COVID-19 (Coronavirus): Member cost-share claims processing for PCP telemedicine services for AmeriHealth Pennsylvania members

April 30, 2020

AmeriHealth is committed to providing our members with access to the care they need. As COVID-19 has escalated into a pandemic, we are working to make sure that our members can receive appropriate testing and treatment for the virus causing COVID-19 if needed.

We encourage all AmeriHealth members to visit our dedicated COVID-19 webpage regularly for the latest news and updates. We will continue to evaluate member needs as the situation changes.

Telemedicine claims

As previously communicated, AmeriHealth is waiving member cost-sharing for a majority of telemedicine primary care physician (PCP) visits for AmeriHealth Pennsylvania members. We are currently implementing processes to ensure provider payments are accurate and processed in a timely fashion.

We also communicated that self-funded customers can opt-out of waiving cost-sharing for non-COVID telemedicine PCP visits; therefore, some AmeriHealth Pennsylvania members may still be required to pay their applicable cost-share. The impact of affected self-funded groups remains low at this time.

In support of the process for PCP visits, we ask that providers not collect member cost-sharing upfront for telemedicine visits and wait until after the claim has been processed to bill the member for any applicable cost-share noted on the Provider Explanation of Benefits.

HMO/POS PCP visits

For HMO/POS members, the following will occur based on the scenario:

  • If a copayment was collected at the time of service, we will process and mail an administrative check to the member for the copayment amount paid. The claim will be adjusted to remove the cost-share. No additional payment will be made to the provider.
  • If a copayment was not collected at the time of service, the claim will be adjusted to pay the provider the copayment amount.
  • If other cost-sharing (i.e., coinsurance, deductible) was not collected at the time of service, the claim will be processed to remove the cost-sharing member liability during adjudication. 
  • If cost-sharing was applied to the claim and it should have been removed, the claim will be adjusted to pay the provider the correct amount. 

PPO PCP visits

For PPO members with a copayment, the following will occur based on the scenario:

  • If a copayment was collected at the time of service, we will process and mail an administrative check to the member for the amount paid. No additional payment will be made to the provider.
  • If a copayment was not collected at the time of service, claims will be processed to remove the member liability during adjudication. This will ensure the provider will be made whole financially.

For PPO members with coinsurance or deductible, claims will be processed to remove the cost-sharing member liability during adjudication. This will ensure the provider will be made whole financially.

Payment adjustments

We have identified some claims that were not processed according to our new review process. We will perform a review of all claims processed in error and will make the necessary adjustments in the coming weeks.

Please note that adjusted payments will not be included in your monthly capitation payment.

Affected providers should expect to see payment adjustments within 7-10 business days after the original claim is paid. We thank you for your patience during this unprecedented time.

As a result of the processes we have recently implemented, you will not need to contact the call center or submit a claim investigation via the NaviNet® web portal (NaviNet Open) to request an adjustment.

Learn more

For detailed information related to our coverage for telemedicine services, please read our articles, COVID-19 (Coronavirus): Telemedicine services for AmeriHealth Pennsylvania members through June 4, 2020. You can also review the recent telemedicine News Article, which can be found in the News & Announcements section of the Medical Policy Portal.

A separate article will be published to address the reimbursement of member cost-share for COVID-19 testing, the administration of the test, as well as approved treatment coverage.

In addition, a separate article will be published to address member cost-share claims processing for AmeriHealth New Jersey members.

We thank you for your patience as we work to address the rapidly changing guidelines established by both the Centers for Medicare & Medicaid Services and state regulators and ensure our compliance.

For more information about the AmeriHealth position on COVID-19, please review the following resources:

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