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 March 27, 2020

    • We’re expanding telehealth services and waiving telehealth cost shares for members. The correct telehealth codes must continue to be used. See the FAQ for additional detail.

    • The American Medical Association (AMA) is offering additional guidance for COVID-19 coding scenarios to help healthcare professionals apply best coding practices. 

    • Premera is extending prior authorization timelines to 6 months from date of approval through April 30, 2020. We’re also suspending the initial and concurrent medical necessity reviews for skilled nursing facilities through April 30, 2020.

    • There are specific coding instructions provided by the CDC, WHO, and CMS for COVID-19. We urge you to use the COVID-19 coding for patients so cost shares can be waived appropriately.

    Get all the latest COVID-19 updates from the Centers for Disease Control and Prevention (CDC),including people at risk for serious illness and hygiene tips for home, school, and work.

    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.

    Premera frequently asked questions about COVID-19 and health plan coverage

  • We're here to support you and help keep our communities safe during the COVID-19 outbreak. We’ll be sending out frequent communications, posting updated information on our websites, and providing links to expert resources for our providers, employers, and members.

    For general questions about COVID-19:
    Washington State Department of Health
    Centers for Disease Control and Prevention (CDC)

    All Premera employees are working remotely until further notice. Currently, all business processes and functions are operating normally, and we don’t anticipate any changes to our ability to meet our usual standards.

    If the situation changes, we’ll be in direct contact to let you know what options are available.

    Commercial and Medicare Supplement members: Per the new WA OIC requirements, we’re waiving in-network copays and deductibles for FDA-authorized COVID-19 testing and other virus/respiratory testing tied to a COVID-19 diagnosis, and the related provider visit.

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

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

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

    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 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.

    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. 

    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.

    This applies to members of plans sold in the state of Washington, regardless of where the member resides. This includes all Premera plans; group, individual, Grandfathered, Non-grandfathered, Associations, OptiFlex, and Student Insurance. Self-insured and OptiFlex groups may participate at their discretion.

    Our approach also includes high deductible health plans per guidance from the IRS.

    Yes. Starting March 25, 2020, Premera will be expanding our telehealth network to address the increased demand related to COVID-19. This expanded coverage will be available until June 30, 2020, with the potential to extend the duration based on business and epidemiological considerations.

    Cost shares will be waived for telehealth services as follows:

    • For members enrolled in PPO plans: all cost shares are waived.
    • For members enrolled in a QHDHP plan: they must meet their deductible before cost sharing will be waived for telehealth medical and behavioral health-related services. If the service provided is to treat COVID-19, the deductible and all other cost shares will be waived.
    • If federal guidance or legislation is adopted after implementation that allows us to extend the cost share waivers prior to deductible for all telehealth medical and behavioral health-related services to QHDHP plans, Premera will allow such waivers based on said guidance or legislation. 

    Who is eligible for this in-network expansion?

    • This will not apply to shared admin, FEP, BlueCard, Providence, HCA, Medicare Supplement, Medicare Advantage, and self-funded plans who opt out.
    • Fully insured plans will be loaded and available on March 25, 2020. Self-funded plans that opt in will be loaded and available by end of day March 26, 2020.
    • This cost share waiver applies to all providers that offer telehealth services through June 30, 2020.

    Can telehealth providers diagnose COVID-19?

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

    Yes. Virtual care is covered under the scope of your current contract with Premera, 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 Advantage patients: CMS has loosened guidelines around telehealth services during the COVID-19 Public Health Emergency. Starting March 6, Premera will cover telehealth visits for Medicare Advantage members billed by any healthcare facility in the same way as a regular, in person visits with the same cost shares. The previous requirement for services to be provided in certain types of originating sites and locations has been waived for the duration of the COVID-19 public health emergency.

    For 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.

    Per Health & Human Services and the Office of Civil Rights, a covered physician or health care providerthat 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. 

    Premera wants to emphasize that this is a temporary relaxation of the rules during this nationwide public health emergency. Correct coding and notification to the patient that the provider is using non-HIPAA compliant communication tools is required. 

    Yes, 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.

    We’re aware of Senate Bill 5385 and are reviewing the requirements and what our current fee schedules include. As we work through the requirements, we’ll make adjustments where needed and communicate those out to you as quickly as possible.

    This is a temporary measure only effective for services requested after February 1, 2020 through April 30, 2020. We want to ensure our members are receiving the services they need. We’ll continue to evaluate and determine if we need to extend these temporary measures.

    Elective surgeries: Many agencies are recommending cancelling or rescheduling non-urgent surgeries due to COVID-19. To support this recommendation, Premera will continue the medical necessity review and extend the authorization time frame for prior authorizations for elective surgeries that were approved between February 1 and through April 30, 2020 to six months from date of approval.

    Skilled nursing facility: Initial and concurrent medical necessity reviews are suspended through April 30, 2020. We’ll continue to load these cases into our system and initially authorize for 30 days. Once 30 days have been exhausted, a review will be done, and an additional 30 days may be authorized. We won’t deny any claim for patients admitted to a skilled nursing facility while this emergency order is in place.

    Our normal processes still apply: Continue to use our online prior authorization tool as required and fax any supporting documents. We’re not currently experiencing any delays in processing, other than requests for additional information. We ask that you wait 5 days before checking online for your authorization.

    Note: This authorization extension doesn’t apply to Medicare Advantage. We’re working on a solution and we'll update you when we have new information.

    We’re hopeful this will eliminate the burden on providers to resubmit a PA for elective surgeries that are postponed and to ensure that we’re authorizing necessary services and supplies as quickly as possible.  

    For advanced imaging and sleep studies: AIM is extending the authorization time frame for 6 months from date of approval.

    For radiation therapy: There is no extension of authorization. AIM’s view is that for these services, timeliness is critical for the patient’s care. They’re always able to extend an authorization if a patient is unable to get into treatment.

    We’ll continue to operate as normally as possible. If there’s an issue where we can’t process claims, we’ll notify you immediately.

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

    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

    People with flu-like symptoms are not being tested for COVID-19 unless they meet certain criteria set by the CDC. The CDC criteria are set as a condition of the FDA-approved emergency use authorization, which allows new tests to be used in emergency situations on high-risk people only.

    The criteria have widened to include people who are hospitalized with symptoms that are otherwise unexplained, in addition to testing people with travel history or a close contact with a known case. These criteria may evolve to include more people over time.

    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.

    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.