Premera Blue Cross Response to COVID-19

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. 

We’re funding up to $100 million in advance payments for eligible providers in Washington and Alaska.

Yes. We’ll begin recoupment beginning January 1, 2021 over a 9-month period. There’s no interest charged for this advance.

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

Legal requirements

Providers must not be in bankruptcy or have filed a petition for bankruptcy; and not knowingly be under an active medical review or an investigation by Premera. 

For providers that don’t participate in Medicare, they must not be in bankruptcy or have filed a petition for bankruptcy; and not knowingly under an active medical review or an investigation by Premera.

Practice requirements

Contracted professional providers in Washington or Alaska that have billed Evaluation and Management (E&M) codes and behavioral health codes in excess of $4,000 for historical year of experience, resulting in at least a $1,000 advance (for Premera insured members).

Contracted dental providers in Washington or Alaska that have billed dental services in excess of $4,000 for a historical year of experience, resulting in at least a $1,000 advance (for Premera insured members).

We had to make a decision on eligibility that was simple to administer. We realize that does leave a lot of providers out of this process. We made a decision to limit to this group of providers.

Complete the screening questionnaire.

We expect payments to begin going out within 20 days of the signed contract being returned. That allows Premera to verify eligibility and for the provider to sign an advance payment agreement.

Eligible providers could be eligible for a 3-month advance based on an average of historical E&M, behavioral health codes and dental codes incurred between October 1, 2018 and September 30, 2019 and paid through December 31, 2019.

We’ll be reviewing claims billed between October 1, 2018 and September 30, 2019 and paid by December 31, 2019. Your payment advance will be based your billed charges for fully insured members.

Premera will begin recoupment January 1, 2021. We’re working through the process for recoupment. There’s no interest charged for this advance.

Our repayment options are flexible and will include single lump sum payments, weekly voucher deductions, and invoicing. We won’t have the details on each of these options until later this year, but we can log your preference in our system and let you know the process for repayment based on your choice.

Yes. Premera will require a signed advance payment agreement. If we don’t receive the agreement, the payment will not be sent.

Yes. Premera is holding on recoupment of overpayments during the healthcare crisis. 

Until we determine that the immediate crisis is over.

It will apply to Premera insured and self-funded group business, which is the large majority of our claims.  It will not apply to individual member, Medicare Advantage member, FEP, or BlueCard member claims.  We’ll continue normal recoupment for overpayments on these claims.

BlueCard member claims are for members of other Blue Cross Blue Shield Plans who receive services in our Washington and Alaska service area and for which Premera pays the provider.

Commercial and Medicare Supplement members: We’re waiving in-network copays, cost shares, and deductibles for FDA-authorized COVID-19 diagnostic testing and treatment through October 1, 2020. Per the new WA OIC requirements, we’re also waiving in-network copays and deductibles for other virus/respiratory testing tied to a COVID-19 diagnosis. This applies to both the test and the related provider visit.  

Medicare Advantage members: We’re waiving all cost shares for the healthcare provider visit and FDA-authorized COVID-19 diagnostic testing for members who meet CDC criteria for testing. All other treatments and services including hospitalization are subject to the usual benefits and cost shares.

We won’t require pre-authorization for medically necessary and FDA-authorized COVID-19 testing. If a member requires testing and treatment for COVID-19 and there isn’t an in-network provider within a reasonable distance to perform those services, the claims will be paid as in-network.

Any care needed once diagnosis of COVID-19 has occurred will be covered consistent with the standard provisions of the member’s health benefits.

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.

Premera is waiving member cost shares including copays, deductibles, and coinsurance for treatment of COVID-19 or health complications associated with COVID-19, including hospitalizations and medical transportation when needed, FDA-approved medications administered inpatient for both in and out of network providers. This waiver is in effect for dates of service from January 1 through October 1, 2020. For Medicare customers, claims received since February 4, 2020 related to COVID-19 will be reprocessed to waive all cost shares and deductibles.

