Premera Blue Cross Blue Shield of Alaska Response to COVID-19

  • Premera Blue Cross Blue Shield of Alaska is here to support members, employers, and healthcare providers during the coronavirus (COVID-19) outbreak.

    Updates as of November 18, 2021

    • The federal Public Health Emergency was extended another 90 days to January 16, 2022. See COVID-19 key dates grid for details.
    • Prior authorization requirements waived for medically necessary air/ground transport for Alaska only.
    • Prior authorization requirements waived for transfers to home health, a skilled nursing facility (SNF), or a long-term acute care hospital (LTAC). Get details in the prior authorizations section in this FAQ.
    • A third COVID-19 vaccine dose was approved and recommended for certain individuals for all 3 vaccines. There are specific codes to use for each specific booster dose. 
    • A booster dose was recommended for those age 65+ or in a care center, and allowed for certain other individuals. There is a separate code for this Pfizer-only booster dose.

    Get all the latest COVID-19 updates from the Alaska Department of Health and Social Services and the Centers for Disease Control and Prevention (CDC).

    If you have health plan questions not covered in these resources, call Premera’s customer service team at the number on the back of the member ID card, or your provider network team. Every question will be answered as soon as possible.

    We’ll be updating the following FAQ as additional information is available.

    COVID-19 key dates

    COVID-19 Coverage
    Note: See related section for more information about health plan coverage.
    End Date
    PHP and IOP available through telehealth became policy:
    • Partial hospitalization programs (PHP) for mental health and substance use disorders
    • Intensive outpatient programs (IOP) for mental health and substance use disorders
    • Telehealth policy updated to allow ongoing coverage effective January 1, 2021.
    Policy effective January 1, 2021
    Allowance for certain procedures to be handled through tele-dentistry became policy (Premera initiative) Policy effective April 1, 2021
    Personal Protective Equipment (PPE) separately billed PPE charges covered for in-person medical provider visits. Bill effective April 16, 2021
    Waiver of prior authorization requirements for home health, skilled nursing facility (SNF), or long-term acute care hospital (LTAC) services (Premera initiative) September 7 through January 16, 2022
    Waiver of medical necessity requirements for air/ground transport in Alaska only to an available Premera-contracted facility September 15 through January 16, 2022
    Applied behavioral analysis (ABA) available through telehealth (Premera initiative  March 31, 2022
    Cost share waivers for FDA-approved COVID-19 diagnostic testing other virus/respiratory testing tied to a COVID-19 diagnosis (Federal Families First Act and Alaska DOI mandate) January 16, 2022*
    Antibody tests covered when done in an inpatient setting; late illness onset, or outpatient inflammatory syndrome in children. Cost shares waived if criteria met. (CDC and EEOC guidelines)

    Policy effective July 1, 2020
    Cost share criteria through January 16, 2022*

    *HHS announced that the COVID-19 public health emergency (PHE) will likely remain in place for the entirety of 2021. However, a PHE declaration is limited by law to a 90-day period that can be terminated early or extended. Premera will extend federally mandated benefits every 90 days upon official renewal of the PHE by HHS Secretary. The HHS will provide 60-day notice if it decides to terminate PHE or allow it to expire.

    COVID-19 vaccines

    Note: We’re updating our vaccine FAQs as information becomes available. Information about vaccines and distribution will continue to evolve.

  • The Centers for Disease Control and Prevention (CDC) officially recommended the administration of a booster vaccine dose from Pfizer/BioNTech or Moderna for people 65+ and residents of long-term care facilities receive a booster shot of Pfizer or Moderna COVID-19 vaccine at least 6 months after the 2nd Pfizer dose. It also includes recommendations for those 50-64 with underlying medical conditions. Those younger than 50 with underlying medical conditions and those at increased risk because of their occupational or institutional setting may also receive a booster at least 6 months after their Pfizer or Moderna second dose.

    •  America's Health Insurance Plans (AHIP) said health plans will continue to cover all vaccine administrative costs for their members as required, while Centers for Medicare & Medicaid Services (CMS) said Medicare will reimburse providers at the same rate for the booster shot as for the previous COVID-19 vaccine dose.
    • Correct coding is required to process your claim. Claims that are incorrectly coded may be rejected. The correct codes are noted in the coding section above.
    • These codes should be billed for the booster dose of the Pfizer vaccine only. Only individuals that meet the requirements established by the FDA and CDC should receive the third dose.

