Premera Blue Cross Response to COVID-19

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

    Updates as of September 30, 2021

    • Prior authorization requirements waived for transfers to home health or SNF facilities through October 31, 2021. Get details in the prior authorizations section in this FAQ.
    • A third COVID-19 vaccine dose was recommended for certain individuals. There are specific codes to use for these doses.
    • 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.
    • The federal Public Health Emergency was extended another 90 days to October 18, 2021. See the COVID-19 key dates grid for details.

    Get all the latest COVID-19 updates from the Washington State Department of Health 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
    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 Washington State OIC mandate) October 18, 2021*
    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 October 18, 2021*
    Medicare Advantage members: cost shares waived for the healthcare provider visit and FDA-authorized COVID-19 diagnostic test for members who meet criteria for testing (CMS guidance) October 18, 2021*
    Applied behavioral analysis (ABA) available through telehealth (Premera initiative) December 31, 2021
    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
    Waiver of prior authorization requirements for home health care or skilled nursing facility (SNF) services (Premera initiative) Sept. 7 through Oct. 31, 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
    Vaccine counseling covered per Executive Order 21-02 effective for dates of service between June 24 and October 17, 2021.  October 17, 2021

    *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 for people age 65+ and residents of long-term care facilities receive a booster shot of Pfizer COVID-19 vaccine at least 6 months after the second Pfizer dose. It also includes recommendations for those age 50-64 with underlying medical conditions. Those younger than age 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 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.

    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.

     

    Executive Order 21-02 allows for billing for COVID-19 vaccine counseling when provided to your patients. Here are the requirements for a claim to be submitted and paid for claims with dates of service beginning June 25, 2021. See the end date grid for dates.

    • This order is for Washington members only on fully insured plans and SEBB members and only for COVID-19 vaccine counseling. You can check a patient’s plan status by using the eligibility and benefits tool on Premera.com.

    • Check a patient’s vaccination status in the provider’s medical records and the Washington State Immunization Information System (WAIIS) database. Contact only those patients that haven’t been fully vaccinated or haven’t started vaccinations.

    • You must have an established relationship with the patient that includes at least one in-person appointment within the past three years with you or another provider at the same clinic.

    • You or your staff must do the outreach.
    • You may use video, phone, or in-person. Text messages, email or voicemail aren’t covered under this order.

    • In order for cost shares to be waived, you must use correct coding when submitting the claim. This includes the correct diagnosis and CPT codes. Fees are based on your current contracted rates:
      • CPT Code 99401 – in-person consultation and available for audio and visual telehealth visits
      • CPT Code 99441 – audio only (telephone) counseling for physicians
      • CPT Code 98966 – audio only (telephone) counseling for non-physicians (Medical Assistants, Nurses, etc.)
      • Diagnosis code Z71.89 in the primary position must be included for the claim to process correctly.

      • If you’re billing for vaccine counseling during a regular office visit, you must append modifier 25 to the counseling procedure code so both the Office Visit and the counseling procedure codes will be paid appropriately.

    • There is a limit of two claims per patient per provider.

     

    Yes. If you’re not a Medicare provider, you must qualify and enroll as a mass immunizer (or other Medicare provider type that allows billing for administering vaccines), so you can bill for administering COVID-19 shots. Enrolling over the phone as a mass immunizer is easy and quick — call your MAC-specific enrollment hotline and give your valid Legal Business Name (LBN), National Provider Identifier (NPI), Tax Identification Number (TIN), practice location and state license, if applicable.

    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.

    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.

    Washington state 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.

    In Washington, to receive and administer the COVID-19 vaccine, providers have to enroll in a federal vaccine distribution program, coordinated through the state immunization program (unless they are part of a national chain registered directly with the CDC [eg, major retail pharmacy chains). Washington state providers can enroll as COVID-19 vaccine providers.

    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 COVID-19 to include adolescents 12 to 15 years of age.

    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 the Uber and Lyft websites.

     

    Washington state has approved the use of the Pfizer COVID-19 vaccine for people age 12-15 starting May 13, 2021. All Washington residents age 12 and older are now eligible for the vaccine.

    View WA state guidance. Use the Washington Department of Health Vaccine Locator Tool to find locations offering the COVID-19 vaccine and see eligibility information.

