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Update on Medicaid coverage of services during the state of emergency
Communication continues to be our greatest strength during these challenges to our healthcare system. As our provider partners, we want to share with you the latest guidelines from AHCA.
Magellan Complete Care along with the Agency for Health Care Administration (Agency) is committed to ensuring that Medicaid recipients diagnosed with the 2019 novel coronavirus (COVID-19) receive all the care needed to address their symptoms. The purpose of this Provider Bulletin is to provide guidance on the flexibilities offered to providers furnishing services to recipients impacted by
In response to the Agency Statewide Medicaid Managed Care (SMMC) Policy Transmittal: 2020-15, Magellan Complete Care will cover all Medically Necessary services required to facilitate testing and treatment of COVID-19 and lift prior authorization requirements with respect to such services as noted in the SMMC Policy Transmittal: 2020-15, a copy of which may be found at: https://ahca.myflorida.com/Medicaid/statewide_mc/pdf/2018-23_plan_comm/PT_2020-15_COVID-19_State-of-Emergency_Coverage_of_Services_03.18.2020.pdf. Pertinent sections of the transmittal are also included below for your convenience.
Magellan Complete Care is committed to making sure that we keep our providers informed of any health plan related updates, to help our members get the care that they need in a timely manner. As the situation evolves, the Agency may make additional changes to assist providers and to meet the needs of recipients and Magellan Complete Care shall respond accordingly.
Magellan Complete Care will be adhering to the requirements set forth in SMMC Policy Transmittal: 2020-15, and will work with you to ensure recipients receive all the coordinated care the Agency expects. Magellan Complete Care needs to hear from you when a Member is admitted to a facility so we may assist your team with coordination of care, discharge planning and any other service needs.
Statewide Medicaid Managed Care (SMMC) Policy Transmittal: 2020-15
COVID-19 State of Emergency: Medicaid Coverage of Services
On March 9, 2020, Governor Ron DeSantis issued Executive Order Number 20-52 declaring a state of emergency related to the 2019 novel coronavirus (COVID-19). During this state of emergency, the managed care plan must ensure there are no gaps in care for its Medicaid enrollees, while implementing procedures and the use of routine screenings to prevent further spread of COVID-19. The Agency for Health Care Administration (Agency) is committed to ensuring that Medicaid recipients diagnosed with COVID-19 receive all the care needed to address their symptoms. The provisions of this policy transmittal are effective immediately, unless otherwise specified in the program specific provisions below.
Prior Authorization Requirements
In order to reduce administrative burdens on key providers that are on the front line serving the populations most impacted by COVID-19, the managed care plan must waive initial and ongoing prior authorization requirements for skilled nursing facilities, long term acute care hospitals, hospital services, physician services, advanced practice registered nursing services, physician assistant services, home health services, and durable medical equipment and supplies. This provision is applicable to all managed care plan enrollees.
In addition to the services listed above, the managed care plan must waive all prior authorization requirements for all services (except pharmacy services) necessary to appropriately evaluate and treat managed care plan enrollees diagnosed with COVID-19. Please refer to official diagnosis coding guidelines that have been published by the Centers for Disease Control (CDC).
Limits on Services
The managed care plan must waive limits on medically necessary services (specifically related to frequency, duration, and scope) that need to be exceeded in order to maintain the health and safety of enrollees diagnosed with COVID-19 or when it is necessary to maintain a enrollee safely in their home. Examples of services include: the 45-day hospital inpatient limit, home health services, durable medical equipment, in-home physician visits, $1,500 outpatient limit, etc.
The managed care plan must lift 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 for 60 days, in accordance with the Governor’s Executive Order #2020-52. This does not apply to controlled substances.
The managed care plan must reimburse for a 90-day supply of maintenance prescriptions when requested by the enrollee and the pharmacy has the requested quantity in stock.
The managed care plan must allow mail order delivery of maintenance prescriptions during the state of emergency. The managed care plan must also pay for a 90-day supply of maintenance prescriptions through mail order delivery. This provision is applicable to all managed care plan enrollees.
The managed care plan must waive co-payments for all services.
Managed Care Plan Appeals and Fair Hearings
If needed, enrollees impacted by COVID-19 must be given more time to submit an appeal through their managed plan or request a fair hearing. In addition, the Agency has federal approval to temporarily delay scheduling of Medicaid fair hearings and issuing fair hearing decisions during the emergency period if there are workforce shortages. The Agency will limit use of this flexibility to those instances where the enrollee is continuing to receive services pending the outcome of the fair hearing.
