Important Information About COVID-19

With the recent emergency use authorization and distribution of the COVID-19 vaccine, our members will likely be looking to you, their health care provider, for direction. Updates and changes are happening quickly, and AmeriHealth Caritas Florida is closely monitoring guidance from local and federal officials to learn the most up-to date information.

It is important for everyone to continue taking steps to protect themselves by social distancing, washing their hands, and wearing a face covering.

AmeriHealth Caritas Florida and the Agency for Health Care Administration (AHCA) remain committed to ensuring Medicaid recipients receive medically necessary care to prevent and treat coronavirus disease (COVID-19). Eligibility and billing guidelines continue to update:

1. For our participating and non-participating providers, we will continue to align with the Medicaid vaccine administration rates. All guidance is applicable to both the fee-for-service and Statewide Medicaid Managed Care delivery systems unless otherwise stated.
2. Reimbursement for COVID-19 Vaccine Administration. Please view the COVID-19 vaccine administration reimbursement rates (PDF).
3. Eligible Recipients and Exclusions (Effective March 11, 2021)
   • For the most current information about who is eligible for the vaccine during and after the public health emergency, visit http://www.floridahealth.gov/.
     • AmeriHealth Caritas Florida covers the COVID-19 vaccine administration by age, as specified in the Food and Drug Administration Emergency Use Authorization approval for each vaccine product. 
       Covered: All Medicaid recipients who have full or limited Medicaid benefits are eligible for Medicaid to cover the administration of the COVID-19 vaccine. This includes individuals:
       • With Medically Needy/ Share of Cost Medicaid who have incurred their share of cost for the month and whose Medicaid is activated.
       • Eligible for Family Planning benefits (beginning March 11, 2021).
       • Eligible for emergency Medicaid services (beginning March 11, 2021).

Not Covered: If the recipient has any other primary insurance, the primary insurance must be billed since Medicaid is the payor of last resort.
AmeriHealth Caritas Florida will not reimburse the COVID-19 vaccine administration for recipients with: Medicare or commercial insurance.

4. No Prior Authorization. There is no prior authorization for the vaccine administration or product.
5. No Co-Payments. There are no co-payments for COVID-19 vaccine administration and products, including no copayments for a physician office visit at which the vaccine is administered.
6. Eligible Providers. AmeriHealth Caritas Florida will reimburse the following providers for the administration of the COVID-19 vaccine for any place of service. This includes Physicians and physician extenders, including those functioning in a County Health Department, Federally Qualified Health Center, or Rural Health Clinic as well as pharmacies for COVID-19 administration rendered by pharmacists.
7. Provider Requirements. The COVID-19 Vaccination Program Interim Playbook (PDF) by the Centers for Disease Control and Prevention (CDC) requires providers who are administering COVID-19 vaccinations to enroll in the federal COVID-19 Vaccination program: To receive/administer COVID-19 vaccine, constituent products, and ancillary supplies, vaccination provider facilities/organizations must enroll in the federal COVID-19 Vaccination Program coordinated through their jurisdiction’s immunization program. Enrolled COVID-19 vaccination providers must be credentialed/licensed in the jurisdiction where vaccination takes place, and sign and agree to the conditions in the CDC COVID-19 Vaccination Program Provider Agreement.
8. Billing and Reimbursement, Open Network Requirement. AmeriHealth Caritas Florida covers COVID-19 vaccine administration costs for our members. COVID-19 reimbursement rates are the same for health plans and the fee-for-service delivery system. Providers should contact AmeriHealth Caritas Florida directly for billing questions and instructions.

If you have fee-for-service coverage questions, please contact the Florida Medicaid Helpline at 1-877-254-1055.

If you have coverage questions, please contact Provider Services at 1-800-617-5727.

For more information related to Medicaid coverage during the state of emergency, please visit the Agency’s COVID web pageOpens a new window.

Please refer to the resources below for the most up-to-date COVID-19 vaccine information and for state guidance.

• DOH COVID-19 Vaccines in Florida
• AHCA Updated Florida Medicaid Coverage of the COVID-19 Vaccine (PDF)
• CMS
• FDA
• CDC
• CDC COVID-19 Vaccine Playbook.(PDF)

COVID-19 testing

AmeriHealth Caritas Florida will cover all medically necessary services required to facilitate testing and treatment of COVID-19 for its eligible members, in accordance with federal and state guidance. No prior authorization is required for COVID-19 testing. Coronavirus testing codes follow:

*Providers cannot use U0001-U0004 or 87635 for antibody testing.

Practitioner Laboratory Coverage for practitioner laboratories that are CLIA certified, may perform the COVID-19 laboratory tests as described within the June 12, 2020 AHCA Provider Alert, are as follows:

Procedure Code

• 86238
• 86769

In order to be reimbursed by AmeriHealth Caritas Florida, the COVID-19 laboratory test must be:

• Authorized by the Food and Drug Administration, including Emergency Use Authorization (EUA). For a list of approved tests, please visit: https://www.fda.gov/medical-devices/emergency-situations-medical-devices/emergency-use-authorizations [fda.gov].
• Ordered by a Florida licensed physician.
• Performed by a laboratory that has CLIA certification or a certificate of waiver [cdc.gov]

CDC links for more information:

• Evaluating and Reporting Persons Under Investigation (PUI) 
• Coding encounters related to COVID-19 

If you suspect you or a patient has COVID-19

The CDC instructs providers to consult with local or state health departments to determine whether patients meet criteria for Persons under Investigation (PUI). Providers should immediately notify infection control personnel at their facility if they suspect COVID-19 in a patient. Please notify your state or local health department if a patient is classified as a PUI for COVID-19.

