2017 Information for Premera Medicare Advantage Medical Providers - Delete

  • Premera Blue Cross offers four Medicare Advantage plans for eligible individuals who have Medicare Parts A and B, and are:

    • Age 65 or older
    • Under age 65 with certain disabilities
    • Current residents of Snohomish, King, Pierce, Thurston, or Spokane County

    Premera Blue Cross Medicare Advantage plans offer your patients Medicare benefits - plus extra benefits for prescriptions and fitness programs - all in one easy-to-use plan. Medicare open enrollment occurs annually, October 15 through December 7.

    Secure medical tools and resources for providers

    Verify eligibility and benefits, check claim status and manage your patient's care.

    Log in to medical tools and resources

  • Provider Directory

    Search for doctors, hospitals, and other specialists within the Premera Blue Cross Medicare Advantage Provider Network.


    Find all the Medicare Advantage medical forms you need, including:

    • Appeal and reconsideration forms
    • Care Management forms
    • Referral forms

    Contact us

    Find the right contact for Medicare Advantage questions, including:

    • General information
    • Member benefits and eligibility
    • Technical issues
    • And more
  • Visit the Premera Blue Cross Medicare Advantage member site to find out more about Pharmacy Services, including our Medication Therapy Management Program.

    Learn more about Promoting Safe Medication Use in Older Adults.

    Premera created a provider network in Snohomish, King, Pierce, Thurston, and Spokane counties that specifically supports our Medicare Advantage Plans.

    Find a complete listing of Premera Blue Cross Medicare Advantage providers, hospitals, and pharmacies using our Find a Doctor Tool.

    Find a Doctor Tool

    2017 Medicare Advantage plans have no out-of-network benefits

    We no longer offer the HMO-POS (Health Maintenance Organization-Point of Service) plan for 2017. We have three HMO plans. This means our plans have no out-of-network benefits except for emergency or urgently needed services. If members see an out-of-network provider, they may be responsible for the cost of their care. When referring Medicare Advantage members, confirm that the provider is in our Medicare Advantage network. Check our Medicare Advantage directory for a current list of our in-network providers and facilities.

    Medicare Advantage network changes

    Effective Jan. 1, 2017, Franciscan Health System will not be a part of our Medicare Advantage provider network. Be sure to check our provider directory before referring your Medicare Advantage patient to ensure that their services are covered by in-network providers and facilities.

    Your patients can visit the Medicare Advantage member website to find more information about our plans, including:

    • Choosing, Comparing Plans
    • Medicare Basics
    • Enrollment, Benefits and Coverage
    • Providers and Service Area
    • Pharmacy Services
  • Care Management Program

  • Premera's care management programs help improve the health and quality of life of our members and support your medical treatment plans.

    Once enrolled, members receive:

    • Condition-specific information, education, and support
    • Referrals to community and national resources
    • Telephone consultations from registered nurses, encouraging patients to take an active role managing chronic conditions or complex healthcare needs
    • Educational materials and access to local wellness classes

    You'll receive regular updates on your patient's progress in the program.

    Enroll by phone or fax

    Enrolling in our care management program is easy. Your patients can enroll on their own or can get assistance by phone (with you or a registered nurse). You can also fax the Care Management Referral Form found on the Premera Medicare Advantage website to 855-339-9713.

    Care management programs support the following conditions:

    Disease Management

    • Asthma
    • Chronic obstructive pulmonary disease
    • Coronary artery disease
    • Heart failure
    • Diabetes

    Care Management

    • Cancer
    • End-stage renal failure
    • Adult complex

    Auto-Immune Disorders

    • Rheumatoid arthritis
    • Lupus

    Neurological Disorders

    • Chronic inflammatory demyelinating polyneuropathy
    • Myasthenia gravis
    • Multiple sclerosis
    • Parkinson's disease

    Hereditary Conditions

    • Cystic fibrosis
    • Gaucher's disease
    • Hemophilia

    Chronic Inflammatory Conditions

    • Inflammatory bowel disease
    • Scleroderma

    Additional support provided for:

    • Care coordination
    • Pain management
    • Transition of care
    • Transplant services

    Patient Support

    • Educational material(s) mailed to patient's home
    • Personal, ongoing phone conversations with a registered nurse
    • Health questions answered by phone
    • Condition self-management
    • Monitoring of preventive health issues and relevant medical test results
    • Support for lifestyle issues, comorbidities, and medication management
    • Access to health and wellness classes

    We encourage you to schedule your Premera Blue Cross Medicare Advantage Plan patients for an Enhanced Annual Wellness Visit. This Medicare benefit is free for your patients and is an opportunity for you to have a discussion with your patients about any health concerns they may have. It's also a time when your patients can have questions answered about their health.

    What is an Enhanced Annual Wellness Visit?

    The Enhanced Annual Wellness Visit is an opportunity for you to meet with your patients to assess their chronic conditions and overall health and wellness. This is a free visit that's part of their preventive benefit and is reimbursed at a higher rate than a traditional Medicare physical.

    It's important to cover the following items during the visit:

    • Current chronic conditions, ongoing treatment plans
    • Screenings for high blood pressure, diabetes, depression, and heart disease
    • Medications
    • Preventive treatments for colon and other cancers, glaucoma, and osteoporosis
    • Lab work, as needed
    • BMI calculation, urinary incontinence, fall risk, and physical and mental health assessments

    Because the Enhanced Annual Wellness Visit includes a routine physical, the patient doesn't have to come in twice for essentially the same type of visit.

