Premera Blue Cross Response to COVID-19

Pfizer-BioNTech vaccines are available to people ages 6 months and up. A Moderna vaccine is available for people ages 6 months and up. A Moderna booster vaccine dose was authorized for youth ages 6-17. This is in addition to the Pfizer booster dose already authorized for children 5-17.

The Novavax vaccine was given emergency use authorization (EUA) approval on July 20, 2022 for people ages 18 and up. It’s a 2-dose series given 3 weeks apart. It’s similar to the same protein base used in flu shots, instead of the mRNA base used in the Pfizer and Moderna vaccines.

Janssen COVID-19 vaccine is only recommended for certain individuals. Read the information provided by the CDC about appropriate use of the Janssen vaccine.

New bivalent boosters are available from Moderna and Pfizer. The current monovalent boosters should only be used in children who are too young to receive one of the bivalent boosters.

• A Pfizer-BioNTech monovalent vaccine is authorized for children 6 months to 11 years and a Moderna vaccine was authorized for children 6 months to 17 years.
• Children need a 3-dose Pfizer primary series or a 2-dose Moderna primary series.
• A new Novavax booster vaccine dose was authorized for people ages 18 and older. New codes apply. 
• A new Moderna bivalent booster vaccine dose was authorized for people ages 12 and older. New codes apply.

Pfizer-BioNTech vaccines are available to youth ages 5-17. A Moderna vaccine is available for youth ages 6-17. A Moderna booster vaccine dose was authorized for youth ages 6-17. This is in addition to the Pfizer booster dose already authorized for children 5-17.

A Pfizer-BioNTech vaccine was authorized for children 6 months-4 years and a Moderna vaccine was authorized for children 6 months-5 years.

Children need a 3 dose Pfizer primary series or a 2 dose Moderna primary series.

If your child turns 12 between the first and second doses of the vaccine, the CDC is recommending they receive the full regular dose for their second shot. 

As a result of the ongoing COVID-19 public health emergency, the Centers for Disease Control and Prevention’s National Center for Health Statistics (CDC/NCHS) has implemented an additional code, U09.9 - post COVID-19 condition, unspecified. 

This code became effective October 1, 2021 to identify conditions following acute COVID-19. It's a secondary diagnosis code added after the specific condition related to COVID-19 is known, such as chronic respiratory failure, loss of smell, loss of taste, multisystem inflammatory syndrome, pulmonary embolism, pulmonary fibrosis etc. This code is not used in cases that are still presenting with active COVID-19 but it conditions which are the consequence of COVID-19.

View the CDC's ICD-10-CM coding guidance.

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

Janssen COVID-19 vaccine is authorized for adults ages 18 years and older in certain limited situations due to safety considerations. For CDC guidance on respective record review, scheduling, and administration of the Janssen vaccine, view Interim Clinical Considerations for Use of COVID-19 Vaccines: Appendices, References, and Previous Updates.

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.

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.

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.

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)
Primary vaccines

Booster doses

Bivalent booster doses

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

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:

• Centers for Medicare and Medicaid Services (CMS)
• Centers for Disease Control and Prevention (CDC)

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

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

The Centers for Medicare & Medicaid Services (CMS) released new information regarding billing for COVID-19 vaccines.

• Effective January 1, 2022, Medicare Advantage plans are required to pay for the vaccine (if providers did not receive it for free) and its administration (including approved booster doses), without cost sharing to the member. In 2020 and 2021, payment for the vaccine was made through original fee for service Medicare.
• The vaccine is covered under the Part B benefit not Part D.

Please note this billing change to avoid any billing errors.  For more information about COVID-19 vaccine policies, see the CMS tool kits.

The new drugs being offered to treat COVID-19 (including Evusheld) currently covered under our policy as emergency use authorization (EUA) drugs may be accepted per policy 05.01.549: Off-label Use of Drugs and Biologic Agents. (Please note: These drugs are covered under mandate and the public health emergency (PHE) and could change.) 

While Premera may not cover this drug in certain circumstances, it is not restricted at this time when acquired through government distribution systems.  When this drug is FDA approved, it is likely that Premera may institute a medical policy with specific criteria on use of this drug. 

Additionally, coding on administration of these drugs are guided by CMS administration codes.  

Because these drugs are approved only through EUA, our stance on this drug could change based on the PHE changes, FDA approval status, or additional data as it becomes available.

Test-to-treat antivirals began distribution by HHS on March 7, 2022. Oral antivirals may only be provided when prescribed by a qualified healthcare provider. Only pharmacies with in-store clinics are eligible for distributing these medications. Get more information and find a test-to-treat location. 

President Joe Biden laid out his strategy to fight the Omicron and Delta coronavirus variants over the winter, which included insurer-funded at-home COVID-19 testing. The rules regarding health plan reimbursement for self-tests purchased by consumers were made available on January 10, 2022. This mandate applies to all commercial plans.

Eligible tests are those with full FDA or EUA authorization and designated as home tests (antigen or molecular approved tests) used for diagnostic purposes (e.g., symptoms or direct exposure). Tests for surveillance purposes such as work or travel continue to be not covered. We will apply the quantity limit of 8 individual tests (not package) per covered member per 30 rolling days. These tests are not available for members with Medicare plans.

You can also order kits directly from the federal government at covidtests.gov (limited to 4 tests per household).

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.

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

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

Cost share waivers 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.

Premera is not required under either state or federal law to provide coverage for; return-to--work testing or occupational testing. We will not cover testing for occupational or accommodation purposes when an employee has an approved vaccine mandate accommodation from their employer. Premera also doesn't cover return-to-school or any travel-related testing. Federal and state law do not require that these tests be reimbursed as part of a health plan. FEP and some self-funded plans are covering testing for travel. You can check member eligibility and benefits on our provider website.

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

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

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.