    People who are fully vaccinated are still strongly protected against hospitalization and death from COVID-19. But immunity against infection can wane over time, and the extra-contagious delta variant is spreading widely. U.S. health authorities want to shore up protection in at-risk people who were vaccinated months ago, though the priority remains getting the unvaccinated their first shots.

    It means a booster of a different brand from your original vaccination. That gives flexibility in situations such as nursing homes where only one type of booster might be brought in. It also gives people at risk of a rare side effect linked to one kind of vaccine the option of switching to a different shot.

    The CDC's recommendations now allow for "mix and match" dosing for booster shots depending on personal preference. Eligible individuals may choose which vaccine they receive as a booster dose. For people who originally got a J&J vaccination, the Moderna and Pfizer shots appeared to offer a stronger boost. But researchers cautioned the study was too small to say one combination is better than another.

    As a federal contractor, Premera is required to follow the federal mandate for contractors. We will require all employees, including telecommuters, to be fully vaccinated by January 1, 2022. Per the federal mandate, there are no test out options, however, we will be accommodating accepted religious and medical exceptions. We will also be offering an incentive to employees vaccinated by January 1, 2022. 

    The CDC does not recommend mixing the vaccines. If you received the Moderna as your initial vaccine, you should wait until the Moderna booster is approved. Moderna is currently testing a half-dose as a booster and expects to submit their findings to the FDA in the next few weeks.

    A third dose of either the Pfizer or Moderna COVID-19 vaccine is recommended for people with moderately to severely compromised immune systems. This additional dose is intended to improve immunocompromised people's response to their initial vaccine series. The third dose should be given at least 28 days after a second dose of either the Moderna or Pfizer COVID-19 vaccine.

    Currently there isn't a recommendation for a second dose of the J&J COVID-19 vaccine.

    The CDC, and many medical practitioners, are strongly recommending everyone get a flu shot this year. With the flu almost non-existent last year due to the stay-at-home orders, masking and handwashing, many are expecting this flu season to come back strongly. According to the CDC, it is safe to get both your COVID-19 vaccine and the flu vaccine at the same time.

    As a contracted provider with Premera, your contract prohibits you from discriminating against any individual based on their health status, which includes vaccination status. If you have further questions, you may want to consult with your own legal counsel.

    Yes. For commercial plans, to receive/administer COVID-19 vaccine, constituent products, and ancillary supplies, vaccination provider facilities/organizations must enroll in the federal COVID-19 Vaccination Program coordinated through their jurisdiction's immunization program. Enrolled COVID-19 vaccination providers must be credentialed/licensed in the jurisdiction where vaccination takes place, and sign and agree to the conditions in the CDC COVID-19 Vaccination Program Provider Agreement. These conditions are detailed in the agreement itself.

    Each state has developed a draft plan for COVID-19 Vaccine preparedness (WashingtonAlaska) addressing a variety of topics. That includes phases of distribution and allocation, identification of critical populations and initial plan for prioritization of administration to different groups.

    If you want to enroll in your state Medicaid program as well, reach out to your representative from the State Medicaid Agency Provider Enrollment Contact List.

    Alaska has developed a draft plan for COVID-19 Vaccine preparedness addressing a variety of topics. That includes phases of distribution and allocation, identification of critical populations and initial plan for prioritization of administration to different groups.

    On August 23, 2021, the FDA approved the Pfizer-BioNTech COVID-19 vaccine for individuals 16 years of age and older. The vaccine continues to be available under Emergency Use Authorization for individuals 12-15 years of age and for the administration of a third dose in certain immunocompromised individuals. The other two vaccines, Moderna and Johnson & Johnson, continue to have Emergency Use Authorization for individuals 18 and older.

    The U.S. Food and Drug Administration (FDA) expanded the emergency use authorization (EUA) for the Pfizer-BioNTech COVID-19 vaccine for the prevention of coronavirus disease 2019 (COVID-19) to include adolescents ages 12 to 15.

    On May 11, 2021, the Biden Administration announced a partnership with both Lyft and Uber to offer free rides to vaccination sites to those in need. You an access the information and request a free ride through Uber and Lyft websites.

    Alaska has approved the use of the Pfizer COVID-19 vaccine for adolescents aged 12 to 15 starting May 13, 2021.  

    These codes must be used for the Pfizer, Moderna, and Johnson & Johnson vaccines. Use the links below to ensure the new codes are in your system to facilitate efficient claims processing.