    We also request that you perform a "condition-pertinent" exam. For example, if the patient has chronic obstructive pulmonary disease, listen to the patient's lungs. If the patient has diabetes mellitus, check the patient's feet. And, for patients with multiple issues, cover areas relevant to those conditions.

    How do I bill for an Enhanced Annual Wellness Visit?

    Submit a claim with G0438/G0439 through your normal claims submission process. If you complete a chronic condition assessment of two or more conditions, include S0250 in addition to the G code. To receive payment, please fax supporting chart notes to 855-348-9135. View Documentation for Enhanced Annual Wellness Visits and How to Bill Enhanced Annual Wellness Visits.

    What needs to be done to qualify for billing the S code?

    To qualify for billing the S code, you must document and assess at least two chronic conditions, including management, evaluation, assessment, and treatment.

    Do I need to fax a chart note to Premera?

    Yes, for each Enhanced Annual Wellness Visit, we need a copy of the chart note faxed to 855-348-9135. We'll pay the enhanced rate if a chronic condition assessment is done. Alternative options for chart note submission are available, such as remote EMR access, FTP sites, or secure email. Please call your provider network executive if those options work better for you.

    What does Premera do with the patient chart note?

    We're required to retain records that support the codes billed. We'll submit the chart note to Medicare in case of a Risk Adjustment Data Validation Audit.

    Does Premera allow an evaluation and management (E&M) visit with an Enhanced Annual Wellness Visit?

    We do not allow an E&M visit with the G0438/G0439. We do allow S0250 for the chronic condition assessment, which adds an additional 3.0 total RVU to the visit. If you bill an additional E&M code, the visit is no longer free for the patient. This often causes confusion in the Medicare population; Premera wants to ensure that the visit is free for our members.

    If you feel there are conditions that need additional treatment, you'll need to schedule a follow-up visit on another day.

    How much does the Enhanced Annual Wellness Visit pay?

    Enhanced Annual Wellness Visits pay at the following rate:

    New Patient Traditional Annual Wellness Visit G0438
    (4.82 RVU)
    Enhanced Annual Wellness Visit; more than
    two chronic conditions reviewed and assessed
    G0438 and
    (7.82 RVU)
    Established Patient Traditional Annual Wellness Visit G0439
    (3.26 RVU)
    Enhanced Annual Wellness Visit; more than
    two chronic conditions reviewed and assessed
    G0439 and
    (6.26 RVU)

    (A standard physical 99397 pays at 3.83 RVU.)

    Can the patient also have a physical in addition to the Enhanced Annual Wellness Visit?

    The Premera Enhanced Annual Wellness Visit already includes a routine physical.

    Does Premera have a template for the Enhanced Annual Wellness Visit?

    Yes. You can download a pre-populated template (either a one-page summary or full version) via onehealthport.com for each patient, based on the information we currently have available. The template includes:

    • Known chronic conditions
    • Medications
    • Recent procedures
    • Additional treating providers

    Can the provider bill the G0438 or G0439 on one day, and then bring the patient back to for a chronic conditions assessment and bill the S0250 on another day?

    No; the S0250 is considered an add-on code for G0438/G0439 and can't be billed independently.

    Does Premera cover the G0402-the Welcome to Medicare visit?

    Premera pays for the G0402-initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment. This is sometimes called the Welcome to Medicare visit. The S-code is not available for billing with this visit.

    Premera encourages the additional benefit of an Enhanced Annual Wellness Visit G0438/G0439 in place of G0402 even in the patient's first 12 months of eligibility. If the provider does a chronic condition assessment, it'd be appropriate to bill S0250, which encompasses a much more comprehensive visit for the member.

    Who is Matrix Medical Network?

    Matrix Medical Network is a group of nurse practitioners Premera has contracted with to perform Enhanced Annual Wellness Visits in the patient's home or nursing facility. Each visit includes a limited physical exam, complete review of prescription and over-the-counter medications, and health history discussion. Matrix takes the time to talk to patients and identify gaps in care that can be shared with the health plan and primary care provider (PCP). The visit usually lasts 60 to 90 minutes. A post-visit summary is provided to the PCP.

    Can a patient see their own PCP after the Matrix visit?

    Yes. Premera supports the PCP-to-patient relationship. Matrix is a collaborative partner, not a PCP replacement.

    What is Advance Care Planning (ACP)?

    Advance Care Planning is a discussion that helps individuals learn about their options for end-of-life care. The discussion includes multiple steps to help determine the type of care that best fits the person's wishes. Once a plan is established, the information can then be shared with family, friends, and physicians, with or without completing relevant legal forms.

    Is ACP a required element of the Enhanced Annual Wellness Visit?

    No. ACP is an optional service that can take place at an enhanced annual wellness visit.

    If ACP occurred in addition to the Enhanced Annual Wellness Visit, how do I report it on a claim?

    You can report HCPCS code G0438 or G0439 for the Enhanced Annual Wellness Visit (AWV) service along with CPT code 99497 (for the first 30 minutes of the ACP discussion) and 99498 (for each additional 30 minutes of the ACP discussion if it applies) on the same claim.

    In order to have the deductible and coinsurance waived for ACP when performed with an AWV, the ACP code(s) must be billed with modifier 33 (preventive services) since payment for AWV is limited to only once a year and the ACP billed with AWV can only be waived once a year.