COVID-19 Utilization Review Updates

The Alaska Division of Insurance issued Bulletin 20-12 on March 29, 2020, requiring insurers, and strongly encouraging third party administrators of self-funded plans, to suspend the following utilization review and notification requirements until June 1, 2020 (subject to further evaluation as the COVID-19 situation develops):

• Preauthorization review for inpatient and outpatient services.
• Concurrent review for inpatient hospital services.
• Retrospective review for inpatient and outpatient services and emergency services. Insurers should pay claims that are otherwise eligible for payment without first reviewing the claims for medical necessity. Insurers may request information to perform a retrospective review, reconcile claims, and make any payment adjustments after June 1, 2020. The timeframes for insurers to conduct a retrospective review or overpayment recovery should be extended for 60 days once retrospective review is resumed.

Preauthorization requirements for post-acute placements, including but not limited to skilled nursing facilities, home health care services, acute rehabilitation services, and long-term acute care hospitals, following an inpatient hospital admission. Insurers may review post-acute placements for medical necessity concurrently or retrospectively, keeping in mind applicable regulations requiring a plan of care for home health care services be established and approved in writing by a physician.

The Georgia Insurance Commissioner issued Directive 20-EX-7 on March 26, 2020, requiring insurers and their private review agents, and strongly encouraging third party administrators of self-funded plans, to suspend the following utilization review functions for 60 days, until May 26, 2020 (this date is subject to further evaluation as the COVID-19 situation develops):

• Preauthorization requirements for scheduled surgeries or admissions at hospitals.
• Concurrent review for inpatient hospital services.
• Retrospective review for inpatient hospital services and emergency services at in-network hospitals. Issuers should pay claims from in-network hospitals that are otherwise eligible for payment without first reviewing the claims for medical necessity. If necessary, issuers may request information to perform a retrospective review, reconcile claims, and make any payment adjustments after the end of the suspension period.
• Preauthorization requirements for post-acute placements, including but not limited to skilled nursing facilities, home health, acute rehabilitation, and long-term acute care. Issuers may review post-acute placements for medical necessity concurrently or retrospectively, keeping in mind applicable regulations requiring a plan of care for home health care services be established and approved in writing by a physician. This requirement remains unchanged, except to the extent that the State has permitted telehealth and verbal orders to suffice for the duration of the COVID-19 emergency.  
• This requirement remains unchanged, except to the extent that the State has permitted telehealth and verbal orders to suffice for the duration of the COVID-19 emergency.  

The Massachusetts Division of Insurance issued Bulletin 2020-10 on March 30, 2020, requiring insurers, and strongly encouraging third party administrators of self-funded plans, to suspend whatever unnecessary procedures or information requirements that may delay providers from being available to provide necessary care. For the duration of Governor Baker’s Emergency Order of March 25, 2020, all insurers should suspend:

• Any prior authorization systems that may be delaying patients from being moved to lower levels of needed care, especially from acute care hospitals to noncustodial rehabilitation care in rehabilitation hospitals and skilled nursing facilities. While insurers are not permitted to require prior authorization, they may conduct concurrent and retrospective reviews after the patient is admitted. Facilities are required to notify the patient’s insurer within 48 hours of a patient’s admission to the rehabilitation hospital or skilled nursing facility.
• Any prior authorization systems that may impede patients from being able to stay home to receive medically necessary and appropriate home health care. While insurers are not permitted to require prior authorization for COVID-19 home health care services, there must be a plan of care that has been established and approved in writing by a provider acting within the scope of their license. Insurers may conduct concurrent and retrospective reviews after home health care has begun. Home health agencies are required to notify the patient’s insurer within 48 hours of the first home health visit.

The New York Department of Financial Services issued Insurance Circular Letter No. 8 on March 20, 2020, requiring insurers and their utilization review agents, and strongly encouraging third party administrators of self-funded plans, to suspend certain utilization management until June 18, 2020—90 days from the issue of Circular Letter No. 8—subject to further evaluation as the situation develops. This requirement applies to all customers and clients and for all diagnoses (whether related to COVID-19 or not).
 

Highlights of Circular Letter No. 8

Suspension of utilization management includes:

• Preauthorization, and concurrent reviews for surgeries and inpatient hospital services, and retrospective review for inpatient hospital services and emergency services provided at in-network hospitals.
• Preauthorization for home healthcare services following an inpatient hospital admission; however, home health care services concurrent or retrospective medical necessity reviews are not prohibited.
• Preauthorization for inpatient rehabilitation services following a hospital admission; however inpatient rehabilitation services concurrent or retrospective medical necessity reviews are not prohibited.

