Cost-sharing waivers for COVID-19 testing and telehealth services have expired as of May 11, 2023.
COVID information for providers
Updated May 11, 2023
The federal public health emergency (PHE) for COVID-19 expired on Thursday, May 11. We’ll work together to make sure Geisinger Health Plan (GHP) members will continue to get the care they need as the PHE unwinds.
COVID-19 coverage updates
Vaccine
Geisinger Health Plan members have no cost-sharing for the COVID vaccine when received in-network. Standard out-of-network coverage and cost-sharing rules apply and may vary by plan.
COVID testing
Member cost-sharing waivers for COVID testing have ended for most Geisinger Health Plan members.
- During the PHE, members didn’t pay for a diagnostic COVID test. They also didn’t pay a visit fee to a primary care provider, urgent care center or emergency room if they were tested for COVID. These cost waivers have ended as of May 11 (applicable to most Geisinger Health Plan members, including self-insured/TPA groups). For GHP Family (Medicaid) and GHP Kids (CHIP) members, these waivers will remain in place through Sept. 30, 2024.
GHP does not cover population surveillance testing or other screening testing performed for non-diagnostic purposes or without suspicion of infection and individual clinical assessment.
- The cost-sharing waiver for antibody tests has also expired as of May 11, for non-Medicaid/CHIP members. This waiver remains in place through Sept. 30, 2024, for GHP Family and GHP Kids members.
- During the pandemic, Geisinger Health Plan waived COVID-19-member cost-sharing — such as deductibles, copays and coinsurance — for in-network inpatient treatment of COVID. These waivers were benefit enhancements that weren’t mandated by the CARES Act or other guidance. These enhancements ended in September of 2022. Cost-sharing was reinstated for all in-network inpatient treatment for COVID beginning on or after Sept. 1, 2022, (with the exception of monoclonal antibody treatment).
Members may call the number on their member ID card for more details.
PROMISe ID service location requirement
PROMISe ID, and related requirements, were reinstated for GHP Family and GHP Kids claims with dates of service on or after Sept. 1, 2021. As of Feb. 27, DHS has reinstated all pre-pandemic requirements for enrollment (MA Bulletin 99-22-11).
Prior authorization
Prior authorization will not be a barrier for any COVID-19-related testing or treatment. GHP will not subject COVID-related testing or treatment to prior authorization.
*Prior authorization for in-network SNF admissions reinstated April 1, 2022.
In 2021, we temporarily removed the prior authorization requirement for admissions to participating skilled nursing facilities (SNFs) for all plans and all diagnoses. As of April 1, 2022, prior authorizations for in-network SNF admissions for all members and all diagnoses should be obtained, as they were before the temporary waiver. SNF admissions are still required to meet medical necessity criteria outlined in medical policy MP332.
*Medicaid note: Prior authorization for Medicaid services was suspended in accordance with DHS guidance in 2020. All services that formerly required prior authorization again require prior authorization for dates of service as of July 1, 2021. COVID-19-related testing and treatment are still exempt from prior authorization requirements until further notice.
Coverage for at-home COVID test kits
Cost-sharing waivers for over-the-counter, at-home COVID test kits, have ended as of May 11, 2023. For GHP Family (Medicaid) and GHP Kids (CHIP) members, these waivers will remain in place through Sept. 30, 2024.
Prescription refills
The early refill allowance for 30- or 90-day prescriptions at retail and mail-order pharmacies also ended May 11, 2023. Members are encouraged to ask about and use home delivery, when available, for their prescriptions. Early refills are available for controlled substances, but won’t apply for prescriptions containing opioids outside of certain conditions.
Telehealth
Waived cost-sharing for telehealth services ended as of May 11, 2023. See the Telehealth services section below for more information.
Visit CMS for information regarding billing for COVID-19 vaccine administration and monoclonal antibody infusion.
Member cost-sharing
There is no member cost-sharing for the COVID vaccine.
Vaccine cost
FDA-approved COVID vaccine doses continue to be paid for with U.S. taxpayer dollars. There is no reimbursement for COVID vaccine doses supplied to a provider at no cost.
Vaccine administration and reimbursement
GHP reimburses CDC COVID-19 vaccination program providers for the administration of FDA-approved COVID-19 vaccine administration in accordance with appropriate state and federal agency guidance. Payment for administration is based on contracted rates or CMS published rates, as applicable.
Members held harmless
Members cannot be billed for vaccine administration fees.
Who to bill
|
Plan type |
Who to bill |
Vaccine administration reimbursement |
Member cost-sharing |
|
Medicare Advantage – Geisinger Gold |
Geisinger Health Plan (as of Jan. 1, 2022) |
None – no member cost-sharing for vaccine or administration when received in network. If a member goes out of network their standard coverage and cost sharing rules will apply. |
|
|
Medicaid and CHIP –GHP Family and GHP Kids |
Geisinger Health Plan |
Based on your contracted rate and the Medical Assistance Program Fee Schedule for Administration of SARS-CoV-2 Vaccines. |
None – no member cost-sharing for vaccine or administration whether received in or out of network through Sept. 30, 2024. |
|
Commercial employer and individual plans – Geisinger Health Plan and Geisinger Marketplace |
Geisinger Health Plan |
In-network based on contracted rates
Out-of-network based on CMS rates |
None – no member cost-sharing for vaccine or administration when received in network. If a member goes out of network their standard coverage and cost sharing rules will apply. |
|
Self-funded TPA plans |
Geisinger Health Plan |
In-network based on contracted rates
Out-of-network based on CMS rates |
None – no member cost-sharing for vaccine or administration when received in network. If a member goes out of network their standard coverage and cost sharing rules will apply. |
Members can receive telehealth services through their in-network provider or through our vendor, Teladoc. Waived cost-sharing for telehealth services has ended as of May 11, 2023.