    COVID-19 Vaccine codes (Medical)

    Code Description
    91300
    (Pfizer Vaccine)
    Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNALNP, spike protein, preservative free, 30 mcg/0.3mL dosage, diluent reconstituted, for intramuscular use
    (Report with administration codes: 0001A-First administration and 0002A-Second administration). Eff. 12/11/2020
    0001A
    (Admin1)
    Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3mL dosage, diluent reconstituted; first dose.  (Report with administration of Pfizer vaccine 91300)
    0002A
    (Admin2)
    Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3mL dosage, diluent reconstituted; second dose.  (Report with administration of Pfizer vaccine 91300)
    91307
    (Pfizer Vaccine pediatric dose)
    Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNALNP, spike protein, preservative free, one-third adult dose, diluent reconstituted, for intramuscular use (Report with administration codes: 0071A-First administration and 0072A-Second administration). Eff. 10/29/2021
    0071A
    (Admin1)
    Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, one-third adult dose, diluent reconstituted; first dose. (Report with administration of Pfizer vaccine pediatric dose 91307)
    0072A
    (Admin2)
    Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, one-third adult dose, diluent reconstituted; second dose.  (Report with administration of Pfizer vaccine pediatric dose 91307)
    91301
    (Moderna Vaccine)
    Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNALNP, spike protein, preservative free, 100 mcg/0.5mL dosage, for intramuscular use
    (Report with administration codes: 0011A-First administration and 0012A-Second administration) Eff. 12/18/2020
    0011A
    (Admin1)
    Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5mL dosage; first dose. (Report with administration of Moderna vaccine 91301)
    0012A
    (Admin2)
    Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5mL dosage; second dose. (Report with administration of Moderna vaccine 91301)
    91303
    (Janssen /Johnson & Johnson Vaccine)
    Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, DNA, spike protein, adenovirus type 26 (Ad26) vector, preservative free, 5x1010 viral particles/0.5mL dosage, for intramuscular use. Eff. Date: 2/27/2021
    0031A Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, DNA, spike protein, adenovirus type 26 (Ad26) vector, preservative free, 5x1010 viral particles/0.5mL dosage, single dose. Eff. Date: 2/27/2021
       
    0003A PFIZER
    THIRD DOSE CODE
    Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS[1]CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA[1]LNP, spike protein, preservative free, 30 mcg/0.3 mL dosage, diluent reconstituted  (Effective August 12, 2021)
    0013A MODERNA
    THIRD DOSE CODE
    Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV[1]2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5 mL dosage;   (Effective August 12, 2021)
    0004A BOOSTER DOSE CODE Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS[1]CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA[1]LNP, spike protein, preservative free, 30 mcg/0.3 mL dosage, diluent reconstituted; (Effective Sept. 25, 2021)

    It's recommended that providers download the new release of PC-ACE. This release includes the coding structure, currently comprised of both a HCPCS Level I CPT code structure issued by the American Medical Association (AMA) and a HCPCS Level II code structure issued by CMS. This code structure was developed to facilitate efficient claims processing for any COVID-19 vaccines and monoclonal antibody infusions that receive FDA EUA or approval. CMS and the AMA are working collaboratively regarding which codes to submit for COVID-19 vaccines and administration.  Most of these codes are not currently effective and not all codes will be used.  Specific code descriptors will be issued in the future.  Effective dates for the codes for Medicare purposes will coincide with the date of the FDA EUA or approval.

    Get the most up to date list of billing codes, payment allowances and effective dates.

    New for Dental Providers: There are specific CPT Medical COVID-19 Vaccine Codes that are used when administering COVID-19 vaccines. There are separate codes for each dose when administering either the Moderna or the Pfizer vaccines, and a single code for the Janssen vaccine. Although there were recent ADA Dental codes created, for faster claim adjudication, we recommend you use the appropriate medical codes for vaccine administration (see the code list above) and submit them on a CMS-1500 Professional claim form instead of a Dental claim form. Submitting vaccine claims using dental codes (noted below) will delay your payment:

    COVID-19 Vaccine codes (Dental use only)

