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Important Information About COVID-19

Prestige Health Choice has been closely monitoring the Centers for Disease Control and Prevention (CDC) for the latest information about COVID-19, and has been engaged in making the necessary plans based on guidance from the CDC. Prestige Health Choice recommends that providers follow CDC, Centers for Medicare and Medicaid Services (CMS), and state-specific guidance with regard to COVID-19 evaluation, testing, diagnosis, treatment, and reporting.

COVID-19 testing

Prestige Health Choice 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:

Test Category Detection Method Procedure Code Coverage Date
CDC Testing Real-Time RTPCR diagnostic panel U0001 On or after 2/4/20
Non-CDC Testing Any technique U0002 On or after 2/4/20
Non-CDC Testing Infectious agent detection by nucleic acid (DNA or RNA) 87635 On or after 3/13/20
Rapid testing using high throughput technologies, as described by CMS Infectious agent detection by nucleic acid (DNA or RNA) U0003 On or after 4/14/20
Rapid testing using high throughput technologies, as described by CMS Any technique U0004 On or after 4/14/20
Other rapid testing Antibody testing 86328 On or after 4/10/20
Other rapid testing Antibody testing 86769 On or after 4/10/20

*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 Prestige, the COVID-19 laboratory test must be:

CDC links for more information:

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:

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

Prestige Health Choice 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 Prestige Health Choice 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.

Prestige Health Choice 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. Prestige Health Choice 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 Prestige Health Choice 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, Prestige Health Choice 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.
  • Prestige Health Choice 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: 

AHCA established COVID isolation facilities to support long-term care providers and help with hospital decompression during the COVID-19 emergency.
AHCA has initiated a process to phase out the role of and to end the agreements with the State-supported COVID-19 isolation facilities. 
AHCA had agreements with 23 facilities, but is in the process of a phased wind-down for COVID-19 isolation facilities. All facilities will cease admitting patients under their COVID-19 specific agreements by October 1, 2020, and will no longer be operating as COVID-19 dedicated facilities.  Please note, with the exception of Miami Care Center, these facilities may choose to continue to accept COVID-19 positive patients under their standard Medicaid agreement as long as they follow appropriate isolation and infection control protocols, adhering to the Centers for Disease Control and Prevention recommendations.
Please see AHCA's COVID-19 isolation facility web page for complete details: https://ahca.myflorida.com/covid-19_inf.shtml

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 Prestige Health Choice 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.

Prestige Health Choice is processing claims in accordance with the AHCA policy transmittal guidelines:

Authorization guidelines

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

Category Authorization exception Exception start date Exception end date
Prior authorization by provider type
Prior authorization requirements are lifted for all members for the following provider types and/or services:
  • Hospital services (including long-term care hospitals). 
  • Nursing facility services. 
  • Physician services. 
  • Advanced practice registered nursing services. 
  • Physician assistant services. 
  • Home health services. 
  • Ambulance transportation. 
  • Durable medical equipment (DME) and supplies.
March 16, 2020

June 18, 2020

*Home Health/DME: We continue to waive authorizations for nebulizers provided in the physician’s office.

Prior authorization for members diagnosed with COVID-19 Prior authorization requirements are lifted for all services (except pharmacy services) rendered to members diagnosed with COVID-19 for all provider types March 16, 2020 Until further notice
Prior authorization requirements for hospital transfers
To facilitate prompt hospital discharges and to ensure adequate inpatient hospital capacity in response to COVID-19, Florida Medicaid is waiving service authorization requirements prior to admission for hospital transfers, including:
  • Inter-facility transfers:
  • Transfers to a long-term care hospital
  • Transfers to a nursing facility.
Prestige Health Choice will require the receiving facility to notify the plan of the admission within 48 hours of the admission. 
July 9, 2020 Until further notice
Benefit limits Benefit limits are waived for medically necessary services (specifically related to frequency, duration, and scope) to maintain the health and safety of members diagnosed with COVID-19 or when necessary to maintain a member safely in his or her home. March 16, 2020 Until further notice
Preadmission screening and resident review (PASRR) Completion of PASRR requirements are waived March 16, 2020 Until further notice
Behavioral health Prior authorization requirements and services limits (frequency, duration, and scope) for all behavioral health services (including community behavioral health services, inpatient behavioral health services, and targeted case management) are waived May 5, 2020 Until further notice

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), Prestige Health Choice has implemented the following exceptions to our normal claims processing guidelines:

Category Claims Processing Exception Exception Start Date Exception End Date
Prior authorization

Prior authorization requirements are lifted for all members for the following provider types and/or services:

  • Hospital services (including long-term care hospitals)
  • Nursing facility services
  • Physician services
  • Advanced practice registered nursing services
  • Physician assistant services
  • Home health services
  • Ambulance transportation
  • Durable medical equipment and supplies

March 16, 2020

June 18, 2020

*Home health/DME: We continue to waive authorizations for nebulizers provided in the physician’s office.

Prior Authorization Prior authorization requirements are lifted for all services (except pharmacy services) rendered to members diagnosed with COVID-19 for all provider types March 16, 2020 Until futher notice
Prior authorization requirements for hospital transfers
To facilitate prompt hospital discharges and to ensure adequate inpatient hospital capacity in response to COVID-19, Florida Medicaid is waiving service authorization requirements prior to admission for hospital transfers, including:
  • Inter-facility transfers:
  • Transfers to a long-term care hospital
  • Transfers to a nursing facility.
Prestige Health Choice will require the receiving facility to notify the plan of the admission within 48 hours of the admission.
July 9 2020 Until futher notice
Benefit Limits

Benefit limits are waived for medically necessary services (specifically related to frequency, duration, and scope) to maintain the health and safety of members diagnosed with COVID-19 or when necessary to maintain a member safely in his or her home.

March 16, 2020 Until futher notice
Preadmission Screening and Resident Review (PASRR) Completion of Preadmission Screening and Resident Review (PASRR) requirements are waived March 16, 2020 Until futher notice
Behavioral Health

Prior authorization requirements and services limits (frequency, duration, and scope) for all behavioral health services (including community behavioral health services, inpatient behavioral health services, and targeted case management) are waived

Behavioral Health COVID-19 State-Specific Guidance Updates

May 5, 2020 Until futher notice
  • 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:

Prestige Health Choice
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:

Prestige Health Choice
Exception Claims Processing
11631 Kew Gardens Avenue, Suite 200
Palm Beach Gardens, FL 33410

For general claims submission guidelines: http://www.prestigehealthchoice.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 PrestigeClaimExceptions@prestigehealthchoice.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@prestigehealthchoice.com and enter Prestige 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.
    • Prestige 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 Prestige member.
  • Pharmacy authorization requirements apply. For additional assistance, please contact Prestige Health Choice Provider Services at 1-800-617-5727.