COVID-19 Payer Information

UPDATE - The Centers for Medicare & Medicaid Services (CMS) have released guidance for implementing several provisions included in the Coronavirus Aid, Relief, and Economic Security (CARES) Act. READ MORE 
Allwell from Absolute Total Care will be following this guidance as we adjudicate Medicare claims for applicable COVID-19 inpatient treatment services. The CARES Act provides for a 20% increase to the inpatient prospective payment system (IPPS) Diagnosis Related Group (DRG) rate for COVID-19 patients for the duration of the public health emergency.

>>>Click here to read past updates

UPDATE -Twenty-one pharmacy chains, including CVS, are participating in the Federal Pharmacy Program. Aetna members are encouraged to visit the CDC website to find out which pharmacies are offering the vaccine in their state. Members should also visit the pharmacy’s website to find out if they are providing COVID-19 vaccines in their area. As part of this program, CVS Health is now administering vaccines in 50 states, Washington D.C. and Puerto Rico.
READ MORE 

Providers should bill for the COVID-19 swab collection using one of these codes. READ MORE 

• Use code 99211 - Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional.
• Use code G2023 - Specimen collection for severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), any specimen source.
• Use code G2024 - Specimen collection for severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), from an individual in a skilled nursing facility or by a laboratory on behalf of a home health agency, any specimen source.
• Use code C9803 - Hospital outpatient clinic visit specimen collection for severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]).

To ensure access for COVID-19 testing and have consistent reimbursement, Aetna will reimburse contracted and non-contracted providers for COVID-19 testing as follows in accordance with the member’s benefit plan. The following rates are used for COVID-19 testing for commercial and Medicare plans, unless noted otherwise. READ MORE 

5/12/2021 - Aetna will follow the guidance provided by the CDC and FDA regarding the age of eligibility to receive the vaccine. As of May 12, 2021, children over the age of 12 are eligible to receive the Pfizer BioNTech vaccine. READ MORE

>>>Click here to read past updates

UPDATE - CPT Assistant/Special COVID-19 Edition May 2021. READ MORE
Current Procedural Terminology (CPT ®) codes for a new vaccine product from Novavax and its administration have been added to previously established vaccine codes for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease 2019 [COVID-19]). The CPT Editorial Panel has approved the latest vaccine product code, which will become effective upon receiving the Emergency Use Authorization (EUA) or approval from the Food and Drug Administration (FDA).

In order to assist CPT code users in differentiating and appropriately reporting the available vaccine product codes and their affiliated immunization administration codes, the American Medical Association (AMA) established a website that features timely updates of the CPT Editorial Panel actions. The most recent COVID-19 update was in the CPT ® Assistant Special Edition: January Update (2021) in which vaccine product code 91303 (Janssen, single-dose vaccine) was established with its corresponding administration code (0031A). This article introduces the Novavax two-dose vaccine code (91304 ) and its associated administration codes (0041A, 0042A).

>>>Click here to read past updates

UPDATE - Quick reference guide, COVID-19 vaccine registration: This guide will assist potential COVID-19 vaccinators with registration and ordering in ImmuNet. READ MORE 
Only one registration is needed per location. Note that practices with multiple locations must separately register each location that plans to order and have vaccines shipped to and stored at that location.

4/30/2021 - COVID-19 information from Amerigroup Community Care. READ MORE 

UPDATE: Send swab tests to Amerigroup-contracted laboratories. READ MORE 
When providing COVID-19 molecular testing services to our members, consider utilizing the following additional in-network, high-quality labs to assist in helping to ensure that our members are receiving high-value healthcare.

UPDATE - COVID-19 Update 12/24/20. READ MORE 
Amerigroup recognizes the intense demands facing doctors, hospitals and all health care providers in the face of the COVID-19 pandemic. Today, unless otherwise required under state and federal mandates, as detailed below, Amerigroup is making adjustments to assist providers in caring for members. These adjustments apply to members of all lines of business, except as noted below, and in-network and out-of-network providers, where permissible. Medicare adjustments and suspensions may have different timeframes or changes where required by federal law.

Inpatient and respiratory care - - Prior authorization requirements are suspended for patient transfers from acute IP hospitals to skilled nursing facilities effective December 21, 2020 through January 15, 2021. These adjustments apply for our Medicare and Medicaid plan members receiving care from in-network providers. While prior authorization is not required, we continue to require notification of the admission via the usual channels and clinical records on day two of admission to aid in our members' care coordination and management. Amerigroup reserves the right to audit patient transfers.

>>>Click here to read past updates

UPDATE - The payer is expanding its temporary suspension of prior authorization for acute in-network admissions from the emergency department to include all diagnoses (including COVID-19) and for in-network transfers and transportation between facilities. READ MORE

3/21/2020 - The payer will Cover and Waive Cost-Sharing for COVID-19 Testing (copays, deductibles, and coinsurance) when performed at a physician's office, urgent care, or ER. READ MORE

UPDATE - From March 17 through Dec. 31, 2020, Anthem will waive member cost shares for telehealth visits from in-network providers, including visits for mental health and substance use disorders, for our Medicare Advantage and Medicaid plans, where permissible. Effective from March 19 through December 31, 2020, Anthem’s affiliated health plans will cover telephonic-only visits with in-network providers. Out-of-network coverage will be provided where required. For out-of-network providers, Anthem is waiving cost shares from March 17 through June 14, 2020. Cost shares will be waived for in-network providers only. READ MORE 

5/1/2020 - Anthem has provided a repository of COVID-19 information including policies, webinar recordings, and Federal Resources available to Providers under the CARES Act. READ MORE

UPDATE - COVID-19 Screenings: Identifying the most appropriate COVID-19 testing codes, testing sites and type of test to use can be confusing. READ MORE 
The guidance below can make it easier for you to refer your patients to high-quality, lower-cost COVID-19 testing sites, find Anthem Blue Cross (Anthem) contracted laboratories and identify that proper CPT codes to use. 