    ADA Code ADA Code Description
    D1701 Pfizer-BioNTech Covid-19 vaccine administration–first dose SARSCOV2 COVID-19 VAC mRNA 30mcg/0.3mL IM DOSE 1
    D1702 Pfizer-BioNTech Covid-19 vaccine administration–second dose SARSCOV2 COVID-19 VAC mRNA 30mcg/0.3mL IM DOSE 2
    D1703 Moderna Covid-19 vaccine administration–first dose SARSCOV2 COVID-19 VAC mRNA 100mcg/0.5mL IM DOSE 1
    D1704 Moderna Covid-19 vaccine administration–second dose SARSCOV2 COVID-19 VAC mRNA 100mcg/0.5mL IM DOSE 2
    D1705 AstraZeneca Covid-19 vaccine administration–first dose SARSCOV2 COVID-19 VAC rS-ChAdOx1 5x1010 VP/.5mL IM DOSE 1
    D1706 AstraZeneca Covid-19 vaccine administration–second dose SARSCOV2 COVID-19 VAC rS-ChAdOx1 5x1010 VP/.5mL IM DOSE 2
    D1707 Janssen Covid-19 vaccine administration SARSCOV2 COVID-19 VAC Ad26 5x1010 VP/.5mL IM SINGLE DOSE

    Dental COVID-19 (Lab tests only)

    ADA Code ADA Code Description
    D0606 Molecular testing for a public health related pathogen, including coronavirus

    If you're having difficulty billing for the COVID vaccine, contact the Express Scripts help desk at 800-922-1557.

    Information about vaccines and distribution will continue to evolve.

    For general questions about COVID-19 vaccines and vaccine trials, and for the CDC playbook:

    The federal government has mandated that the cost of the vaccine will be $0 for everyone in the U.S. The cost for administering the vaccine will be covered by insurance, for those with coverage, or waived for those without coverage. Providers may bill an insurance company for administrative costs.

    The cost of the actual vaccine is being covered by the government for non-Medicare plans beginning January 1, 2022. The cost of administering the vaccine will be covered by insurers, like Premera. CMS has recently released expected costs for vaccine administration. We expect the vaccines will be billed by dose, similar to how other 2-dose vaccines are billed.

    Currently only those in Phase 1a category are receiving doses of the vaccine. For Phase 1b and 1c, you may need a doctor's note or identification to prove you're eligible when the vaccine becomes available. We expect to know more about requirements in early January.

    A pediatric dose of the Pfizer-BioNTech COVID-19 vaccine is available for children aged 5 to 11. If a child turns 12 before their second dose, they can receive either the pediatric dose or the full dose. The Pfizer-BioNTech COVID-19 vaccine is available for adolescents aged 12 to 15. Moderna and Johnson & Johnson vaccines are approved for those 18 and older.

    You may not be fully protected from contracting the COVID-19 virus. There are many vaccines that require more than one dose to ensure adequate immune response (i.e., antibodies) and to protect you from contracting a virus.

    For some vaccines (primarily inactivated vaccines), the first dose does not provide as much immunity as possible. So, more than one dose is needed to build more complete immunity. The vaccine that protects against the bacteria Hib, which causes meningitis, and the vaccine that protects against shingles, are good examples.

    If you get your second shot too early or too late, you DO NOT need to repeat the dose.

    If you accidentally get the wrong vaccine for your second shot, you DO NOT need to repeat the dose. For example, if you get the Pfizer vaccine and then for your second shot you accidentally get the Moderna vaccine, you do not need another dose of either the Pfizer OR Moderna vaccine.

    You should receive a vaccine card from the provider letting you know when you'll need to get your second dose and which vaccine you received. You may also be asked to provider your email address or phone number for a reminder as well. Premera is looking into reminders as well, but because claims for vaccinations can come in up to 60 days after the fact, we may not be able to provide timely reminders.

    The Centers for Disease Control and Prevention (CDC) officially recommended the administration of a third vaccine dose from Pfizer/BioNTech or Moderna for such individuals, including patients who have been receiving active cancer treatment for tumors or blood cancers, those who have received organ transplant or stem cell transplant, and those with moderate or severe primary immunodeficiency. America's Health Insurance Plans (AHIP) said health plans will continue to cover all vaccine administrative costs for their members as required, while Centers for Medicare & Medicaid Services (CMS) said Medicare will reimburse providers at the same rate for the booster shot as for the previous COVID-19 vaccine dose.

    Correct coding is required to process your claim. Claims that are incorrectly coded may be rejected. The correct codes are noted in the coding section above. These codes should be billed for the third dose of the Pfizer and Moderna vaccines. Only individuals who meet the requirements established by the FDA and CDC should receive the third dose.

    There are no requirements currently that you must get the vaccine. It is, however, highly recommended.

