Posted in #Medicareadvantage, #unitedhealthcare, Training, Updates

UHC: Payment for COVID-19 testing coverage, outpatient SNF

Previously, UHC would not reimburse for COVID-19 testing when done outside of a skilled inpatient stay at a SNF.

However, during the PHE, starting Jan 27,2020 and then renewed on April 21,2021, subject to further extension, UHC is going to pay for the COVID-19 testing that is done outside of the skilled inpatient stay at a SNF.

This change applies to the following Medicare Advantage Plans:

  • Medicare Advantage Plans
  • Dual Eligible Special Needs Plans (DSNP)
  • Chronic Special Needs Plans (CSNP)
  • UnitedHealthcare Assisted Living Plans (IE-SNP)
  • FIDE/MMP Plans

Plans that this change DOES NOT APPLY TO:

  • UnitedHealthcare Nursing Home Plans (ISNP)
  • UnitedHealthcare commercial plans
  • UnitedHealthcare Community Plans (Medicaid Only Plans)

UHC will re-process the claims, there is no further action needed.

UHC will reprocess claims previously paid at $0 to be reimbursed at 100% of the Medicare fee schedule. No action is required from affected SNFs for these adjustments.

The following codes are going be reimbursed at 100% of Medicare Fee Schedule:


COVID-19 testing performed during an approved skilled stay are subject to Centers for Medicare and Medicaid Services (CMS) consolidated billing rules and are not separately reimbursable, except for the UnitedHealthcare Nursing Home Plan (ISNP). New applicable CMS covered COVID-19 testing codes may be added periodically. We may add or remove codes from the following list, in accordance with CMS coverage guidelines.

Find this information helpful? Then subscribe to my blog, via my home page! Check out my on demand webinars, coming soon! As well as members only subscription: where we will dive into the updated/current reimbursement policies for various insurance carriers.

In a meantime, check out my latest posts below:

Posted in #Medicare, Training

Do you know what is your Local CMS MAC?

As a provider you see Medicare patients and file their claims to Medicare every day, but do you know who is the one the processes those claims?

Well, the short answer is your Local CMS MAC.

What is a Local MAC? MAC stands for Medicare Administrative Contractor- a private healthcare insurer that processes the fee-for-services claims for Medicare Part A/B beneficiaries, Home Health, and DME claims.

According to as of 2019 there are 13 Medicare A/B MACs and 4 DME MACs. They are responsible for processing  claims for ” nearly 68% of Medicare population”.

MACs provide LCDs- Local Coverage Determinations for services that are done by you-provider.  By contacting your local MAC you can find out if a service or medication is covered or not. This step will help you reduce the number of your unnecessary denials and decrease the amount of days in your A/Rs.  

I am located in New York, so my local MAC is for Jurisdiction K- Medicare Part B claims ONLY.  The company that provides LCDs and processes my claims is NGS or National Government Services. 

Below are the most current A/B MAC + DME MAC jurisdictions.


Posted in Training, Updates

EmblemHealth Commercial and Exchange Plans – order Prior Auths through Express Scripts

Just a reminder to all of providers that accept EmblemHealth Commercial and Exchange Plans- starting 08/03/2020 Express Scripts will be responsible for utilization management of most specialty and step therapy drugs (specialty medications).

This change does NOT apply to EmblemHealth Medicaid and Medicare Plans or adult chemotherapy and supportive agents. Providers should follow the prior authorization guidelines through EmblemHealth. (Please see below)

EmblemHealth Commercial and Exchange Plans– Requesting an EPA (electronic Prior Authorization) Steps:

1. If your practice utilizes an EHR, you would be able to order it electronically.

2. You may also utilize: Covermymeds, Surescipts or ExpressPath- here you are able to create a free account and request an ePA.

Request Prior Auth by Phone & Fax:

1. Pharmacy Drug Reviews- phone 844-516-3324 (available 24/7/365) or by fax#: 877-251-5896

2. Medical Drug Reviews- phone 877-681-9866 (available 8am to 7pm EST) Monday through Friday, or by fax#: 866-896-1209


Requesting Prior Authorizations for EmblemHealth Medicaid and Medicare Plans:

1. Specialty Drugs- phone 888-447-0295 (available 8am to 6pm, Monday through Friday), or fax# 877-243-4812

2. Pharmacy Drugs- phone 877-362-5670 (available 8am to 6pm, Monday through Friday) or fax# 877-300-9695

IMPORTANT: if your patient has received an Authorization Approval prior to 08/03/2020, from EmblemHealth- it is valid until the expiration date of the authorization. Subsequent requests have to go through Express Scripts NOT EmblemHealth. (Your claims will be denied if you do not request an authorization from Express Scripts after 08/03/2020 and beyond)

For the full provider announcement, please see the slideshow below.