​​COVID-19 (Coronavirus): Member cost-share claims processing for PCP, specialist, and behavioral health telemedicine services

July 1, 2021

This article was revised on July 1, 2021, to update the contact information for claim investigations. To learn about telemedicine coverage, please read this ​ article.

For more information about telemedicine services, please refer to Medical Policy #00.10.41h: Telemedicine Services (Independence). It was posted as a Notification on December 31, 2020, and went into effect July 1, 2021.

Telemedicine claims

Independence is waiving member cost-sharing for COVID-19 related telemedicine primary care physician (PCP), specialist, and behavioral health visits only. Please read the telemedicine article for coverage details.

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.

In support of the process for PCP, specialist, and behavioral health 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 visits

For HMO/POS visits, 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 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

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.

*Claim adjustments to pay the copayment or other cost-sharing are processed using the J3490 code. Any corrected claim submissions to remove the J3490 code will require another adjustment to the corrected claim to reimburse for the copayment or other cost-sharing.

Independence is committed to providing our members with access to the care they need during the COVID-19 pandemic. We encourage all Independence members and providers 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.

Learn more

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