    We can't provide you with employment law advice on this topic. You'll want to check in with your own legal counsel to determine if there are any restrictions or considerations to that requirement. The vaccine will be covered under your health plan benefits.

    Not quite yet. According to studies, we need more than 65% of the population to get the COVID-19 vaccine in order to begin to see protection among the general population. Once you receive both doses of a vaccine, you may be able to resume normal activities. In the meantime, continue to exercise caution, wash your hands frequently, and wear a mask.

  • COVID-19 testing and cost-share waivers

  • The new Families First Coronavirus Response Act requires all group health plans, including self-funded plans, to provide coverage for provider-ordered testing, including U.S. Food and Drug Administration (FDA)-approved COVID-19 diagnostic testing products and items and services related to testing furnished during an office, telehealth, urgent care center or emergency room visit. We have removed the group waivers that were previously in place to comply with this mandate.

    Premera follows state and federal mandates related to end dates for these services. See the COVID-19 Key Dates section in this FAQ for current dates.

    Commercial and Medicare Supplement members: We're waiving in-network cost shares (coinsurance, copays, and deductibles) for members requiring provider-ordered COVID-19 and influenza testing. All other treatments and services including hospitalization not related to a COVID-19 diagnosis will be subject to the usual benefits and cost shares.

    Pre-authorization isn't required for provider-ordered COVID-19 testing. If a member requires COVID-19 testing and treatment and there isn't an in-network provider within a reasonable distance, the claims will be paid as in-network.

    Note: HHS announced that the COVID-19 public health emergency (PHE) will likely remain in place for the entirety of 2021. However, a PHE declaration is limited by law to a 90-day period that can be terminated early or extended. Premera will extend federally mandated benefits every 90 days upon official renewal of the PHE by HHS Secretary. The HHS will provide 60-day notice if it decides to terminate PHE or allow it to expire.

    Premera's Benefit Coverage Guideline is effective for serology tests for dates of service July 1, 2020 and forward. Premera will reimburse for serology tests that are for the purpose of supporting a COVID-19 diagnosis as part of the treatment or management of a patient's medical condition.

    Serology tests provided on an inpatient basis are presumed to be for diagnostic purposes. Tests performed on an outpatient basis require records confirming that the test is for the diagnosis of the disease or condition of a patient.

    The Benefit Coverage Guideline for individual plan patients and non-individual plan patients follows CDC guidance on scenarios in which serology testing can be used for diagnostic purposes:

    • Serologic testing can be offered as a method to support diagnosis of acute COVID-19 illness for persons who present late. For persons who present 9-14 days after illness onset, serologic testing can be offered in addition to recommended direct detection methods such as polymerase chain reaction.
    • Serologic testing should be offered as a method to help establish a diagnosis when patients present with late complications of COVID-19 illness, such as multisystem inflammatory syndrome in children.

    Serological tests will not be covered when provided as the sole basis of diagnosis for current infection with COVID-19.

    We will be covering claims with dates of service June 30, 2020 or earlier.

    While cost share waivers, including copays, deductible and coinsurance for all COVID-19 related treatment (both inpatient and outpatient) ended on June 30, 2021, treatment costs are still covered as a medical expense. Cost share waivers for COVID-19 diagnostic testing and related provider visit remain in place.

    See the COVID-19 Key Dates section in this FAQ for current dates. You can check eligibility and benefits on our website.

    FDA-authorized COVID-19 home test kits are only covered when ordered by a licensed physician or pharmacist. Home test kits will not be covered if used for non-diagnostic purposes (e.g. travel, return to work, etc.). Members may submit claims for reimbursement for in-home tests only when they are ordered by a physician or pharmacist. There may also be tax implications for using HSA funds to purchase in-home tests that are used for purposes other than diagnostic.

    Yes. Drive-through diagnostic testing for COVID-19 is and cost shares will be waived as they are for in-clinic testing.

    S.B. 241 is a comprehensive coronavirus-related bill that assumes firefighters, emergency medical technicians, paramedics, peace officers, or health care providers who contract COVID-19 during the public health emergency declared on March 11 is presumed to have contracted it during employment.

    When a member of this group seeks care, they should notify you they believe they contracted COVID-19 in the course of their job. You then codes the claim and submit as a workers' compensation claim. Premera pends the claim and asks the member to complete an incident questionnaire to obtain the worker's compensation information.

