COVID-19 (Coronavirus): Member cost-share claims processing for AmeriHealth New Jersey members

June 29, 2020

This article was revised on June 29, 2020, to update the effective timeline.

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 the AmeriHealth New Jersey COVID-19 webpage regularly for the latest news and updates. We will continue to evaluate member needs as the situation changes.

Coverage of member cost-share

As previously communicated, AmeriHealth New Jersey is waiving member cost-sharing (i.e., copayment, deductible, and coinsurance) for the following services:

  • Telemedicine/Telehealth. AmeriHealth New Jersey will waive member cost-sharing for all telemedicine visits, including non-COVID-19 related services.
  • Testing. AmeriHealth New Jersey will waive member cost-sharing for certain COVID-19 diagnostic tests and the administration of such tests when performed at a physician's office, urgent care center, the emergency room/department (ED), or a drive-through testing center or during a telehealth or home health visit. In addition, we will cover certain medically appropriate COVID-19 antibody testing with no member cost-share in accordance with federal guidelines and company medical policy for the duration of the COVID-19 pandemic.
  • Inpatient treatment.
    • AmeriHealth New Jersey will waive member cost-sharing for in-network, inpatient, acute care treatment of members diagnosed with COVID-19, whether for medical or behavioral health.
    • AmeriHealth New Jersey will waive member cost-sharing for ED visits associated with admissions for in-network, inpatient, acute care treatment of COVID-19 whether for medical or behavioral health.

Note: Cost-sharing is not waived for outpatient services provided in the ED.

We also communicated that self-funded customers can opt-out of waiving cost-sharing for non-COVID telemedicine visits and COVID treatment coverage; therefore, some members may still be required to pay their applicable cost-share.

Claims processing

Processes have been implemented to ensure provider payments are accurate and claims are processed in a timely fashion and in accordance with applicable law and regulatory guidance.

The following chart outlines how claims will be processed for the various services provided to AmeriHealth New Jersey members – specifically regarding member cost-sharing:

Service Effective dates Claim process

Telemedicine/Telehealth

March 6, 2020 – March 20, 2020

Claims for PCP visits with a date of service March 6, 2020 through March 20, 2020, will process without member cost-share.

March 21, 2020 through the public health emergency or December 31, 2020, whichever is later

All telemedicine/telehealth claims with a date of service on or after March 21, 2020, will process without member cost-share.

Testing for COVID-19

March 6, 2020 through the public health emergency or December 31, 2020, whichever is later

Claims with a date of service on or after March 6, 2020, will process without member cost-share.

Inpatient treatment for COVID-19 diagnoses

March 30, 2020 – December 31, 2020

Claims with a date of service on or after March 30, 2020, will process without member cost-share.

ED visits associated with admissions for COVID-19

March 30, 2020 – December 31, 2020

Claims with a date of service on or after March 30, 2020, will process without member cost-share.

*Or the duration of the public health emergency as described in Executive Order 103.

Payment adjustments

If cost-sharing was inadvertently applied to the claim and it should have been removed, the claim will be adjusted to pay the provider the correct amount. 

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

In support of this process, we ask that providers wait until after the claim has been processed to bill the member for any applicable cost-share noted on the Provider Explanation of Benefits.

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 of services during the COVID-19 public health emergency, please review our news articles on our Medical Policy Portal.

We thank you for your patience as we work to address the rapidly changing guidelines established by 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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