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

June 30, 2021

This article was revised on June 30, 2021, to update the effective timeline for testing and treatment coverage.

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 in-network telemedicine/telehealth visits, as well as out-of-network COVID-19 related services. Non-COVID-19 out-of-network services are not covered unless included in the applicable benefit design or permitted by AmeriHealth New Jersey due to network adequacy or access limitations. In such cases, member cost-sharing for out-of-network telemedicine/telehealth services is​ ​waived. MDLive® cost-sharing is waived for all MDLive telemedicine visits.

  • Testing. AmeriHealth New Jersey will cover COVID-19 testing for diagnostic and antibody tests in accordance with federal and state guidelines and the company's medical policy until October 31, 2021 or for a period of 90 days after the end of both the public health emergency and state of emergency, whichever is later.* For complete details, please review the policy News Article, Testing for SARS-CoV-2 (Coronavirus Disease 2019 (COVID-19)) for AmeriHealth New Jersey Members (Updated June 16, 2021).

  • Inpatient treatment (see table for effective dates).
    • ​​AmeriHealth New Jersey will waive member cost-sharing for in-network, inpatient, acute care treatment of members diagnosed with COVID-19.

    • AmeriHealth New Jersey will waive member cost-sharing for emergency room/department (ED) visits associated with admissions for in-network, inpatient, acute care treatment of COVID-19 whether for medical or behavioral health.

For services not related to COVID-19, we will continue to apply the appropriate member cost-sharing.

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.

*The waiver of cost-sharing for both in and out-of-network testing and diagnosis of COVID-19 will continue until 90 days after the end of both the state of emergency and public health emergency declared by the state of New Jersey. For High Deductible Health Plans, in-network cost-sharing waivers will remain in effect through June 30, 2021, unless prohibited by law.

For High Deductible Health Plans, in-network cost-sharing waivers will remain in effect through October 31, 2021, unless prohibited by law.

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 6, 2020, through the later of either June 30, 2021, or for a period of 90 days following the end of the state of emergency and public health emergency

In-network telemedicine/telehealth claims as well as out-of-network COVID-19-related claims with a date of service on or after March 21, 2020, will process without member cost-share. Member cost-sharing for out-of-network telemedicine/telehealth services is waived if they are included in the applicable benefit design or permitted by AmeriHealth New Jersey due to network adequacy or access limitations. Read more about telemedicine/telehealth coverage here.

Testing for COVID-19

March 6, 2020, through the later of either October 31, 2021, or for a period of 90 days after the end of both the public health emergency and state of emergency, 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 –       October 31, 2021

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

ED visits associated with admissions for treatment of COVID-19

March 30, 2020 –      October 31, 2021

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

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

As a result of the processes we have implemented, you will not need to contact the call center or submit a claim investigation via PEAR Practice Management on the Provider Engagement, Analytics & Reporting (PEAR) portal to request an adjustment.​

AmeriHealth New Jersey is committed to providing our members with access to the care they need during the COVID-19 pandemic. We encourage all AmeriHealth New Jersey members to visit our dedicated COVID-19 webpage for AmeriHealth New Jersey regularly for the latest news and updates. We will continue to evaluate member needs as the situation changes.

Learn more

Read more about our coverage of services during the COVID-19 pandemic in our News Articles on our Medical and Claim Payment Policy Portal.