    Any member that is presumed COVID-19 with these job titles must file a claim with the appropriate workers' compensation carrier; this could be Office of Worker's Compensation or their Self-Funded Compensation Carrier. The claim will either be processed by workers' compensation or by Premera, depending on the results of the incident questionnaire.

    The following summary of coding instruction is provided by the CDC, the World Health Organization (WHO), and CMS related to COVID-19. We urge you to use this COVID-19 diagnosis and procedure coding for patients so cost shares may be waived appropriately.

    There are two new HCPCS codes for lab tests to detect COVID-19: Code U0001 for the CDC test panel and code U0002 for other tests. In addition, two additional COVID test HCPCS codes U0003/U0004 for high throughput technologies are covered.

    The American Medical Association added a new CPT code for reporting the novel coronavirus tests: 87635: Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique.

    Per the CDC, a new ICD-10 emergency code, U07.1, 2019-nCoV acute respiratory disease, has been established by the WHO for reporting the virus, effective with the next update, October 1, 2020. Premera is accepting this code and encourages you to use it.

    To identify patients in the interim who've tested positive for COVID-19, current CDC guidance instructs to code first for the presenting illness followed by B97.29 - Other coronavirus, as the cause of diseases classified elsewhere.

    For the new serology tests, the AMA created new CPT lab test codes: 86328 and 86769. Use these codes when submitting a claim for the antibody test.

    As of January 1, 2021, new specific diagnosis codes must be used for all claims related to COVID-19 testing, treatment, and vaccines.
    You can learn more about the codes through the following Centers for Disease Control (CDC) resources:
    CDC: New COVID-19 ICD-10 Codes Effective January 1, 2021
    One-page announcement of further additions to ICD-10 codes.
    CDC: New COVID-19 Official Coding Guidelines
    Chapter-specific coding guidelines, pages 28-33.

    The AMA is offering additional guidance for COVID-19 coding scenarios to help healthcare professionals apply best coding practices. The scenarios include telehealth services for all patients.

    COVID-19 testing examples include coding for when a patient:

    • comes to the office for an E/M office visit and is tested for COVID-19
    • receives a telehealth visit regarding COVID-19
    • is directed to come to a physician's office or physician's group practice site for testing
    • receives a virtual check-in/online visit regarding COVID-19 (not related to an E/M visit)
    • is directed to come to a physician's office for testing

    There is also a quick-reference flowchart that outlines current procedural terminology (CPT®) reporting for COVID-19 testing. AMA also outlines CMS payment policies and regulatory flexibilities related to COVID-19. Check the AMA COVID-19 resource center for additional resources.

    COVID tests for travel aren't covered typically by the plan. This will not apply to Shared Admin, Commercial, Medicare Advantage and most self-funded plans. Normal plan benefits apply in this situation for our members. FEP and some self-funded plans are covering testing for travel. You can check eligibility and benefits on our website.

    Premera is not required under either state or federal law to provide coverage for  return-to-work testing or occupational testing. We will not cover testing for occupational or accommodation purposes when an employee has an approved vaccine mandate accommodation from their employer. Federal and state law do not require that these tests be reimbursed as part of a health plan.

    Return-to-work/return-to-school COVID tests aren't covered by the plan. Tests done for return to work or school, travel, or purposes other than diagnosing when a patient has symptoms or exposure, may not be coded as diagnostic and may not be billed to the plan. These tests are strictly member liability.

    Some lab companies are charging members a $10 non-refundable service fee for "physician oversight services" when a member orders testing directly through a lab. The $10 fee is for an independent physician who orders test for the member. The member also has the option to consult with this physician to discuss their results. This fee is not submitted to insurance for reimbursement by the lab service or the physician. This type of service fee and claim are not covered by the medical plan. To avoid this type of service fee, members should use their own provider or clinic when requesting COVID-19 testing.

    As of November 1, 2020, Personal protective equipment (PPE) will no longer be separately reimbursable effective.

    When PPE is worn as part of a dental, medical or pharmacist healthcare visit, it's considered part of the practice expenses included in the main dental medical or pharmacy related procedure rendered to a patient. PPE will not be separately reimbursable.

    Review additional details in the Personal Protective Equipment payment policy.

  • Virtual care

  • Per guidance from the Centers for Medicare & Medicaid Services (CMS), Premera began allowing POS11 for telehealth visits to allow reimbursement consistent with an in-office visit during the public health emergency. CMS guidance ends on September 1, 2021, and Premera will no longer pay telehealth visits at the higher POS11 code in Alaska.

