Cost-Sharing Waived for COVID-19 Related Services

In order to comply with Section 6008(b)(4) of the Families First Coronavirus Response Act, the Division of Medicaid (DOM) is suspending cost-sharing for COVID-19-related testing, treatment, and services, including vaccines, prescription medications, specialized equipment and therapies, regardless of ultimate diagnosis, starting with dates of service (DOS) on or after March 1, 2020, until the end of the COVID-19 emergency. 

Effective  May 11, 2020 , providers – whether medical or pharmacy – are prohibited from collecting copayments from Medicaid beneficiaries.

DOM is in the process of implementing claims system updates to allow the use of a copay exception code on the claim in the Medicaid beneficiary ID field indicating that the service was COVID-19 related. Once this implementation has been completed, providers must place the copay exception code “V” as a suffix to the beneficiary’s Medicaid ID number to avoid a copayment deduction from the claim’s total payment amount. 

Providers will be notified through a Late Breaking News article when the system update has been made, at which time copayments may be charged for non-COVID-19-related treatments and services.

Medical Claims (CMS-1500 and UB-40)

As part of the system update, DOM will mass adjust medical fee-for-service (FFS) claims for dates of service March 1, 2020, up to the date of the completion of the system update, reversing the copay deduction from the claim’s payment amount. Medical providers are required to refund copayments to beneficiaries who have paid a copayment from March 1, 2020, up to the date of the system update. 

After the system change, medical providers must include the “V” modifier on all COVID-19-related claims as described above and are allowed to charge copayments for non-COVID-19-related treatments and services.

Pharmacy Claims (NCPDP D.0) 

All pharmacy claims with DOS March 1, 2020, through April 2, 2020, on which a $3.00 copay was charged have already been adjusted, reflecting a $3.00 credit on remittance advice statements dated April 6 and April 13, 2020. Pharmacy providers are required to refund $3.00 copayments to beneficiaries who have already paid $3.00 copayments.

No copayments were charged on pharmacy claims for DOS April 2, 2020, through April 8, 2020. Claims after this date until the system change is implemented will show a $3.00 deduction for copayment. However, this will be credited back to pharmacies after the system change is made.

After the system change until the end of the COVID-19 emergency, Pharmacy providers should enter a “V” immediately after the beneficiary ID when:

The prescriber has indicated a diagnosis of COVID-19 on the prescription,

The prescriber notates the beneficiary may have COVID-19 illness on the prescription, or

The beneficiary states that they may have COVID-19 or are being treated for COVID-19.

Denied Telehealth Claims for Claim Exception Code 0365

DOM and Conduent are aware of the issue where Telehealth claims are denying for claim exception 0365 PROCEDURE/PLACE OF SERVICE CONFLICT. DOM implemented a system fix to correct the issue. Providers will need to resubmit claims. If you have any questions, please contact Conduent Provider and Beneficiary Services at  800-884-3222 .