States including New York have already communicated this change to providers, so those providers will likely not request authorization for services. However, claims must be processed during this time, even if pre-certification has not been requested.

As many states recommence elective services, Aetna is resuming standard prior authorization protocols for inpatient admissions effective May 7, 2020, except in certain states with executive orders or DOI mandates in place.
 

Executive Orders

In selected states and territories (AK, AR, DE, GA, MA, NV, NY, PR and RI) where there are executive orders or DOI mandates in effect, the following processes remain in place:
 

Acute Care Hospital Admissions

• Precertification/Prior authorization for admission to an acute care facility is waived in the states and territories noted above for all Commercial and Medicare Advantage (MA) Part C plans.

• The Acute Care facilities are encouraged to notify Aetna of the admission within 48 hours electronically through Aetna’s provider portal on Availity, NaviNet, or your preferred EDI vendor using the existing Precertification Request transaction. Providers can also submit their request by calling Aetna directly (refer to the back of the members’ ID cards for the correct telephone number).*
  • Aetna will allow facilities that wish to submit clinical information at time of admission to continue with the current clinical reviews process. For all others, Aetna will review claims and clinical information as needed at the time of claims submission unless prohibited by regulation.

Timelines for Related Executive Orders

Dates for the waivers are as follows:

• AK original effective date March 25, 2020 through November 15, 2020
• AR effective date April 8, 2020
• DE effective date April 14, 2020 through May 14, 2020
• GA effective date March 25, 2020 through May 25, 2020
• MA effective date April 30, 2020
• NV effective date March 30, 2020
• NY effective date March 25, 2020 through June 18, 2020
• Puerto Rico effective date April 7, 2020
• RI effective date April 29, 2020

Post-Acute Waiver

Aetna will continue its previously announced temporary waiver nationally for initial precertification/prior authorization for admissions from acute care hospitals to post-acute facilities, in accordance with AHIP guidance.

Unless otherwise required under State and Federal mandates, Anthem CA health plans will suspend select prior authorization requirements protocols to allow health care providers to focus on caring for patients diagnosed with COVID-19. These adjustments apply to members of all lines of business, including JAA self-insured plan members.

The Anthem CA UM team will remain flexible with Retrospective and/or Predetermination reviews as there may be an increase in these after standard operations resume. They are also exercising flexibility with inpatient continued stay reviews since facility staff are strained in providing timely medical records; these cases may be left open for potential retro review at a later date.  

Anthem CA will continue to send to their TPA partners precertification information via daily UM files.  However, as many hospitals are already overwhelmed by COVID-19 activity, it is highly likely that at least some facility providers will be redirecting their resources that supported utilization management notification requirements to patient/clinical support. This will result in fewer precertification requests and member penalties in situations that pre-certification requests didn’t occur.  
 
As such, if CA JAA clients are able to support Anthem’s guidance and want to avoid member penalties during this period, Anthem CA recommends suspending any pre-certification penalties through June 20, 2020. 

• Prior authorization requirements are suspended for patient transfers: All hospital inpatient transfers to lower levels of care (by land only). Although prior authorization is not required, Anthem requests voluntary notification via the usual channels to aid in our members’ care coordination and management.
• Concurrent review for discharge planning will continue unless required to change by federal or state directive.
• Prior authorization requirements are suspended for COVID-19 Durable Medical Equipment including oxygen supplies, respiratory devices and continuous positive airway pressure (CPAP) devices for patients diagnosed with COVID-19, along with the requirement for authorization to exceed quantity limits on gloves and masks.
• Respiratory services for acute treatment of COVID-19 will be covered. Prior authorization requirements are suspended where previously required.

Anthem GA is taking measures outlined by the Georgia Department of Insurance in Directive 20-EX-7, asking all insurers to suspend certain utilization management review and notification requirements to free up staff for clinical support:

• Suspension of Preauthorization Requirements for Scheduled Surgeries or Admissions at Hospitals. Hospitals should still use best efforts to continue admission notification to Anthem within 48-hours to verify eligibility and benefits for all members prior to rendering services and to assist with ensuring timely payments.
• Suspension of Concurrent Review for Inpatient Hospital Services. Hospitals should use best efforts to continue to submit concurrent reviews when able to assist with ensuring timely payments.
• Waive requirements for location-based credentialing to allow providers to practice in locations at which they do not usually practice.

