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:

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.

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. 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.

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. 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 State of Emergency declared by the Governor in Executive Order 103 of 2020 and for 90 days thereafter.

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.

Horizon NJ Health will continue to accept claims for telemedicine and telehealth services billed 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

In accordance with the Division of Medical Assistance and Health Services (DMAHS) guidelines, please submit all claims for telemedicine and telehealth services as if the service was provided in the office setting. Please do not submit the telehealth codes for audio–only telemedicine services.

• For professional claims billed on the CMS-1500, please submit with the appropriate HCPCS or CPT codes, modifiers 95 or GT and place of service (POS) 02 or 11.
• For facility claims billed on the UB04, please submit with the appropriate revenue code, HCPCS or CPT codes and modifiers 95 or GT.

View a full list of existing and extended codes for COVID-19.

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.

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.