    For providers who are delivering services via telehealth, Premera will require providers to continue use the correct telehealth place of service (POS) 02 with the procedure code appended with either modifier 95 or GT. Claims with modifiers indicating they were telehealth, if billed with POS 11, will be rejected up front and will require the correct POS to match the service billed. We will no longer accept POS 11 for telehealth services.

    Refer to your Premera contract for allowable information for virtual care codes. For specific coding information for Premera patients, see our telehealth payment policy for Alaska.

    In addition to our existing Premera contracted behavioral health providers (Talkspace, brick-and-mortar providers, and Employer Assistance Programs), virtual access for behavioral health and substance use disorder treatment (opioid and alcohol) may include access to the expanded telehealth network, depending on the member's benefit plan design:

    • Doctor On Demand – Doctor On Demand was added to our telehealth network. These services are available to member adults and children in all states.
    • Boulder Care - Boulder Care is a digital care provider, offering long-term support and medication-based treatment for opioid use disorder (OUD) and common co-occurring conditions for members 18 years and older. Their digital platform allows patients to connect with providers 24/7 through secure video and messaging with clinicians, care advocates, and peer coaches. Boulder Care is working towards 50 states licensure. If they aren't licensed in a certain state, they will transition the member to an in-network provider for the appropriate services.
    • Workit Health – Workit Health is a digital care provider offering support for alcohol use disorder (AUD). Via Workit web and phone apps, members age 18 and older have a "recovery in their pocket" harm reduction and sobriety solution that provides 24/7 access to interactive therapeutic courses, online support groups supervised by licensed care teams. Workit is working towards 50 states licensure. If they aren't licensed in a certain state, they will transition the member to an in-network provider for the appropriate services.

    Additional covered telehealth services include:

    • Applied behavioral analysis (ABA)
    • Partial hospitalization programs (PHP) for mental health and substance use disorders
    • Intensive outpatient programs (IOP) for mental health and substance use disorders

    Yes. Premera offers Talkspace for all our members. This is an online, virtual behavioral health provider resource. Many local mental health providers are also offering virtual services. Your patient should check with their provider first, or they can go directly to Talkspace.com/premera.

    Yes. For Premera-contracted providers, your current contract covers telehealth services if the care provided is appropriate within the scope of the provider's licensure. This change applies to Premera's individual and commercial members. However, some self-funded employer groups don't cover virtual care, so be sure to check your patient's benefits before providing care.

    Note: Telehealth services aren't coded like in-office visits due to different modifiers and place of service codes needed to identify a telehealth service. There are additional codes that can be used for online video encounters as well as telephone visits in conjunction with the office visit codes.

    Refer to your Premera contract for allowable information for virtual care codes. For specific coding information for Premera patients, see our telehealth payment policy for Alaska.>

    For dental providers: You may bill the following visit types via tele-dentistry adding tele-dentistry modifier code of D9995/6:

    • D0140 - Limited Oral Evaluation – Problem Focused
    • D0170 - Re-evaluation, limited problem focused (established patient, not post-operative visit): This code is appropriate when assessing a previously existing condition related to trauma, or a follow-up evaluation for continuing issues
    • D0190 – Screening of a patient. A screening, including state or federally mandated screenings, to determine an individual's need to be seen by a dentist for a diagnosis.
    • This temporary modification becomes policy on April 1, 2021.

    Premera wants to emphasize that this is a temporary relaxation of the rules during this nationwide public health emergency. Correct coding and notification to the patient that the provider is using non-HIPAA compliant communication tools is required.

    Refer to your Premera contract for allowable information for virtual care codes. For specific coding information for Premera patients, see our telehealth payment policy for Alaska.

    Premera will be extending the payment of telehealth visits at the in-person allowed amount, during the national public health emergency, beyond September 1, 2020 as previously communicated. For providers who are delivering services via telehealth, Premera will require providers to continue use the correct telehealth place of service (POS) 02 with the procedure code appended with either modifier 95 or GT. Claims with modifiers indicating they were telehealth, if billed with POS 11, will be rejected up front and will require the correct POS to match the service billed. We will no longer accept POS 11 for telehealth services. 

    Premera wants to emphasize that this is a temporary relaxation of the rules during this nationwide public health emergency. As additional information becomes available from CMS or other state regulators, we'll adjust our policies and notify you of the change. Only claims for telehealth visits from providers who members normally see in-person, in-office will be processed in this manner, and claim costs will be no more than what would have been paid had the member been able to see their providers in person.