GHP’s Teladoc service offerings
We’re encouraging members to get care through Teladoc in two convenient ways:
- Online: Visit teladoc.com to download the Teladoc smartphone app. Use the app to create an account, fill out a short medical history questionnaire and schedule an online doctor visit. This is the fastest way to get in touch with a doctor. Teladoc will provide an estimate of when a doctor will contact them.
- By phone: Call 800-TELADOC to request a call from a doctor. Teladoc will provide an estimate of when a doctor will contact them.
In-network provider telehealth services
GHP will cover in-network telehealth and virtual care services that allow members to avoid unnecessary trips to the office. This includes telehealth services for any physical or behavioral health diagnosis, virtual screenings for COVID, and other routine medical needs such as cold, flu, allergy, rash or sinus infection.
Our goal is to make sure members get the care they need — through telehealth or otherwise — and we’ll continue to work with providers to address concerns about coverage and reimbursement.
Telehealth billing tips
Location codes
- Beginning with dates of service, Jan. 1, 2024, you’ll need to bill using telehealth location codes 02 or 10, along with any applicable telehealth modifiers, for telehealth services. Location code 02 refers to telehealth provided other than in a patient's home, and location code 10 to telehealth provided in a patient's home. Services billed with location code 02 or 10 are paid at the facility rate.
- You can continue to bill as if “face-to-face”, using the same location code that would be billed for an in-person visit through Dec. 31, 2023.
Modifiers
- Modifiers for telehealth services:
- 95 - Synchronous telemedicine service rendered via real-time interactive audio and video telecommunications system
- 93 - Synchronous telemedicine service rendered via telephone or other real-time interactive audio-only telecommunications system
- Modifiers for telehealth mental health services:
- FQ - A telehealth service was furnished using real-time audio-only communication technology
- FR - A supervising practitioner was present through a real-time two-way, audio/video communication technology
We follow CMS regarding which CPT codes modifiers 95 and 93 can be used with. CMS allows 95 and 93 modifiers to be appended to a limited set of CPT codes. You can find these codes on the CMS Telehealth Services website.
In the 2023 CPT book:
- Codes that can be billed with modifier 95 are designated by a star and are listed in appendix P.
- Codes that can be billed with modifier 93 are designated by a speaker symbol and are listed in appendix T.
Note: Make sure real-time interactive audio and video or real-time interactive audio-only telecommunications systems are HIPAA compliant.
DHS revalidation and other enrollment requirements reinstated.
In April 2020, to mitigate the effects of the COVID-19 crisis, the Centers for Medicare and Medicaid Services (CMS) approved the PA Department of Human Services' (DHS) request for provider enrollment flexibilities (Provider Quick Tip 240). These flexibilities waived the application fees and allowed some providers to enroll provisionally and temporarily.
Starting Feb. 27, 2023, DHS reinstated all pre-pandemic requirements for enrollment (MA Bulletin 99-22-11).
Providers must revalidate enrollment for each service location every 5 years (MA Bulletin 99-16-10).
DHS has issued additional information on how to check the status of your enrollment (Provider Quick Tip 265).
GHP Family and GHP Kids reinstated PROMISe ID verification requirements as of Feb. 27.
On March 15, 2020, GHP Family (Medical Assistance) and GHP Kids (CHIP) suspended PROMISe ID verification claim edits to offer providers maximum flexibility in fighting the COVID pandemic.
In conjunction with DHS lifting COVID emergency measures, GHP Family and GHP Kids put PROMISe ID verification claim edits back into place for dates of service on or after Feb. 27 of this year.
As of Feb. 27, all facilities, offices, individual providers and other practitioners who render, order, refer or prescribe items or services to GHP Family and GHP Kids members must be enrolled with DHS with a valid PROMISe ID specific to each practice location — for claims to pay.
ORP provider billing requirement reinstated.
The PA Department of Human Services (DHS) has issued a notice reinstating the requirement to include the NPI of ordering, referring and prescribing (ORP) providers on Medical Assistance claims, including your claims for GHP Family members. The ORP requirement was previously relaxed in response to the COVID pandemic.
Claims for encounters on or after Jan. 1, 2021, where the ORP provider is required but do not contain the NPI for the ORP provider, may be affected. A valid NPI is needed for the provider types and specialties listed in the PH and CH ORP Required PT-SP Chart.
The ORP requirement will be applied to GHP Family claims as of March 15, 2021. We will not reprocess GHP Family claims that have already been adjudicated.
- If your GHP patient has questions about their coverage, they should call the customer service phone number on the back of their member ID card.
- View the CMS COVID-19 vaccine toolkit for healthcare providers for details on vaccine administration and billing.
- Have questions about COVID? Visit the CDC website at cdc.gov/coronavirus for current news, testing information and prevention guidelines.
- The Pennsylvania Department of Health website also offers a robust supply of printable and shareable fact sheets, covering just about every topic that COVID may impact.
- Neighborly is a resource that helps individuals and families find free or reduced-cost services in their communities. They can search for local resources to access food, housing, childcare, transportation, utility assistance, healthcare, financial assistance and other needs. Visit Neighborly.