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 April 9, 2021

    • Washington state has revised vaccine eligibility to include everyone over the age of 16 effective April 15, 2021. See the vaccine section for details.

    Premera is waiving cost shares for all COVID-19 related testing and treatment. Learn more.

    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) April 21, 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 April 21, 2021*
    Cost share waivers for treatment related to COVID-19 diagnosis is waived  (Premera initiative) June 30, 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) April 21, 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 long-term facility services (Washington state OIC mandate) May 2, 2021
    Prescription “refill too soon” override (Premera initiative) June 30, 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 will not be allowed Policy effective November 1, 2020

    *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. We anticipate that broad scale vaccination across our populations (those not in the first few phases) will likely not be until mid-2021.

  • 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.

    Three vaccines have made it through all the required trials and have received Emergency Use Authorization (EUA) from the FDA. Vaccine made by AstraZeneca is expected in the first quarter of 2021. Johnson and Johnson's single-dose vaccine received EUA for their COVID-19 vaccine on March 2.

    The CDC Director has approved additional phases of the COVID-19 vaccination program. Note that each state can vary who is included in each phase or accept the CDC recommendations.

    Phase 1a: Healthcare personnel and residents/staff of long-term care facilities

    1. Health care personnel. Health care personnel are defined as paid and unpaid persons serving in health care settings who have the potential for direct or indirect exposure to patients or infectious materials.
    2. Residents and staff of long-term care facilities. Long-term care facility residents are defined as adults who reside in facilities that provide a variety of services, including medical and personal care, to persons who are unable to live independently.

    Phase 1b: Frontline essential workers and Persons aged 75 years or older

    Phase 1c: Persons age 65-74 years, persons aged 15-64 with high-risk conditions, essential workers not recommended in Phase 1b

    The National Academies of Sciences, Engineering, and Medicine (NASEM) and the CDC’s Advisory Committee on Immunization Practices (ACIP) will provide guidance on who gets the vaccine first when one is available via Emergency Use Authorization or FDA approval.

    Each state can determine if they’ll follow the CDC guidance on each phase. States have their own Department of Health websites that will be tracking information, providing updates on available vaccine doses, who is eligible to administer the vaccine, and who is included in each phase. Visit the CDC website for specific state information – scroll down to “How do I get a vaccine?” and select your state.

    Phase 1b Tiers (in order) Groups

    Tier 1

    • All people 65 years and older
    • People 50 years and older in multigenerational households.

    Phase 1B Tier 2 is now open:
    • All critical workers in certain congregate settings (no longer tiered by age; list of qualifying congregate settings has been expanded) 
    • People age 16 or older who are pregnant (new qualification) 
    • People age 16 or older who have a disability that puts them at higher risk  

    As of March 31, Washington state started vaccination phase 1B, tiers 3 and 4. These new tiers open eligibility to individuals 16 or older with two or more comorbidities, as well as anyone age 60 or older and people with HIV and HCV who have at least one other illness or disease.
     
    The new tiers also include individuals working in restaurants, manufacturing, or construction, or living or working in congregate settings such as group homes, including individuals experiencing homelessness who live in or access services in congregate settings. 
     
    Governor Inslee also announced all Washington residents age 16 and older are eligible for the vaccine beginning April 15, 2021.

    Additional phases now have tentative dates. View the WA additional phases here.

    View more WA state guidance.

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

    After the emergency use authorization (EUA) or licensure of each COVID-19 vaccine product by FDA, CMS will identify the specific vaccine code(s), by dose if necessary, and specific vaccine administration code(s) for each dose for Medicare payment. CMS and the American Medical Association (AMA) are working collaboratively on finalizing a new approach to report use of COVID-19 vaccines.

    Codes are now available for the Pfizer, Moderna and Astra-Zenica. Use the links below to ensure the new codes are in your system to facilitate efficient claims processing.

    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.

    If you’re having difficulty billing for the COVID vaccine, contact the Express Scripts help desk at 800-922-1557.

    Most states are now requiring proof of residency for any COVID vaccination. That may include a driver’s license or utility bill showing your current address.