Providers should report recognized exposures, regularly monitor themselves for fever and symptoms of respiratory infection, and not report to work when ill. Providers in low-, medium-, or high-risk exposure categories who develop signs or symptoms compatible with COVID-19 are strongly encouraged to contact their established point of contact (public health authorities or their facility’s occupational health program) for medical evaluation prior to returning to work.

The CDC has also introduced an interactive “self-checker” on its website. The self-checker tool isn’t intended to replace a medical diagnosis or treatment. Rather, it was developed to help individuals decide when to treat their symptoms safely at home and when to seek medical care.  For more information please visit the CDC’s dedicated testing site.

CDC links for more information:

• CDC: Healthcare Professionals: Frequently Asked Questions and Answers
• Interim U.S. Guidance for Risk Assessment and Public Health Management of Healthcare Personnel with Potential Exposure in a Healthcare Setting to Patients with Coronavirus Disease (COVID-19)

For more resources and guidance, please access the CDC COVID-19 homepage.

Access and availability to care

Office closures and use of telehealth during the COVID-19 response period

AmeriHealth Caritas Florida continues to monitor the latest information regarding COVID-19, and wants to help ensure that our members have access to care for their health care needs. To help accomplish that, we ask that any participating provider who will be closing their office for an extended period of time to notify AmeriHealth Caritas Florida at 1-800-617-5727 and their patients/members, and indicate whether virtual visits, telephonic consultation, and/or secure web-portal consultation will be available during this period.

AmeriHealth Caritas Florida covers telehealth visits for our members in accordance with state and federal policy.  Similar to Medicare, many states are adopting expanded or interim policies related to the originating site, payment for telephonic visits, and expanded licensure.

If your office plans to close or limit on-site visits, and provide virtual, telephonic, or web-based support, please see updated guidance provided by the state at https://ahca.myflorida.com/Medicaid/alerts_90-day.shtml. You can access recent telehealth guidance from the U.S. Department of Health and Human Services (HHS) Office for Civil Rights (OCR) here: https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html. AmeriHealth Caritas Florida will provide updates as we receive them.

If your office is closing for an extended period of time and not offering virtual, telephonic, or web-based visits, please direct your patients who are our members to contact AmeriHealth Caritas Florida Member Services at 1-855-355-9800 (TTY 1-855-358-5856). We have tools in place to connect members to alternate providers who can support their continued care. Members can also receive support by calling our 24/7 Nurse Call Line at 1-855-398-5615.

COVID-19 Isolation Centers (nursing facilities)

Due to COVID-19, the Agency for Health Care Administration (AHCA) has designated certain nursing facilities or portions of nursing facilities (“wings”) as COVID-19 Isolation Centers. AHCA has entered into agreements with these nursing facilities to pay specialized Medicaid rates for these specific entities, which is an enhanced rate to cover additional costs related to treating COVID-19 patients. The rate letters created for these specific COVID-19 Isolation facilities are posted to the Agency’s website [ahca.myflorida.com].

Payment and billing procedures for these COVID-19 Isolation Centers or wings are as follows:

• For Medicaid recipients receiving COVID-19 related services within the COVID-19 Isolation Center or wing, AmeriHealth Caritas Florida will pay at Intermediate I — Standard Medicaid Rate. Providers are directed to bill using Condition Code 39 (Private Room Medically Necessary) to identify the COVID-19 Isolation Center or wing.
• AmeriHealth Caritas Florida will pay Medicaid bed hold (leave) days in the COVID-19 Isolation facility or wing that meet the criteria in the Nursing Facility Services Coverage Policy, and any applicable policy waiver in effect during the emergency, at the Single Level — Bed Hold rate.

September 2020 Update: 

Telemedicine

During the current State of Emergency, please visit the AHCA website for the most current updates on how telemedicine services may be provided to Florida Medicaid enrollees, including AmeriHealth Caritas Florida members. General information can be found at: https://ahca.myflorida.com/covid-19_alerts.shtml.

The AHCA Medicaid Frequently Asked Questions (FAQs) are updated frequently and can be found at: https://ahca.myflorida.com/COVID-19_Medicaid.shtml#alerts.

AmeriHealth Caritas Florida is processing claims in accordance with the AHCA policy transmittal guidelines:

• Medical and behavioral health providers (PDF)
• Therapy service and Early Intervention Services (PDF)
  Please remember that therapy authorization requirements still apply.
• Well Child Visits provided via Telemedicine during COVID-19 (PDF) are not reimbursable for members 24 months or younger.

