).

What types of Covid-19 Testing is not covered?

Independent Health does not cover Covid-19 testing for screening purposes, such as:

  • Tests required by an employer, such as weekly testing or to return to work;
  • Tests required to attend school (both students and staff);
  • To attend events such as weddings, sports games, camps, concerts and other entertainment; and testing for travel purposes (domestic and international, including Canada).
  • To participate in a sport or team activity;
  • For public health surveillance.

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.

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.

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:

Independent Health Self-Funded Services logo
Nova Medicare Network logo
Nova logo

How do we contact IH?

Existing methods remain in place:

Department / Purpose
Fully Insured Plans
Self-Funded Plans

Utilization Management

Provider Relations

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.

Brook

Brook

The Brook Health Companion mobile app, in partnership with Independent Health, is offering FREE access to the app for everyone throughout Western New York.

 

Case Management

Case Management

Independent Health has a team of dedicated case managers available to assist you and your patients during an acute health crisis or when transitioning from one care setting to another.

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.