COVID-19 Frequently Asked Questions

A. . Effective immediately and through March 31, 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.

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.

These changes apply to Horizon BCBSNJ fully insured members, including those covered through Medicaid, Medicare, 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).

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.

Physicians and facilities are prohibited from billing any fully insured Horizon BCBSNJ member, State Health Benefits Program (SHBP) or School Employees’ Health Benefits Program (SEHBP) member for any services connected to COVID-19 evaluation or testing, performed in keeping with the Centers for Disease Control and Prevention (CDC) guidelines.

A. Please submit claims as you regularly do.

In order for cost-sharing obligations to be waived, claims must include one of the following diagnosis codes in addition to any other diagnosis appropriate to report on the claim:

• Z20.828 - Contact with and suspected exposure to other viral communicable diseases

• Z03.818 - Encounter for observation for suspected exposure to other biological agents ruled out

• B97.29 – Other Coronavirus as the cause of diseases classified elsewhere

• U07.1 - 2019-nCoV acute respiratory disease

Based on CDC recommendations, we believe that one of these would be most appropriate to report when a patient is evaluated and COVID-19 was considered in the differential diagnosis. Other diagnoses, in addition to these codes, should also be reported as appropriate.

Claims that do not include one of the above diagnoses will be processed normally and the reimbursement will be reduced by any applicable member cost sharing based on the benefit plan.

Please visit the CDC websiteCDC website opens a dialog window for additional information regarding diagnosis coding related to COVID-19.

A. Horizon BCBSNJ is prepared to accept the following codes:

A. Claims for COVID-19-related services should include one of the following diagnosis codes:

• Z20.828 - Contact with and suspected exposure to other viral communicable diseases

• Z03.818 - Encounter for observation for suspected exposure to other biological agents ruled out

• B97.29 - Other Coronavirus as the cause of diseases classified elsewhere

• U07.1 - 2019-nCoV acute respiratory disease

Based on CDC recommendations, we believe that one of these would be most appropriate to report when a patient is evaluated and COVID-19 was considered in the differential diagnosis. Other diagnoses, in addition to these codes, should also be reported as appropriate.

Claims that do not include one of the above diagnoses will be processed normally and the reimbursement will be reduced by any applicable member cost sharing based on the benefit plan.

Please visit the CDC websiteCDC website opens a dialog window for additional information regarding diagnosis coding related to COVID-19.

A. You will be reimbursed per the terms and conditions of your participating provider agreement.

Claims that do not include Z20.828, Z03.818, B97.29 or U07.1 will be processed normally, and reimbursement will be reduced by any applicable member cost sharing based on the benefit plan.

A. Horizon BCBSNJ’s fully insured members, including those covered through Medicaid, Medicare, 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 have any out-of-pocket costs for services related to COVID-19 testing or treatment.

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.

Horizon BCBSNJ will cover, with no cost share to the member, the appropriate medically necessary diagnostic testing for COVID-19.

Yes. Horizon BCBSNJ will cover the cost of a COVID-19 vaccine recommended by CDC’s Advisory Committee on Immunization Practices (ACIP) and the U.S. Preventive Services Task Force (USPSTF).

Horizon BCBSNJ has waived prior authorization requirements for:

• Diagnostic testing and evaluation for individuals presenting with concerns of COVID-19
• Lab studies or diagnostic testing for COVID-19 required during an ER evaluation or inpatient hospital stay
• All inpatient admissions with date of admission on or prior to June 14, 2020, unless extended
• Post-acute facility inpatient admissions to Skilled Nursing, Subacute Physical Rehabilitation and Inpatient Acute Physical Rehabilitation facilities for dates of admission prior to or on June 14, 2020, unless extended* (When you have a patient in a post-acute facility for longer than 14 days, concurrent review will be applied.)
• Supplemental oxygen for all patients who are discharged from the ER prior to or on August 31, 2020, unless extended

These changes take effect immediately for Horizon BCBSNJ members, including those covered through Medicaid, Medicare, fully insured and self-insured policies.

* This does not apply to Federal Employee Program® (FEP®) members.

All of our mission critical vendors have the capability to recover business operations within 24 to 72 hours. As part of our vendor delegation process, we review and approve all of our vendor business continuity plans and redundant capabilities annually. Horizon BCBSNJ is working closely with these vendors to mitigate any potential disruption related to COVID-19.