    Each state is working directly with the federal government to order and distribute the vaccines. Washington is working with individual communities and health care facilities to ensure each area receives vaccines and can administer the vaccines. 

    Information about vaccines and distribution will continue to evolve.

    For general questions about COVID-19 vaccines and vaccine trials, and for the CDC playbook:

    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.

    The CDC website has information on each state. On the vaccine page, go to "How do I get a vaccine?" and select your state. In Washington state you can use the Phase Finder tool.

    The CDC conducts webinars on the vaccines and safety measures:
    February 14: What Every Clinician Should Know about COVID-19 Vaccine Safety Sign up for webinar.

     

    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.

     

     

    Many pharmacies are now beginning to get vaccines as well. You can make a vaccine appointment using the following links:

     

     

    In King County, two new mass vaccination sites opened on February 1. You must be 75 or older or 50 and over and unable to live independently. King County residents can register for an appointment through the public health’s vaccine website, Getting Vaccinated in King County.

     

    In Spokane, residents can go to the Spokane Arena. Appointments are required. Visit the CHAS Health website for registration information.

     

    Many locations are requiring you to bring proof of your eligibility for the vaccine (such as a screen shot of the Washington Department of Health Phase Finder showing your eligibility) and identification.

     

    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.

    Not currently. The vaccines were only tested on adults. The Pfizer vaccine is approved for those 16 and older; Moderna and Johnson & Johnson vaccines are approved for those 18 and older. New studies to test COVID-19 vaccines are beginning for those age 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.

    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.

  • Frequently asked questions about COVID-19 and health plan coverage

    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.

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

    We haven’t set an end date for the Advance Payment Program. We’ll continue to disperse funds up to the $100 million available.

    Yes. We’ll begin recoupment January 1, 2021 for providers that have received funds by August 1, 2020. For providers that receive funds after August 1, 2020, recoupment will begin at a later date dependent on receipt of funds. 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.

    Payments typically are sent 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.

    Our repayment options are flexible and will include single lump sum payments and quarterly payments, both will include invoicing. Emails will be going out shortly to providers that received funds. You must indicate the repayment option and return the document within 30 days. Recoupment for funding received by August 1, 2020 will begin on January 1, 2021.

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

  • 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. Per WA OIC requirements, we’re also waiving in-network copays and deductibles for other virus/respiratory testing tied to a COVID-19 diagnosis. 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.

    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. All other treatments and services including hospitalization not related to a COVID-19 diagnosis will be subject to the usual benefits and cost shares.

    For Medicare customers, claims received since February 4, 2020 related to COVID-19 will be reprocessed to waive all cost shares and deductibles.

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

    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.

    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.

    As of November 1, 2020, Personal protective equipment (PPE) will no longer be separately reimbursable effective.

    When PPE is worn as part of a dental, medical or pharmacist healthcare visit, it’s considered part of the practice expenses included in the main dental medical or pharmacy related procedure rendered to a patient. PPE will not be separately reimbursable.

    Review additional details in the Personal Protective Equipment payment policy.

  • Telehealth

  • Telehealth cost share waivers ended on January 1, 2021. Depending on benefit plan design, the expanded telehealth network continues to be available to members.

    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 (depending on 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.

    Premera will be extending the payment of telehealth visits at the in person allowed amount, during the national public health emergency, beyond September 1, 2020 as previously communicated. 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.  

    Premera wants to emphasize that this is a temporary relaxation of the rules during this nationwide public health emergency. As additional information becomes available from CMS or other state regulators, we'll adjust our policies and notify you of the change. Only claims for telehealth visits from providers who members normally see in-person, in-office will be processed in this manner, and claim costs will be no more than what would have been paid had the member been able to see their providers in person.

    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 March 25, 2020, the OIC’s second emergency order required we waive or expedite prior authorization requirements for home health care or long-term care facility services. See the COVID-19 Key Dates section in this FAQ for current dates.

  • Pharmacy and prescriptions

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

    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.

    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.

    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.