In response to the COVID-19 pandemic, the Benefit Funds have temporarily changed certain policies to help ensure your 1199SEIU patients have access to medical services during the federal COVID-19 Public Health Emergency (PHE).
Be sure to check the Funds website for changes and updates on temporary policy changes enacted by the Funds in response to the PHE. You may also call our Provider Relations Call Center at (646) 473-7160 to speak to a representative. Below are frequently asked questions (FAQ) to assist you in understanding coverage rules and policy changes that are in effect.
1. Do you cover COVID-19 testing? (As of 09/29/21)
Yes, the Funds cover diagnostic testing for the coronavirus, as well as antibody testing when ordered by a doctor. However, the Funds will not cover employment-related tests, antibody tests when there was a previously confirmed COVID-19 diagnosis, or antibody tests performed on the same date of service as a COVID-19 test and all antibody tests starting November 1, 2021. Based on CMS coding guidelines, providers should use the following codes when billing for COVID-19 testing:
|Lab Codes||Code Description||Billable Provider Type|
|U0001||For the laboratory test developed by the CDC||CDC Lab and Urgent Care Only|
|U0002||For FDA-approved laboratory tests developed by entities other than the CDC using any technique||Lab, Provider’s Office, Urgent Care, Facility|
|U0003||For high-production technologies COVID-19 lab tests using any technique||Lab and Urgent Care Only|
|U0004||For high-production technologies COVID-19 lab tests using the probe technique||Lab and Urgent Care Only|
|C9803||For hospital outpatient COVID-19 specimen collection||Hospital Outpatient Only|
|86328||For laboratory antibody tests using the multi-step technique||Lab, Facility, Provider’s Office, Urgent Care|
|86769||For laboratory antibody tests using the single-step technique||Lab, Facility, Provider’s Office, Urgent Care|
|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||Lab, Facility, Provider’s Office, Urgent Care|
|87426||Infectious agent antigen diagnostic test for the lab||Lab, Facility Only|
|87811||Infectious agent antigen diagnostic test with direct visual observation||Lab, Provider’s Office, Urgent Care, Facility|
2. Are you waiving member cost sharing during this time? (As of 09/29/21)
Yes, effective March 18, 2020, until the end of the PHE, we are waiving the following co-pays for COVID-19 related visits and diagnostic services:
- For Home Care Benefit Fund members: $5/$10 co-pays for office visits (PCPs/Specialists); $25 inpatient co-pay
- For Greater New York Benefit Fund members: $75 ER co-pay
In addition, there is no co-pay for telehealth services.
3. Are you covering telehealth services through the 1199SEIU provider network? (As of 09/29/21)
Yes. Effective March 18, 2020, until the end of the PHE, we are covering telehealth services for your 1199SEIU patients in an effort to help limit contact during the COVID-19 crisis. We are covering consults via phone, video and other virtual means for all eligible medical and mental health services, including COVID-19-related services, except for telehealth services provided by an urgent care center. Effective October 15, 2021, the Benefit Funds will no longer cover telehealth services provided by an urgent care center and will deny any claims with telehealth procedure codes or modifiers where the place of service is 20.
4. Are the operations of the Benefit Funds affected by the COVID-19 mandated protocols?
The Funds’ physical offices, including our 498 Seventh Avenue at West 37th Street location, are open, and we continue to provide services for Funds members. We encourage providers to use our self-service options. To check 1199SEIU 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 [email protected]. Please visit the Funds website’s “For Providers” page 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. We encourage all providers to submit claims electronically and enroll in our Electronic Funds Transfer (EFT) 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?
See information below for inpatient, outpatient and all other services.
Effective March 24, 2020, to June 17, 2020, we temporarily suspended our prior authorization, continued-stay review and retrospective review requirements for inpatient admissions performed at a hospital. Prior authorization and continued-stay review requirements resumed on June 18, 2020. From March 24 to June 17, facilities were 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). Prior authorization and continued-stay review requirements resumed on June 18, 2020.
- All inpatient admissions, including behavioral health (for NY, NJ and CT hospitals only)
- *Acute physical rehabilitation
- Hospice (Inpatient)
*Benefits are not provided by the Funds for care in a sub-acute nursing home or skilled nursing facility.
Exceptions: Benefits are not provided by the Funds for care in a sub-acute nursing home or skilled nursing facility.
- Long-term acute care (LTAC)
- Experimental services
Note: Inpatient Claims Prepayment Review Programs have been reinstated through MedReview, effective June 18, 2020. Facilities may contact MedReview via phone at (212) 897-6000 (main number) or (212) 897-6096. You can submit medical records securely via fax at (212) 897-6010 or via email at [email protected].
Effective March 24, 2020, to June 17, 2020, we temporarily suspended our prior authorization requirements for outpatient ambulatory surgeries performed at a hospital. Prior authorization requirements resumed on June 18, 2020. 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.
Other outpatient services, including ambulatory surgical procedures performed at a freestanding Article 28 ambulatory surgical centers, are still subject to prior authorization. The prior authorization time frame for approved services will temporarily be extended to 180 days through September 30, 2020.
Exceptions: Please continue to contact the Funds’ Care Management Programs at (646) 473-7446 for prior authorization of:
- Experimental services
All other services
- Ambulance Service (non-emergent)
- Cardiac/Pulmonary Rehabilitation
- Bone Growth Stimulator
- Continuous Glucose Monitoring (CGM)
- Hospital beds
- INR Machine
- Insulin pumps
- Negative Pressure/ Wound Therapy (Input)
- Oral Appliances
- Oxygen / BiPap
- Pneumatic Compression Devices
- Prosthetic Devices (all)
- Speech Devices
- Transcutaneous electrical nerve stimulators (TENS)
- Ventricular (VAD) Assist Devices
- Wearable Defibrillators
- Full and Split Night Sleep Studies (OSA Testing)
- Homecare requests including
- Enteral feeding
- Intermittent skilled nursing services
- Negative Pressure Wound Therapy (NPWT)
- Physical/Occupational/Speech Therapy
- Private duty nursing (120 hours per calendar year)
- Hyperbaric Oxygen Therapy (HBOT)
- Intensive Outpatient Program (IOP)
- Lymphedema Therapy
- Nutritional Services
- Partial Hospitalization Program (PHP)
- 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 Program at (646) 473-7446 for prior authorization of:
- Air Ambulance
- Experimental services
Please continue to contact the Funds’ Wellness Member Assistance Program at (646) 473-6900 for prior authorization for:
- Transcranial Magnetic Stimulation (TMS)
Inpatient, home care and non-emergency ambulance prior authorization temporarily suspended from December 23, 2020, to February 21, 2021.
Inpatient UM Prior Authorization was temporarily suspended from December 23, 2020, to February 21, 2021, for medical, behavioral health, hospice and acute rehabilitation for New York only pursuant to DFS directives. No extensions for outpatient and elective admission authorizations were put in place. The standard 90-day authorization remained in effect. In addition, during this same period, authorization for home care services and non-emergency ambulance was suspended.
7. Are there temporary changes to other medical management programs?
Effective immediately, eviCore will extend existing authorizations on file for the following programs for members who 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. Time frames for approved services will temporarily be extended to 180 days through September 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 (MBM) Program drug authorizations on file for members currently receiving drug treatment will be extended by CareContinuum 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 March 1, 2020, through May 31, 2020, will be extended through June 30, 2020. Time frames for approved services will temporarily be extended to 180 days through September 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.