Anthem GA has agreed to comply with these requests for commercial Individual, employer-based fully-insured, self-insured (ASO), and Medicare plans for 60 days effective March 26, 2020, and then re-evaluate if an extension is warranted. Self-insured plans have the option to opt-out in the measures described.

Anthem NY has agreed to comply with the New York Department of Financial Services’ (DFS) March 20, 2020 request for their fully-insured clients beginning March 20, 2020 until June 20, 2020 (90 days). After those 90 days, they will then re-evaluate if an extension is warranted.  
 
For Anthem NY’s JAA clients, they will continue to send to their TPA partners pre-certification information via the daily UM files. However, as many of the NY hospitals are already overwhelmed by COVID-19 activity, it is highly likely that at least some NY facility providers will be redirecting their resources that supported utilization management notification requirements to patient/clinical support. This will result in fewer precertification requests and member penalties in situations that pre-certification requests didn’t occur. 
 
As such, if NY JAA clients are able to support NYS guidance and want to avoid member penalties during this period, Anthem NY has recommended suspending any pre-certification penalties through June 20,^, 2020. Additional recommendations will be made if NYS announces an extension. 

• Prior authorization requirements are suspended for patient transfers: All hospital inpatient transfers to lower levels of care (by land only). Although prior authorization is not required, Anthem requests voluntary notification via the usual channels to aid in our members’ care coordination and management.
• Concurrent review for discharge planning will continue unless required to change by federal or state directive.
• Prior authorization requirements are suspended for COVID-19 Durable Medical Equipment including oxygen supplies, respiratory devices and continuous positive airway pressure (CPAP) devices for patients diagnosed with COVID-19, along with the requirement for authorization to exceed quantity limits on gloves and masks.
• Respiratory services for acute treatment of COVID-19 will be covered. Prior authorization requirements are suspended where previously required.

Anthem OH has agreed to comply with the New York Department of Financial Services’ (DFS) March 20, 2020 request for their fully-insured clients beginning March 20, 2020 until June 20, 2020 (90 days). After those 90 days, they will then re-evaluate if an extension is warranted.  
 
For Anthem OH’s JAA clients, they will continue to send to their TPA partners pre-certification information via the daily UM files. However, as many hospitals are already overwhelmed by COVID-19 activity, it is highly likely that at least some facility providers will be redirecting their resources that supported utilization management notification requirements to patient/clinical support. This will result in fewer precertification requests and member penalties in situations that pre-certification requests didn’t occur. 
 
As such, if OH JAA clients are able to support NYS guidance and want to avoid member penalties during this period, Anthem OH has recommended suspending any pre-certification penalties through June 20,^, 2020. Additional recommendations will be made if NYS announces an extension. 

• Prior authorization requirements are suspended for patient transfers: All hospital inpatient transfers to lower levels of care (by land only). Although prior authorization is not required, Anthem requests voluntary notification via the usual channels to aid in our members’ care coordination and management.
• Concurrent review for discharge planning will continue unless required to change by federal or state directive.
• Prior authorization requirements are suspended for COVID-19 Durable Medical Equipment including oxygen supplies, respiratory devices and continuous positive airway pressure (CPAP) devices for patients diagnosed with COVID-19, along with the requirement for authorization to exceed quantity limits on gloves and masks.
• Respiratory services for acute treatment of COVID-19 will be covered. Prior authorization requirements are suspended where previously required.

Update effective 10/9/2020
 
Utilization Management Changes and Billing Guidance for Providers (Applies to all states)
Cigna is committed to supporting providers and facilities and has made some adjustments to authorization requirements, medical necessity reviews, precertification, discharge planning, and claim payment.
In response to the COVID-19 pandemic, in some cases Cigna is waiving or modifying Prior Authorizations, and in other cases there will be no change.
 
Claims for services with no authorization requirements or with adjusted authorizations should be paid.
 

Below is a list of important information Cigna has shared with providers.

UTILIZATION MANAGEMENT (applicable to admissions between 3/15/20 to 12/31/20)

• Cigna will suspend retrospective reviews for medical necessity of inpatient hospital admissions and emergency services for the first 72 hours.
• Cigna has waived precertification for home health care services.
• Cigna has extended the response timeframe for an additional 90 days for requests for additional information.

UTILIZATION MANAGEMENT (applicable to admissions between 3/15/20 to 10/31/20)

• Cigna will waive providers’ requirement to submit a new precertification request when the member already has an approved request for the same service and is referred to another similar participating provider (e.g., getting CT scan at another facility).