This benefit applies to members of insured group, individual, grandfathered, and non-grandfathered plans, associations, and Premera’s Medicare enrollees. Self-funded group plans have the option to participate. This includes qualified high deductible plan participants. For Premera Medicare customers, regulators have not communicated an end date for this flexibility.  Premera will adjust our policy as regulator guidance becomes available.

This will not apply to Shared Admin, FEP, and Self-funded plans that opt-out. Normal plan benefits apply in this situation for our members. You can check eligibility and benefits on our website.

The following summary of coding instruction is provided by the CDC, 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 (AMA) 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 have 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.

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.

Premera will not include testing coverage (molecular/antigen or antibody tests) for return to work strategies for our insured book of business just as we don’t cover drug testing for employment purposes, as an example. The CDC said in its Interim Guidelines that antibody test results “should not be used to make decisions about returning persons to the workplace.” The EEOC has stated that because of this, “requiring antibody testing before allowing employees to re-enter the workplace is not allowed under the ADA”. Current versions of the antibody test can’t reliably tell a person that they’re immune, can’t be re-infected or can’t transmit the virus to someone else.

Return to work COVID test aren’t covered by the plan.  The member may want to check with their employer on whether they will reimburse the member for this expense or bill directly to the employer.

Yes, the Families First Act expanded the types of diagnostic coronavirus lab tests that must be covered by insurance. On April 21, the FDA granted emergency clearance to the first in-home diagnostic test for the coronavirus, a nasal swab kit that will be sold by LabCorp. The tests are available to consumers with a doctor’s order in most states.

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

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.  

PPE billed by dentists using D1999 is payable under our current fee schedule and subject to all applicable member benefits, medical policies, payment policies, etc.

Yes. Premera has expanded our telehealth network to address the increased demand related to COVID-19. This expanded coverage will be available until December 31, 2020, with the potential to extend the duration based on business and epidemiological considerations.

Cost shares waived for telehealth services:

Telehealth cost shares will be waived for all in-network providers.  If a telehealth provider charges you a copay, deductible, or coinsurance for telehealth services through December 31, Premera will reimburse when the claim is processed.

Who is eligible for this in-network expansion?

• This will not apply to shared admin, FEP, BlueCard, Providence, HCA, and self-funded plans who opt out.

Can telehealth providers diagnose COVID-19?

• Telehealth providers can’t diagnose or order any COVID-19 testing. An in-person test is required for a COVID-19 diagnosis.
• Telehealth providers can diagnose and treat acute and chronic illnesses that do not include COVID-19 symptoms and fulfill necessary prescriptions or order lab tests at local facilities.

In addition to our existing Premera contracted behavioral health providers (Teladoc BH*, brick and mortar providers and Employer Assistance Programs), we’re introducing new virtual access for behavioral health and substance use disorder treatment (opioid and alcohol):   

• Doctor On Demand – We're now adding Doctor On Demand's behavioral health services for dates of service April 16 through June 30, 2020. 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

*Teladoc behavioral health is currently available only for self-funded groups who previously opted-in to Teladoc behavioral health in addition to their general Teladoc election.  

Effective May 1, 2020, as self-funded groups renew, Teladoc behavioral health will automatically be added for groups that already have general Teladoc services elected. Cost shares would then apply for Teladoc behavioral health through December 31, 2020, depending on whether the group elected to temporarily waive cost shares for telehealth. Teladoc behavioral health will not be added for self-funded groups who do not already have Teladoc services.

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 Washington.

For Medicare patients: CMS has loosened guidelines around telehealth services during the COVID-19 Public Health Emergency. Starting in March, Premera will cover telehealth visits for Medicare Advantage and Medicare Supplement members with no cost shares. The previous requirement for services to be provided in certain types of originating sites and locations has been waived for the duration of the COVID-19 public health emergency.

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.

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. 

