COVID-19 Frequently Asked Questions
Horizon BCBSNJ has announced several actions we are taking for our fully insured members, as well as members covered by the State Health Benefits Program (SHBP) and the School Employees’ Health Benefits Program (SEHBP). Please know that other self-insured health plans are responsible for the specific plan designs they choose to offer to their employees, and we will continue to work with them to administer their plan designs as directed.
Below are answers to questions you may have as you treat your patients.
A. Effective immediately and through June 30, 2021, all fully insured members, including those covered through Medicaid, Medicare Advantage, Individual and Small Group policies, as well as members covered by the State Health Benefits Program (SHBP) and the School Employees’ Health Benefits Program (SEHBP) will not pay any cost share amounts (copay, coinsurance, deductible) for covered services related to COVID-19, including:
- Charges associated with a visit to an in-network or out-of-network primary care physician or urgent care center or Emergency Room (ER) for evaluation of symptoms identified as possible indicators of COVID-19 infection.
- Covered benefits associated with inpatient and outpatient care when delivered by in-network professionals and facilities, and when the claim indicates treatment was related to a primary diagnosis of COVID-19.
Other self-insured health plans are responsible for the specific plan designs they choose to offer to their employees, and we will continue to work with them to administer their plan designs as directed.
A. COVID-19 viral testing with an FDA-authorized test is covered when performed for diagnostic purposes in health care settings, including pharmacies and drive-up testing sites. Testing that is performed for population screening (for example, back-to-school or return-to-work purposes) and in preparation for travel is not covered.
Home test kits for members showing symptoms of COVID-19, and for members who are asymptomatic but have a known exposure to COVID-19, are also covered. However, shipping and handling, and any administration fees charged by the lab, are not covered.
Regardless of where diagnostic testing is performed — in a health care setting or pharmacy, at a drive-up testing site or through a home test kit — testing must be ordered by a health care professional.
Any test for population screening (for example, back to school or return-to-work purposes) is not covered.
A. Please submit claims as you regularly do.
When evaluating a patient for COVID-19, member cost sharing for the Evaluation and Management services related to this condition will be waived when one of the following codes are submitted:
- Z11.52 – Encounter for screening for COVID-19
- Z20.822 – Contact with and (suspected) exposure to COVID-19
- J12.82 – Pneumonia due to coronavirus disease 2019
- U07.1 - 2019-nCoV acute respiratory disease
Based on CDC recommendations, these codes should be considered as most appropriate when a patient was evaluated and COVID-19 was considered. Other diagnoses, in addition to these codes, should also be reported, as appropriate. Reimbursement for claims that do not report one of the above diagnoses will be reduced by any applicable member cost sharing based on the benefit plan.
TheCDC released new COVID-19-specific diagnosis codeseffective January 1, 2021.
A.Horizon BCBSNJ is prepared to accept the following codes when testing reflects the correct description and place of service:
Code Description U0001 CDC testing laboratories to test patients for SARS-CoV-2 U0002 Non-CDC laboratory tests for SARS-CoV-2/2019-nCoV (COVID-19) U0003 Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique, making use of high throughput technologies as described by CMS-2020-01-R. U0004 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC, making use of high throughput technologies as described by CMS-2020-01-R. 86328 Immunoassay for infectious agent antibody(ies), qualitative or semi-qualitative, single step method (e.g., reagent strip): severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]); Represents a simple single-step test, often used as a point-of-care test, that could be done in a physician office setting 86769 Antibody; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]); Represents a multi-step method test, likely to be done by an independent lab or hospital 87635 Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique 99000 Handling and/or conveyance of specimen for transfer from the office to a laboratory 99001 Handling and/or conveyance of specimen for transfer from the patient in other than an office to a laboratory (distance may be indicated) G2023 Specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), any specimen source G2024 Specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), from an individual in a skilled nursing facility or by a laboratory on behalf of a home health agency, any specimen source
Network and non-network providers may perform services through telemedicine platforms. As such, Horizon BCBSNJ will cover the cost of office visits performed through telemedicine at the benefit level under your plans.
In addition, Horizon BCBSNJ recently announced some changes to help its members when care is received through in-network doctors.
- For all fully insured, SHBP/SEHBP, Medicaid and Medicare members Horizon BCBSNJ will relax its telemedicine rules to allow members to get covered services by phone, chat or video, from in-network and out-of-network health care professionals.
- Self-insured health plans are responsible for the specific plan designs and may not cover telephone visits.
These changes will remain in effect through the State of Emergency declared by the Governor in Executive Order 103 of 2020 and for 90 days thereafter.
No. As with all routine, primary care, mental health or follow-up office visits, no prior authorization is required.
You should submit claims as you currently do today.
For claims for audio-only telemedicine services, Horizon BCBSNJ is prepared to accept the following codes:
Consistent with previous announcements, Horizon BCBSNJ will continue to accept claims for telemedicine services when modifiers 95 or GT are appended to CPT® or HCPCS codes that ordinarily describe face-to-face services including but not limited to:
- Professional services related to diagnosis or treatment of COVID-19
- Routine care
- Mental health care and substance use treatment
Regardless of the coding paradigm, Horizon BCBSNJ will reimburse up to the allowed amount, and providers may not collect member cost share that would otherwise be collectible.
Health care professionals, facilities and ancillary providers should continue to ensure a high-level of accuracy and compliance with the most current and appropriate coding practices, rules and guidelines
All services that can be performed through telemedicine platforms are eligible regardless of whether the service is for medical care or behavioral care. Please consult Horizon BCBSNJ’s telemedicine services guidelines:
Furthermore, Horizon BCBSNJ is relaxing telemedicine rules to allow phone-only visits with providers.
Yes, the providers’ reimbursement rates for telemedicine and telehealth visits are the same as if they performed the same service in the office setting. Horizon will reimburse up to the allowed amount.
No, only one Evaluation and Management Services code will be paid to the provider. The services from both visits can be combined to determine the appropriate level of care.
There is no global period for telemedicine care, with the exception of subsequent hospital care. Hospital care is limited to one telemedicine visit every three days and subsequent nursing facility care is limited to one telemedicine visit every 30 days.
New patients are eligible for telemedicine. However, new inpatient consultations and initial inpatient care are not eligible.
For the provider to be reimbursed for telemedicine services, either the provider or the member has to physically be in New Jersey at the time services are provided. The member must be active with Horizon NJ Health.