INPATIENT LEVEL OF CARE (applicable 3/23/20 to 12/31/20)

• Concurrent review for continued stay at these facilities will begin on the first business day after transfer.
• Communicated 4/3/20: Cigna has waived the precertification requirement for urgent transfer of patients from acute inpatient site of care to SNF, AR, and LTACH facilities.

PRIOR AUTHORIZATIONS EXTENSIONS (applicable 1/1/20 to 12/31/20)​

• Elective outpatient Prior Authorization decisions have been extended from 90 days to 180 days for all services. Claims will remain payable as long as the service is performed within 6 months of the original authorizations. This applies to decisions made from January 1, 2020 through December 31, 2020.

Updated 10/9/20:  PERSONAL PROTECTIVE EQUIPMENT (PPE) CHARGES FROM DENTISTS
With states easing COVID-19 restrictions, dentists are currently impacted with higher costs for Personal Protective Equipment (PPE) and materials they need to resume routine dental service. To assist, Cigna Dental will reimburse contracted dentists $8 per customer visit for billed PPE, for claims processed between June 15 and July 31, 2020.

Payers will see the $8 on repricing files for dental code D1999. Payers can elect not to reimburse for this service through the claim adjudication process. It remains Cigna's standard that PPE and infection control processes are inclusive to the fees already charged for dental procedures received by in-network contracted dentists. As such, customers should not be charged for PPE by contracted dental provider for claims processed outside of the period noted. 

The following suspensions of select pre-certification requirements applies to all states starting March 1, 2020, for a duration of 90 days.

• Prior authorization requirements are suspended for patient transfers, SNF, LTAC and rehab:
  • All hospital inpatient transfers to lower levels of care (by land only). Although prior authorization is not required, HealthLink requests voluntary notification via the usual channels to aid in our members' care coordination and management.
• Concurrent review for discharge planning will continue, except for COVID-19 related admission, unless required to change by federal or state directive. All other medical necessity review is still being conducted at this time.
• Prior authorization requirements are suspended for COVID-19 Durable Medical Equipment including oxygen supplies, respiratory devices, and continuous positive airway pressure (CPAP) devices for patients diagnosed with COVID-19, along with the requirement for authorization to exceed quantity limits on gloves and masks.
• Respiratory services for acute treatment of COVID-19 will be covered. Prior authorization requirements are suspended where previously required.

For groups that utilize our healthcare management solution, Trustmark Health Benefits is honoring the federal mandate, which states that we cannot subject any testing to precertification requirements if it is related to COVID-19. This federal mandate is in place until the earlier of the end of the federal emergency or December 31, 2020.

No adjustments are being made to Aetna stop-loss policies. Aetna will cover approved claims under those policies consistent with the short-term change in their prior authorization policies during the COVID-19 crises, through May 6, 2020. Additionally, ASA will consider the same for other networks assuming their policies are substantially similar to Aetna/ASA’s.

Update (6/1/20)
Aetna Signature Administrators® (ASA)  has provided the following guidelines that are considered in-force through September 30, 2020, at which point ASA will provide updates.

Participant share of COVID-19 testing
For plan sponsors who choose to waive their covered participants’ share of COVID-19 testing copays, deductibles, and coinsurance, Aetna will include participant share under the stop-loss policy as a reimbursable expense, without prior notification or plan document amendment.

Participant share of Telemedicine & Virtual Visits
For plan sponsors who choose to waive their covered participants’ share of telemedicine & virtual visit copays, deductibles, and coinsurance, Aetna will include the member share under the stop-loss policy as a reimbursable expense without prior notification or plan document amendment.

Costs associated with COVID-19 treatment
Aetna will consider claims related to the testing and treatment of COVID-19 as eligible expenses under stop-loss subject to the terms of the stop loss policy.

Temporary closures in order to minimize potential COVID-19 spread
Employees/members who are actively-at-work and covered under stop-loss immediately prior to a temporary closure due to COVID-19 will be considered actively-at-work for purposes of stop-loss consideration during the temporary closure, assuming stop-loss premiums for all employees are paid during that temporary closure.

Early Rx Refills
For plan sponsors who choose to allow their participants to fill prescriptions early to ensure they have a 30-day supply, Aetna will consider these costs as eligible expenses under the stop-loss policy without prior notification or plan document amendment.