Yes. Premera is following CMS guidance on telehealth payments during the COVID-19 health crisis. Providers who normally bill POS 11 for a patient in-office visit should continue to use POS 11 for telehealth visits and the procedure code appended with either modifier 95 or GT (GT can't be used for a Medicare claim). If the provider normally bills POS 19 and 22 for their in-person visits, then they should continue to bill using 19 and 22 but append modifier 95 or GT to their procedure code.

This allows claims to process for reimbursement consistent with an in-office visit during the public health emergency. This change is in effect through August 31, 2020, per CMS guidance. We'll be reviewing claims back to March 6 and will remit any additional funds due.

This billing guidance is in effect during this public health emergency for fully insured group and individual plans. Shared admin, and self-funded plans who have opted out of this process are excluded from this guidance.

For Medicare Advantage patients, view the CMS list of telehealth services and codes. Bill services either with the place of service in which you ordinarily see patients with a modifier 95 or with place of service of 02 to reflect telehealth.

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 Washington. 

For Medicare Advantage patients, view the policy page and then go to the Enhanced Benefits tab at the top and search for “Remote Technologies” for correct telehealth codes.

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.

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.

Per Health & Human Services and the Office of Civil Rights, 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.

For Medicare, view the CMS list of telehealth services and codes. Bill services either with the place of service in which you ordinarily see patients with a modifier 95 or with place of service of 02 to reflect telehealth.

Yes, ABA services can be provided virtually for dates of service on or after 3/20/20. 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 Washington.

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.

Many local mental health providers are offering virtual services. Your patient should check with their provider. 

Yes, there are changes and impacts. With many providers shifting care to telehealth services, CMS recently relaxed requirements related to telehealth services for Medicare Advantage populations due to the COVID-19 pandemic. We have a guide available that provides insights on the impact of telehealth services on star ratings and risk adjustment only. For telehealth impact related to commercial risk adjustment review this CMS guidance.

Authorizations extensions and suspensions ended on June 1, 2020.

Authorizations extensions and suspensions ended on June 1, 2020.

Yes. We’ve adjusted our refill too soon policy for medications. This allows pharmacies to override refill too soon edits during a declared emergency at the pharmacy counter. Members have access to Express Scripts mail order prescriptions. This extension ends on October 15, 2020.

Some telehealth providers have also temporarily waived their refill policies prohibiting the refill of chronic medications beyond twice in a calendar year. Providers will consider clinical appropriateness, patient safety and professional judgement. 

The extensions for prescriptions ended on June 30, 2020.

We frequently see drug shortages in the U.S. based on manufacturer issues, raw product issues, etc. We may see new reported shortages based on the COVID-19 impact to Chinese manufacturers.

Premera will respond to these shortages the same way we do today, by ensuring the following:

• The pharmacy team will check public and industry resources to identify new shortages that may impact our members.
• We’ll review medical policies to determine if adjustments are needed to ensure access to alternative medications (should we change our preferred drugs or update prior authorization criteria to account for shortages both short and long term).
• Our review processes already account for drug shortages. If a drug we require as first-line therapy is in short supply, we’ll waive this requirement based on market realities and approve coverage when preferred formulary alternatives are in short supply.

We’re also reviewing rejected claims to see if members are getting the medications they need. If we see any drug shortages, we’ll seek other options to meet member needs. We’ll continue to monitor the situation with our pharmacy partners, so members won’t run out of needed medications.

Premera has been covering chloroquine and hydroxychloroquine since March, 2020 as they had Emergency Use Authorization from the FDA for COVID treatment. However, on Monday, June 15, the US Food and Drug Administration revoked its emergency authorization of chloroquine and hydroxychloroquine stating they were unlikely to be effective in treating COVID-19. In addition to not helping treat the disease, the drugs were linked to "serious cardiac adverse events and other serious side effects. These drugs still have an indication for other conditions (e.g. lupus, rheumatoid arthritis, malaria) and will continue to be covered for these uses. Quantity limits for new starts on these medications will remain in effect.