Ancillary

  • Our Ancillary team has overall responsibility for vendor products and cross-regional contracts. These responsibilities include:

    • Contracting
    • Fee schedule maintenance
    • Facilitating issue resolution
    • Provider/vendor education

    To contact our Ancillary team, see Contact information for Physician and Provider Relations on our website.

    Ancillary provider specialties include:

    Alternative care:

      • Massage therapy
      • Naturopaths
      • Dieticians/Nutritionists
      • Acupuncturists
      • Chiropractors

    Home based services:

      • Home health
      • Home hospice
      • Private duty nursing
      • Home infusion
      • Home medical equipment, including prosthetics and orthotics

    Other specialties:

      • Inpatient hospice
      • Physical therapy
      • Occupational therapy
      • Speech therapy
      • Laboratories
      • Ambulance
      • Dialysis centers
      • Skilled nursing facilities (SNF)
      • Applied behavior analysis

    The following benefit quotes can't be obtained online. Please contact Customer Service at 877-342-5258, option 2 for:

    • Home infusion services
    • Ambulance (non-emergent)
    • Vision hardware
    • Dieticians/nutritionists
    • Private duty nursing
  • Claims and billing

    Claims submission

    Our billing guidelines are described in the Claims and Payment section of the Provider Reference Manual. Please note the following additional information:

    • Bill Home Health, Hospice, Dialysis, and SNF claims on a UB-04 claim form with appropriate revenue codes.
    • Bill all other ancillary provider types with a CMS 1500 claim form.
    • HCPC codes are required for suppliers of Home Medical Equipment, Prosthetics and Orthotics and Home Infusion. Include modifiers when applicable. (NU for purchase, RR for rental)
  • Home based services

    Premera contracts with a variety of providers that deliver home-based services.

    Home health

  • Premera contracts with providers that are licensed as home health agencies. The services in an approved home health agency are covered for medically necessary treatment of an illness or injury, subject to the following limitations (for most members):  

    • The member is usually homebound, meaning that:
      • Leaving the home could be harmful to the member or involves a considerable and taxing effort, and
      • The member is unable to use transportation without assistance
    • The member's condition must be:
      • Serious enough to require confinement in a hospital or skilled nursing facility in the absence of home healthcare
      • There is no trained caregiver in the home to adequately provide the needed medically necessary service

    The types of services covered under the home health benefit can include skilled nursing, home health aide services, rehabilitative therapy, social services, respiratory therapy and nutritional services. These agencies must be credentialed by us and bill services through the home health agency. Covered employees of a home health agency include:  

    • Registered nurse (RN)
    • Licensed practical nurse (LPN)
    • Certified Nursing assistant (CNA)
    • Physical therapist
    • Occupational therapist
    • Speech therapist
    • Master's level social worker (MSW)
    • Licensed respiratory therapist
    • Registered dietician (RD)  

    When requesting coverage for visits from Care Management, include the member's treatment plan and goals with the faxed request. Please notify our Care Management department of any changes in treatment plan.

  • Home infusion

  • We contract with providers who are licensed to provide home infusion therapy

    Requirements

    For home infusion services, each member must have a written physician's plan of care, which includes the medication prescription and statement of medical necessity.

    The medication prescription must include the:

    • Drug
    • Route
    • Frequency
    • Dose of each medication prescribed

    The physician is required to approve changes for infusion therapy. The statement of medical necessity renewal is required with each initial therapy request.

    Changes in therapy require renewal only if they are long-term drugs and/or therapies (e.g., IGG, prolastin).

    Billing

    Bill drugs using the appropriate HCPC code, including NDC number. Units of billed services must be equal the dosage referenced in the HCPC code description.

  • Home medical equipment

  • Home medical equipment is:

    • Able to withstand repeated use
    • Primarily and customarily used to serve a medical purpose
    • Not generally useful to a person in the absence of illness or injury
    • Appropriate for use in the home.