    This guidance is in effect for Alaska group plans, FEP, and Individual plans. Self-funded plans and Shared Admin are excluded from this guidance.

    Refer to your Premera contract for allowable information for virtual care codes. For specific coding information for Premera patients, see our telehealth payment policy for Alaska.

    Per Health & Human Services and the Office of Civil Rights (OCR), a covered physician or healthcare provider who wants to use audio or video communication technology to provide telehealth to patients during the COVID-19 nationwide public health emergency can use any non-public facing remote communication product that is available to communicate with patients. OCR is exercising its enforcement discretion to not impose penalties for noncompliance with the HIPAA rules in connection with the good faith provision of telehealth using such non-public facing audio or video communication products during the COVID-19 nationwide public health emergency. This exercise of discretion applies to telehealth provided for any reason, regardless of whether the telehealth service is related to the diagnosis and treatment of health conditions related to COVID-19. Additionally the criteria that telehealth may only be used with established patients is being relaxed and new patient encounters can be billed with these codes.

    Providers can care for new patients via a telehealth virtual encounter and bill those services using the appropriate CPT that reflects the services rendered, in addition to the telehealth modifier and place of service. Virtual care for an established patient should also be billed with an appropriate CPT, many of which are found in Premera's payment policy. Note that these services must also be billed using the appropriate telehealth modifier and place of service.

    Yes, ABA services can be provided virtually for dates of service on or after March 20, 2020. This is temporary and will be in effect until government agencies indicate that we no longer need to practice social distancing.

    Claims for services provided virtually must be submitted with appropriate telehealth modifiers using the codes that are currently on the ABA fee schedule. See our telehealth payment policy for Alaska.

    Reimbursement for virtual care will be at the same amount as if the service were provided in-person.

    This change applies to Premera's individual and commercial members. However, some self-funded employer groups do not cover virtual care, so you'll need to check benefits for your patient before providing care.

    With the increasing use of telemedicine to interact and treat patients, it can be difficult to capture information and do a physical exam. Fortunately, synchronous audio and video platforms make it possible for providers to capture almost all areas of a physical exam. We've developed a tip sheet using best practices and information from Telemedicine: Conducting an Effective Physical Exam to help you conduct an effective physical exam during a telehealth visit.

  • Prior authorizations

  • Effective September 15, 2021, Premera is waiving requirements for Alaska air and ground transport. Refer Premera members to a contracted provider when possible to reduce member cost share. To find a list of contracted providers, use our provider directory and search for ambulance air transport.

    This is not a guarantee of payment. Claims for this admission will be paid based on benefits and eligibility in effect at the time of service. Sign in to the provider portal to review member benefit limits. Premera reserves the right to perform a retrospective review of services if claims or payment discrepancies arise.

    Effective September 7, 2021, Premera is waiving prior authorization requirements for home health, skilled nursing facility (SNF), or long-term acute care hospital (LTAC) services. This waiver applies to all plans, except FEP. For documentation, please provide admission notification and discharge date via fax at 888-742-1487. Refer Premera members to a contracted facility when possible, to reduce member cost share. To find a list of contracted SNFs, use our provider directory and search for skilled nursing.

    This is not a guarantee of payment. Claims for this admission will be paid based on benefits and eligibility in effect at the time of service. Sign in to the provider portal to review member benefit limits. Premera reserves the right to perform a retrospective review of services if claims or payment discrepancies arise.

  • Pharmacy and prescriptions

  • 90-day refills:

    • Most plans have access to mail-order prescriptions. Ask your provider about getting a 90-day supply.
    • Medicare Advantage members: Use this mail-order form.
    • Medicare Supplement members: If you have a separate Part D prescription drug plan, contact your Part D plan administrator for more information.

    Note: Some prescriptions aren’t eligible for mail order. Members should check their plan benefits or contact customer service at the number on the back of their ID card.

    Drugs that have received Emergency Use Authorization (EUA) or full FDA approval for the treatment of COVID will be covered under current policies and according to your health plan benefits.

  • Advance payment program

  • We want our community to be healthy. And to be healthy, we need to have a strong provider network. This focus is consistent with Premera’s emphasis on the role of front-line providers in our healthcare system and supportive of our members’ most common needs throughout the months ahead.

    The advance payment program ended on July 31, 2021.

    If you have unanswered questions, submit them to AdvanceProviderProgram@Premera.com. We’ll respond within 5 business days.