Please get the latest COVID-19 news from credible information sources, such as:

• World Health OrganizationWorld Health Organization opens a dialog window

• Centers for Disease Control and Prevention (CDC)Centers for Disease Control and Prevention (CDC) opens a dialog window

• National Institutes of HealthNational Institutes of Health opens a dialog window

• The New Jersey Department of HealthThe New Jersey Department of Health opens a dialog window

Physicians and health care professionals can collect the appropriate specimen at the health care facility where the patient is seen and the test is ordered, and send the specimen to laboratories using standard procedures. If you have any questions, please contact the labs directly.

Patients cannot be sent to a Quest Diagnostics (Quest) or LabCorp location or their draw sites to have a specimen collected.

Additional testing facilities are also available to the public.

Horizon BCBSNJ covers FDA-authorized antibody testing performed by a lab that has the appropriate Clinical Laboratory Improvement Amendments (CLIA) certification and when testing is performed consistent with the Centers for Disease Control and Prevention (CDC)’s Interim Guidelines for COVID-19 Antibody Testing.

The test must be for a diagnostic purpose consistent with CDC guidelines and ordered by a licensed health care practitioner. These CDC guidelines specifically note Serologic testing should not be used to determine immune status in individuals until the presence, durability, and duration of immunity is established. Currently, the clinical use of serologic or antibody testing for COVID-19 is to support a diagnosis of COVID-19 in patients who are seeking care late in their course of illness or in patients who are seeking care for late complications, such as multisystem inflammatory syndrome in children. Antibody tests should not be used as a sole basis for diagnosis. When antibody testing is covered, no cost sharing is applicable during the COVID-19 public health emergency.

The FDA released this video to help patients understand which tests are available.

Yes, Horizon BCBSNJ has implemented an early refill program to help our members. The early refill program will be retired on June 30, 2020, for commercial members; however, these members are still able to obtain early refills of their medications as outlined in their benefits. For our Medicaid and Medicare Advantage members, the early refill program will remain in place until further notice. This enables members to get early refills for maintenance medications (consistent with the member’s benefit plan) and/or encourages members to use the 90-day mail order benefit. Horizon BCBSNJ will also ensure formulary flexibility if there are shortages or access issues. We will not hold patients liable for additional charges stemming from obtaining a non-Preferred medication resulting from shortages or access issues.

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, including common video platforms such as FaceTime and Skype, from in-network and out-of-network health care professionals. Horizon BCBSNJ will also waive the member out-of-pocket costs for covered services, including diagnosis and treatment of COVID-19, routine care, therapy or mental health care when provided by an in-network health care professional through telemedicine.

• 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 end of public health emergency and State of Emergency declared by the Governor in Executive Order 103 of 2020.

Members with out-of-network benefits may get covered services from their preferred health care professional using these platforms or phone, but they remain responsible for their out-of-network, out-of-pocket costs according to the terms of their individual policies.

Please consult Horizon BCBSNJ’s telemedicine services guidelines:

• Horizon BCBSNJ Policy

• Horizon NJ Health Policy

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:

• 99441

• 99442

• 99443

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

• Therapy

• 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:

• Horizon BCBSNJ Policy

• Horizon NJ Health Policy

Furthermore, Horizon BCBSNJ is relaxing telemedicine rules to allow phone-only visits with providers. Members will incur no out-of-pocket costs for telemedicine visits, including via phone, when delivered by an in-network health professional. This change applies to covered services including diagnosis or treatment of COVID-19, routine care, therapy or mental health care. This is effective immediately and through the end of public health emergency and State of Emergency declared by the Governor in Executive Order 103 of 2020.

Yes, the providers’ reimbursement rates for telemedicine visits are the same as if they performed the service in the office setting. Horizon BCBSNJ will reimburse up to the allowed amount, and providers may not collect member cost share that would otherwise be collectible.

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.

The federal Health and Human Services Department has waived HIPAA enforcement regarding platforms. This allows providers to use any reasonable means of communication to work with their patients. However, we encourage the use of secure technology whenever possible. Providers should review new standards announced by the U.S. Department of Health and Human Services’ Office of Civil RightsU.S. Department of Health and Human Services’ Office of Civil Rights opens a dialog window.

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.