1. Do you cover laboratory testing for COVID-19?

Yes, we cover laboratory testing of COVID-19 through the Benefit Funds. Based on CMS guidelines, labs should use the following codes when billing for COVID-19 testing performed on or after February 4, 2020:

  • U0001: for the laboratory test developed by the CDC
  • U0002: for FDA-approved laboratory test developed by entities other than the CDC
  • 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

2. Are you waiving member cost sharing during this time?

Yes, effective immediately, we are waiving the following co-pays:

  • For Home Care Fund members: $5/$10 (PCP/specialists) co-pays for office visits, telehealth services; and $25 inpatient co-pays related to COVID-19 diagnostics services.
  • For Greater New York Fund members: $75 ER co-pay for COVID-19 related visits.

3. Are you covering telehealth services through the 1199SEIU provider network?

Yes. Effective March 18, 2020, we are temporarily covering telehealth services for your 1199SEIU patients in an effort to help everyone limit contact with others during the COVID-19 crisis. We will cover consults via phone, video, and other virtual means for all eligible medical and mental health services, including COVID-19 related services until June 15, 2020.

4. Are the operations of the Benefit Funds affected by the COVID-19 mandated protocols?

Our physical offices are closed, but we are providing essential services with remote staffing. We encourage providers to use our self-service options. To check 1199 patient eligibility, benefit and claim status information, please visit our provider portal at www.NaviNet.net, or call 888-819-1199 to be connected to our 24-hour automated claims and eligibility system. You can also email us at Providers@1199Funds.org. Please visit the “For Providers” section of our website at for important updates.

5. Have your claims processing operations been impacted by the COVID-19 crisis?

We are able to process all claims, however electronic claims require minimal intervention and are likely to be processed more quickly during this time. We encourage all providers to submit claims electronically and enroll in our electronic fund transfer payment program administered by Change Healthcare. Please visit our Claims page for details.

6. How are your prior authorization and other review policies affected by the COVID-19 crisis?

Effective March 24, 2020, we temporarily suspended our prior authorization requirements, continued stay review, and retrospective review requirements for inpatient admissions and outpatient ambulatory surgeries performed at a hospital for 60 days. We will re-evaluate on May 24, 2020 whether to extend the temporary suspension relative to the COVID-19 situation. From March 24 to May 24, facilities are required to notify the Funds’ designated utilization management reviewer within 48 hours of all admissions and discharge planning by calling CareAllies at (800) 227-9360. Please note that all services provided during this period will be subject to retrospective review once normal operations have resumed, and final payment will be based on member eligibility at the time of service. Prior authorization, continued stay review and retrospective review are suspended for the following services provided in the tri-state area NY, NJ and CT.

  • All Inpatient Admissions, including Behavioral Health (for NY hospitals only)
  • *Acute Physical Rehabilitation
  • Hospice (Inpatient)
  • **Other Outpatient/Ambulatory Surgical Procedures

*Benefits are not provided by the Fund for care in a sub-acute nursing home or skilled nursing facility.

**Other outpatient services including ambulatory surgical procedures performed at a freestanding Article 28 Ambulatory Surgical Center are still subject to prior authorization. Prior Authorization timeframe for approved services will temporarily be extended to 180 days.

In addition, effective March 9, 2020, with an exception of certain services, we are temporarily suspending prior authorization review for the following services reviewed by the Benefit Funds. We will re-evaluate on May 24, 2020:

  • Ambulance Service (non-emergent)
  • Cardiac/Pulmonary Rehabilitation
  • DME
  • Bone Growth Stimulator
  • Continuous Glucose Monitoring (CGM)
  • Oral Appliances
  • Oxygen / BiPap
  • Hospital beds
  • INR Machine
  • Insulin pumps
  • Negative Pressure/ Wound Therapy (Input)
  • Pneumatic Compression Devices
  • Prosthetic Devices (all)
  • Speech Devices
  • TENS
  • Wearable Defibrillators
  • Wheelchairs
  • Ventricular (VAD) Assist Devices
  • Full and Split Night Sleep Studies (OSA Testing)
  • Homecare requests including
  • Intermittent skilled nursing services
  • Physical/Occupational/Speech Therapy
  • Private duty nursing (120 hours per calendar year)
  • Enteral feeding
  • Negative Pressure Wound Therapy (NPWT)
  • Hyperbaric Oxygen Therapy (HBOT)
  • Nutritional Services
  • Lymphedema Therapy
  • Prosthetic Devices
  • Requests for Outpatient Allergy visit beyond 20 per calendar
  • Request for Outpatient Physical/Occupational/ Speech therapy beyond 25 visits per discipline per calendar year

Exceptions: Please continue to contact the Funds Care Management Programs at (646) 473-7446 for prior authorization for:

  • Air Ambulance
  • Experimental services
  • LTAC

Please continue to contact the Funds Wellness Program/MAP at (646) 473-6868 for prior authorization for:

  • Intensive Outpatient Program (IOP)
  • Partial Hospitalization Program (PHP)
  • Transcranial Magnetic Stimulation (TMS)

7. Temporary changes to other medical management programs:

Effective immediately, eviCore will extend existing authorizations on file for the following programs for members that were previously approved for an additional three (3) months if the extended authorization period does not exceed clinical practice guidelines. All existing authorizations on file expiring March 1, 2020 to May 31, 2020, will be extended through June 30, 2020.

  • Medical Oncology Program
  • Laboratory Management Program for Certain Outpatient Molecular and Genomic procedures
  • Radiology Review program for elective outpatient MRA/MRI, CT/CTA and PET imaging studies, as well as nuclear cardiology services
  • Radiation Therapy Management Program

All new requests still require prior authorization. To initiate a new authorization or to verify an existing authorization period, please log on to www.eviCore.com or contact eviCore at (888) 910-1199.

Medical Benefit Management drug authorizations on file for members currently receiving drug treatment will be extended by Care Continuum for an additional three (3) months if the authorization period for the drug does not exceed clinical practice guidelines. For example, MBM drug authorizations expiring in March 1, 2020 through May 31, 2020 will be extended through June 30, 2020. Prior authorization is required for all new drug therapy cases. To initiate a new authorization or to verify an authorization period on an existing drug therapy, please log on to www.express-path.com or contact CareContinuum at (877) 273-2122.

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