Preadmission Screening and Resident Reviews
The managed care plan must not reimburse for claims for nursing facility services provided prior to the date of completion of Preadmission Screening and Resident Review (PASRR) requirements. (Attachment II, Section X.E.1.e.) During this state of emergency, however, all PASRR processes are postponed until further notice by the Agency. During the state of emergency and until otherwise advised by the Agency, the managed care plan may not deny payment based upon the lack of completion of PASRR requirements for new admissions to a nursing facility.
Provider Enrollment and Credentialing
The managed care plan must ensure that enrollees impacted by COVID-19 are able to see non-participating providers if they are unable to access covered services from participating providers. The managed care plan must ensure that providers (including out of state providers and providers not licensed in Florida) not known to Florida Medicaid that rendered services during the state of emergency complete the Agency’s provisional (temporary) enrollment process to obtain a provider identification number for services rendered to enrollees. The Agency will make available the process for provisional provider enrollment at http://www.mymedicaid-florida.com by Thursday, March 19, 2020.
Provider Payment Provisions
Provisional Enrollment Process for Out of State Providers or non-Medicaid Providers
To be reimbursed for services rendered to eligible Florida Medicaid recipients from March 16, 2020, until such time as AHCA and Magellan Complete Care specify, providers who are out of the state of Florida or for providers not already enrolled in Florida Medicaid, please visit the link below to complete the provisional provider enrollment process:
Once you have your provisional Medicaid ID, any Medically Necessary services rendered to one of our Member(s), please forward your claims to the address below. If a provider is not known to Florida Medicaid and rendered a service during the timeframe stated above, please complete AHCA’s provisional enrollment process to obtain a provider identification number. Magellan Complete Care can assist in this process if needed.
Magellan Complete Care continuously encourages providers to submit claims and encounters electronically. Electronic submission is less costly for the providers. Our team is trained in options for submission and is happy to schedule time with providers with questions or concerns about this method of submission. Information on submission of clean claims, claims do’s and don’ts, etc. are available on Magellan Complete Care’s provider portal.
Claims and encounters submission instructions can be found on our website at the following link:
Claims can be submitted:
- Via our Direct Submit capability, allowing providers to submit claims files through a secure FTP connection or the Magellan Complete Care website
- Via clearinghouse. Magellan Complete Care obtains support from multiple clearinghouses in order to provide redundancy and to offer a broad range of options for our providers. Our payor ID is 01260 for Emdeon and all other clearinghouses.
- For out of state providers and non-PAR providers that are unable to submit claims electronically, please submit paper claims via mail to the address below:
Magellan Complete Care
PO Box 2097
Maryland Heights, MO 63043
Magellan Complete Care will reimburse non-participating providers at the rates established in the Medicaid fee schedules referenced in Rule 56G-4.002, F.A.C. and the provider reimbursement rates/reimbursement methodologies. These can be accessed through the links below:
Minimum documentation requirements
Magellan Complete Care’s claims processing unit may request clinical documentation to substantiate claims, but it is not required with your initial claim’s submission.
For any questions regarding claims inquiry please contact us at 800-327-8613 or via email to FLMCCCustomerService@magellanhealth.com
Face-to-Face Provider Site Visits
In order to reduce community-spread of the virus, the Agency (and Magellan Complete Care) will be postponing face-to-face provider-site visit requirements (e.g., enrollment, credentialing, etc.) until further notice. Whenever possible, these requirements will be met telephonically or through audio/visual technology.
The Centers for Medicare and Medicaid Services has issued a set of blanket waivers that states may utilize in response to COVID-19. The Agency has already received authority for many of these waivers related to health care facilities and licensure requirements. The Agency is actively working to receive the federal authority needed for many of the items listed in this alert related to the Medicaid program. For a full list of the blanket waivers issued by CMS, click on this link: https://www.cms.gov/files/document/covid19-emergency-declaration-health-care-providers-fact-sheet.pdf.
The Agency will be issuing subsequent guidance related to additional flexibilities or service enhancements that will be enacted to ensure there is no disruption in care for Medicaid recipients in the event of workforce shortages or limitations in recipients seeking care in provider offices (e.g., telemedicine, expanding the participant directed option in the Long-Term Care program, etc.).