Potential delays to stop-loss reimbursement requests
Aetna does not expect delay to standard stop loss claim reimbursement timing. Aetna’s claim analysts have remote work procedures which have been implemented to ensure minimal disruptions in stop-loss claim reimbursement.

Berkley is unable to make a blanket statement across their book of business regarding compliance with each network in all states. However, Berkley has approved individual requests to waive the pre-authorizations in NY. 

Berkley has stated that they will support Cigna’s stated UM position effective 7/15/2020 through 12/31/2020.

Cigna stop-loss mirrors the underlying health benefit plan, and Cigna stop-loss will cover any procedures and treatments covered under the health benefit plan. If a Plan Sponsor chooses to cover testing, treatments, etc., or to amend their plan (i.e., to relax eligibility guidelines regarding furloughs, temporary layoffs, reduced hours, sick leave, FMLA, etc.) the Cigna stop-loss policy will mirror that coverage.

• If a Plan Sponsor chooses to cover COVID-19 testing, they should work with their Trustmark client manager to determine whether it should be handled as a preventive care benefit or standard lab/x-ray benefit. 
• Plan Sponsors wishing to relax eligibility rules or timing requirements or amend their underlying health benefit plan to offer more comprehensive coverage during the COVID-19 pandemic relief period, should contact their contact Trustmark client manager for further information. 
• Cigna will not re-rate the current policy due to COVID-19 coverage changes or eligibility flexibility through the relief period March 1–August 31, 2020. Cigna is also waiving the 60-day notification requirement for current year health benefit plan changes. 
• With the suspension of Utilization Management (UM) review in New York, services that would normally require UM will still be covered under the health benefit plan and therefore will be covered under the Cigna stop-loss (ISL & ASL as applicable). Cigna will not re-rate stop-loss or propose pooling point or attachment point changes mid-year due to this change. 

Plan document requirements:

• Amendments are required to reflect the plan document changes.

HIIG, at this time, will be complying or honoring state mandates, but not PPO networks.

HIIG is agreeable to the Cigna’s stated UM changes to the authorization requirements effective 7/15/2020 through 12/31/2020.

HM will continue to comply with applicable state and federal laws. HM will not reject a claim incurred between March 1, 2020 and June 30, 2020, solely due to the plan's waiver of a prior authorization requirement. However, HM’s stop loss policies follow the original underlying plan to determine eligible claims expenses. Should the underlying plan need to be amended specifically to waive prior authorization requirements through June 2020, HM requires review and approval of the amendment and reserves the right to revise premium and/or other terms and conditions of the policy if the amendment is deemed to be a material change.

HMIG has stated that they will support Cigna’s stated UM position effective 7/15/2020 through 12/31/2020.

Optum will follow state mandates once the states issue a bulletin.

Optum has stated that they will support Cigna’s stated UM position and handling network authorizations to 12/31/2020.                  
 

Due to the COVID-19 crisis, the Department of Insurance in certain states has recommended that utilization management review and notification requirements be waived to lessen the burden on clinical support staff. Under the circumstances, Sun Life supports such a change through May 31, 2020 in any state where the Department of Insurance has recommended it, at which time we will evaluate the need for an extension. Through May 31, 2020, such a change will not impact claim eligibility for reimbursement under the Stop-Loss Policy.

Sun Life has stated that they will support Cigna’s UM position effective 7/15/2020 through 12/31/2020. Sun Life is agreeable to accept an email or a copy of the plan amendment for any changes. 

Swiss RE will comply with the states that have formally requested insurance companies suspend certain utilization management review and notification requirement. However, Swiss Re is not making any broad agreements that are outside of policy or plan provisions or its normal processes and procedures beyond what was stated in its COVID-19 Response and Update 4.1.20. 

Swiss Re has stated that they will support Cigna’s UM position that falls within the requirements by State or Federal Rule for suspension of UM review and notification (UR) requirements, if required by State or Federal rule. If not required by State or Federal Rule, Swiss Re will accept such suspension for a period of up to 6 months. Plan amendment is required. The amendment can be retroactive to March 1, 2020 if received by August 30, 2020.

TMHCC will allow for the elimination of pre-authorization requirements for inpatient hospital admissions with no change to the stop loss terms for a period of 60 days or as required by state mandate. TMHCC is agreeable to accept any notification of how the plan will address and administer their updated guidelines. TMHCC will also allow retroactive changes. 

TMHCC has stated that they will support Cigna’s UM position effective 7/15/2020 through 12/31/2020. TMHCC is agreeable to accept any notification of how the Plan will address and administer updated guidelines.