    If you need homebound vaccination services or know of someone who needs this service in the state of Washington, check out these resources:

    • Call your local health jurisdiction for homebound vaccination services. 

    • Call Washington state’s COVID-19 Assistance Hotline to let them know you need homebound vaccination services. Call 800-525-0127 or 888-856-5816, then press #. Phone interpretation is available. 

    • Use this survey link to complete a registration form that will connect you to available county and/or state mobile vaccine teams.


    Specific 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)
    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
    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
    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:

     

    Outside of Washington state, the CDC website has information on each state. Go to "How do I get a vaccine?" and select your state. 

    Here is information for Washington state:

    • Use Washington state’s online tool at findyourphasewa.org. Bring your patience as the website sometimes gets overwhelmed.
    • The Washington state Department of Health (DOH) has a map and list of where you can get vaccinated. Be sure to call the location to verify that they do have vaccines available, as it changes daily.
    • People without internet access can call DOH at 800-525-0127, press #, or 888-856-5816. Be patient, the phone line is often flooded with calls.
    • To get on a wait list at MultiCare, call 833-770-0530.
    • You can also view Virginia Mason’s wait list and fill out the form.
    • There’s also a public Facebook group where volunteers are helping people find appointments. Check it out at Find a COVID shot WA.

     

    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 currently. 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.

    Check with your state to determine what identification or referral may be required for each phase.

    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. Studies to test COVID-19 vaccines are beginning for those under the age of 12.

    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 that 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 copays, cost shares, and deductibles for members requiring provider-ordered COVID-19 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.

    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 criteria for testing following CMS guidance. All other treatments and services including hospitalization are subject to the usual benefits and cost shares.

    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.

    For Medicare Advantage members: if the antibody test is ordered by a physician, cost shares are waived per CMS.

    While cost share waivers, including copays, deductibles, and coinsurance for all COVID-19 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 remains in place.

    See the COVID-19 Key Dates section in this FAQ for current dates. 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.

    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 will not include testing coverage (molecular/antigen or antibody tests) for return-to-work or return-to-school 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/return-to-school 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.

    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 covered and cost shares are 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.

    On April 16, 2021, Washington Substitute Senate Bill 5169 went into effect mandating that personal protective equipment (PPE) for medical providers be covered as a separate expense up to $6.57 for each individual patient encounter. Patients may not be billed for provider PPE. This bill is now in effect for dates of service beginning April 16, 2021, for the duration of the federal public health emergency related to COVID-19.

     

    • This coverage is for in-person medical provider visits only.
    • Self-funded groups are not included in this bill. Claims for PPE for patients that are part of a self-funded group will be denied.
    • Claims may be billed using the American Medical Association's current procedural terminology code 99072 or as subsequently amended.
    • This exception does not apply to dental plan services or regular pharmacy services, only those medical services billed by a dentist or a pharmacist on a CMS-1500 professional claim form.  
    • All other billings of code 99072 by providers not called out in the exception section of the policy would continue to be subject to denial of payment on this code per the policy criteria.
    • This bill is not retroactive; providers may not bill for any PPE costs prior to the effective date and is limited to the covered service according to the terms and conditions of the health benefit plan and does not apply to an expense for personal protective equipment. 

    Read complete SSB-5169.

    PPE is not separately reimbursable for dental or pharmacy visits as it’s considered part of the practice expenses included in the main dental or pharmacy related procedure rendered to a patient.

    Review additional details in the PPE payment policy.

  • Virtual care

  • 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:

    • DoctorOn 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 Washington.

    For Medicare patients: CMS has loosened guidelines around telehealth services during the COVID-19 Public Health Emergency.  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.
    • 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.

    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.  

    This guidance is in effect for WA group plans, FEP and Individual plans. Some Self-Funded groups have opted out of this guidance. Shared Admin 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.

    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.

    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.

  • Prior authorizations

  • Effective September 7, 2021 through October 6, 2021, Premera is waiving prior authorization requirements for home health care or skilled nursing facility (SNF) services.

    This waiver applies to all plans, except the Federal Employee Program (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.

    See the COVID-19 Key Dates section in this FAQ for current dates.

  • 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 info.

    Note: Some prescriptions aren't available 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.