Authorization guidelines

In accordance with Florida Medicaid Health Alerts and Policy Transmittals (https://ahca.myflorida.com/covid-19_alerts.shtml) related to the 2019 novel coronavirus disease (COVID-19), AmeriHealth Caritas Florida has implemented the following prior authorization and benefit limit exceptions:

Claims Payment Exception process

In accordance with Florida Medicaid Health Alerts and Policy Transmittals (https://ahca.myflorida.com/covid-19_alerts.shtml) related to the 2019 novel coronavirus (COVID-19), AmeriHealth Caritas Florida has implemented the following exceptions to our normal claims processing guidelines:

• Non-participating providers meeting the above criteria were not required to obtain authorization for medically necessary services effective March 16, 2020 to June 18, 2020.
  • Note: Non-participating providers must have a valid Florida Medicaid ID. Providers that need to obtain a provisional (temporary) Medicaid ID should refer to the Provisional Provider Enrollment section below.

Claims meeting the above criteria can be submitted electronically (using payer ID 77003), or via paper to the following address:

AmeriHealth Caritas Florida
Attn: Claims Department
P.O. Box 7367
London, KY 40742

If you have a claim that does not meet any of the above criteria, but you believe should be considered as an exception to normal claims processing requirements as a result of Statewide Medicaid Managed Care (SMMC) Policy Transmittal: 2020-15, please complete the COVID-19 Claims Payment Exception Form (PDF). These claims will require additional consideration and should be mailed to:

AmeriHealth Caritas Florida
Exception Claims Processing
11631 Kew Gardens Avenue, Suite 200
Palm Beach Gardens, FL 33410

For general claims submission guidelines: http://www.amerihealthcaritasfl.com/provider/claims-and-billing/index.aspx.

If you have any questions related to the Claims Payment Exception process, please call 1-800-617-5727 or email us at AmeriHealthCaritasFloridaClaimExceptions@amerihealthcaritasfl.com.

Provisional provider enrollment

Providers must have a valid Florida Medicaid ID. Providers that need to obtain a provisional (temporary) Medicaid ID should follow the steps below:

1. Open the Provisional Provider Enrollment Form (PDF). 
2. Email the completed form to PNM_Inquiries@amerihealthcaritasfl.com and enter AmeriHealth Caritas Florida Provisional Enrollment Request in the subject line.

For more information regarding Provisional Enrollment, please access the AHCA Provisional Enrollment page.

Non-essential services

Elective procedures

In accordance with Executive Order 20-72, hospitals, ambulatory surgical centers, office surgery centers, dental, orthodontic and endodontic offices, and other health care practitioners’ offices were prohibited from providing non-essential elective medical procedures. As a result, procedures that may have already been prior approved by the managed care plan were postponed.

In order to reduce the administrative burden for providers that already obtained approval for procedures postponed as a result of this executive order, the managed care plan extended the approval period for affected authorizations for at least six months. Pursuant to Executive Order 20-112, non-essential elective medical procedures are no longer prohibited.

Pharmacy

• Florida Medicaid lifted all limits on early prescription refills during the state of emergency for maintenance medications, except for controlled substances. The edits prohibiting early prescription refills will remain lifted until further notice by AHCA. This will assist recipients who may need to be self-quarantined for a period of time.
• Florida Medicaid will reimburse for a 90-day supply of maintenance prescriptions when available at the pharmacy. The recipient must request that the pharmacy dispense a 90-day supply.
• Recipients may also ask about the availability of no cost prescription delivery as many retail pharmacies have added this option due to COVID-19 concerns.
• AmeriHealth Caritas Florida Members may also use Walgreens Pharmacy mail order service. Members can call Walgreens Mail Order at 1-800-345-1985 to have their prescriptions delivered direct to their home. Providers may also call Walgreens Pharmacy mail order service on behalf of a AmeriHealth Caritas Florida member.
• Pharmacy authorization requirements apply. For additional assistance, please contact AmeriHealth Caritas Florida Provider Services at 1-800-617-5727.

As a valued provider, you play a significant role in helping protect our members.  According to the Centers for Disease Control and Prevention, a report released in May 2020 indicated a decrease in the number of routine pediatric vaccines ordered and administered due to families staying home during the COVID-19 pandemic. AmeriHealth Caritas Florida recognizes that childhood vaccinations are an important part of maintaining a child’s health.

Drive-through immunizations

AmeriHealth Caritas Florida recommends the following billing practices for a brief, five-minute conversation with a recipient’s parent or guardian prior to a drive-through visit for child immunizations:

The brief conversation before a drive-through immunization should not take the place of a well-child visit. Every reasonable effort should be made to have a comprehensive well-child visit in person or via telemedicine.

Below we’ve compiled the Vaccine Toolkit that includes helpful resources for you to educate parents on the importance of timely vaccines for their child. These resources come from the CDC and the American Academy of Pediatrics (AAP). Thank you for all you do for our members!

CDC: Resources for Encouraging Vaccinations During COVID-19 Pandemic Includes:

• Web content
• Social media content
• Images

AAP: #CallYourPediatrician Campaign Includes:

• Social media content.
• Videos.
• Images.