    General coverage

    Coverage of home medical equipment is subject to medical necessity. We do not cover equipment that:

    • Cannot reasonably be expected to perform a therapeutic function in an individual case
    • Substantially exceeds the level required for the treatment of the illness or injury

    Rental and purchase

    Please note the following guidelines:

    • We may allow charges for renting home medical equipment when a member rents equipment for a short period of time.
    • If the rental exceeds the period of time allowed by the prescription, we require documentation of medical necessity.
    • Reimbursement for rental items can't exceed contracted purchase price.

    Repairs and service

    When necessary, we cover repair and servicing charges for patient-owned equipment due to normal use. Repair charges are not covered if they are greater than the cost of replacing the equipment. Refer to the replacement guidelines below.

    All claims for home medical equipment repairs or servicing are subject to review by Premera. If not covered by the manufacturer's warranty, Premera covers the rental fee for necessary loaner equipment while member-owned equipment is being repaired or serviced.

    Replacement

    For replacement of home medical equipment, the referring physician must submit a new prescription, and the supplier must indicate the condition of the present equipment on the prescription. Claims for replacement are subject to our review.

    Billing

    Each supply provided should be itemized using appropriate HCPC codes and modifiers.

    Prosthetics/orthotics

    Generally, the benefits for external prosthetic devices (including fitting expenses), with the exception of intraocular lens, are provided when such devices are used to replace all or part of an absent body limb, or to replace all or part of the function of a permanently inoperative or malfunctioning body organ.

    In general, foot orthotics (shoe inserts) and therapeutic shoes (orthopedic) are covered when prescribed for the condition of diabetes or for corrective purposes.

  • Hospice care

  • Premera contracts with providers who are licensed as outpatient hospice agencies. Outpatient hospice care is designed to be used by patients who meet all of the following conditions:

    • Have life threatening conditions
    • Expected to live for no more than six months, and
    • Desire and require palliative care

    Covered services for hospice care require that this care be:  

    • Part of a prescribed written plan
    • Periodically reviewed
    • Approved by a physician (MD or DO) 

    Because the patient's care may change, the plan should be reviewed every 60 days and revised as needed.

    Respite care is unique to hospice care. It is designed to relieve anyone who lives with and cares for a terminally ill person.

    Total hours of covered service for respite care may vary. It is important to verify coverage for all available hospice services at the time you receive the referral.

  • Alternative care services

  • We contract directly with providers who are licensed to provide chiropractic services.

    Coverage

    Chiropractic manipulative treatment (CMT) services are covered when the care is medically necessary and the CMT is for a diagnosed neuromuscular condition that may be improved or resolved by standard chiropractic treatment.

    CMT services that are eligible for coverage are specifically limited to treatment by means of manual or instrument assisted manipulation. Services other than CMT (including diagnostic imaging) may be covered under the member's rehabilitation or other medical benefit and are subject to member eligibility, benefits, and copay or coinsurance requirements.

    Chiropractic wellness, preventive services, and maintenance therapy are not covered benefits. For more information about coverage and policy guidelines, the Premera Chiropractic Medical Policy and the Physical Medicine & Rehabilitation/Physical Therapy Medical Policy can be viewed online. The medical policy covers medical necessity and documentation requirements, and lists procedures or techniques that we consider investigational. Chiropractic Position Papers that give additional information regarding medical necessity, documentation of care, use of Evaluation and Management CPT codes, delegation of duties, treatment plans for physical medicine and rehabilitation, and multiple copays are on our web site.

    New Technologies or Treatments

    New technologies or treatments may not be covered. A pre-service review can be requested to confirm coverage and medical necessity. See the Integrated Health Management – Reviews section of our manual for more information.

    Premera contracts directly with providers who are licensed to provide massage therapy services.

    Coverage

    Massage Therapy is covered under the Physical Medicine and Rehabilitation benefit. Services may be considered medically necessary when performed to meet the functional needs of a patient who suffers from physical impairment, functional limitation or disability due to disease, trauma, congenital anomalies, or prior therapeutic intervention. Maintenance programs are a member benefit exclusion and aren’t covered.

    Massage therapists are required to obtain and keep the member’s medical massage prescription on file. The prescription for medically necessary massage must come from a clinician who has prescribing authority. It needs to specify a diagnosis as well as the frequency and duration, or number, of medical massage visits.