• For a new or established patient, CPT code 99211 would be appropriate if patient is being seen for no other services besides a specimen collection.
• For a patient assessment in addition to a specimen collection it is appropriate to bill the applicable E&M service, CPT codes 99202-99215. Specimen collection is a component of the E&M service and not separately reimbursable.
• Effective April 1, 2021, CPT codes G2023 and G2024 are appropriate when billed by clinical laboratories only and are not appropriate for provider practices.
  

>>>Click here to read past updates

UPDATE - COVID-19 Update 4/28/21. We recently updated the effective date about reimbursement for the administration of the COVID-19 vaccine. The cost of COVID-19 FDA-approved vaccines will initially be paid for by the government. READ MORE

Effective May 1, 2021, for members of our fully-insured employer and individual plans, as well as self-funded plans, Anthem will reimburse for the administration of COVID-19 FDA-approved vaccines at a rate of $40 per administration. Anthem will cover the administration of COVID-19 vaccines with no cost share for in- and out-of-network providers, during the national public health emergency, and providers are not permitted under the federal mandate to balance-bill members.

For members of Medicare Advantage plans, CMS issued guidance (https://www.cms.gov/files/document/COVID-19-toolkit-issuers-MA-plans.pdf) that the COVID-19 vaccine administration should be billed by providers to the CMS Medicare Administrative Contractor (MAC) using product-specific codes for each vaccine approved. This will ensure that Medicare Advantage members will not have cost sharing for the administration of the vaccine.

For members of Medicaid plans, Medicaid state-specific rate and other state regulations may apply.

UPDATE - COVID-19 Update: We recently updated information about reimbursement for the COVID-19 vaccine. The cost of COVID-19 FDA-approved vaccines will initially be paid for by the government. READ MORE 

For members of our fully-insured employer and individual plans, as well as self-funded plans, Anthem will reimburse for the administration of COVID-19 FDA-approved vaccines at a reasonable prevailing rate. Anthem will cover the administration of COVID-19 vaccines with no cost share for in- and out-of-network providers, during the national public health emergency, and providers are not permitted under the federal mandate to balance-bill members.

For members of Medicare Advantage plans, CMS issued guidance that the COVID-19 vaccine administration should be billed by providers to the CMS Medicare Administrative Contractor (MAC) using product-specific codes for each vaccine approved. This will ensure that Medicare Advantage members will not have cost sharing for the administration of the vaccine.

For members of Medicaid plans, Medicaid state-specific rate and other state regulations may apply.

>>>Click here to read past updates

UPDATE - COVID-19 Update 4/28/21. We recently updated the effective date about reimbursement for the administration of the COVID-19 vaccine. The cost of COVID-19 FDA-approved vaccines will initially be paid for by the government. READ MORE

Effective May 1, 2021, for members of our fully-insured employer and individual plans, as well as self-funded plans, Anthem will reimburse for the administration of COVID-19 FDA-approved vaccines at a rate of $40 per administration. Anthem will cover the administration of COVID-19 vaccines with no cost share for in- and out-of-network providers, during the national public health emergency, and providers are not permitted under the federal mandate to balance-bill members.

For members of Medicare Advantage plans, CMS issued guidance (https://www.cms.gov/files/document/COVID-19-toolkit-issuers-MA-plans.pdf) that the COVID-19 vaccine administration should be billed by providers to the CMS Medicare Administrative Contractor (MAC) using product-specific codes for each vaccine approved. This will ensure that Medicare Advantage members will not have cost sharing for the administration of the vaccine.

For members of Medicaid plans, Medicaid state-specific rate and other state regulations may apply.

>>>Click here to read past updates

UPDATE - COVID-19 Update 4/28/21. We recently updated the effective date about reimbursement for the administration of the COVID-19 vaccine. The cost of COVID-19 FDA-approved vaccines will initially be paid for by the government. READ MORE

Effective May 1, 2021, for members of our fully-insured employer and individual plans, as well as self-funded plans, Anthem will reimburse for the administration of COVID-19 FDA-approved vaccines at a rate of $40 per administration. Anthem will cover the administration of COVID-19 vaccines with no cost share for in- and out-of-network providers, during the national public health emergency, and providers are not permitted under the federal mandate to balance-bill members.

For members of Medicare Advantage plans, CMS issued guidance (https://www.cms.gov/files/document/COVID-19-toolkit-issuers-MA-plans.pdf) that the COVID-19 vaccine administration should be billed by providers to the CMS Medicare Administrative Contractor (MAC) using product-specific codes for each vaccine approved. This will ensure that Medicare Advantage members will not have cost sharing for the administration of the vaccine.

For members of Medicaid plans, Medicaid state-specific rate and other state regulations may apply.

>>>Click here to read past updates

UPDATE - COVID-19 Update 4/28/21. We recently updated the effective date about reimbursement for the administration of the COVID-19 vaccine. The cost of COVID-19 FDA-approved vaccines will initially be paid for by the government. READ MORE

Effective May 1, 2021, for members of our fully-insured employer and individual plans, as well as self-funded plans, Anthem will reimburse for the administration of COVID-19 FDA-approved vaccines at a rate of $40 per administration. Anthem will cover the administration of COVID-19 vaccines with no cost share for in- and out-of-network providers, during the national public health emergency, and providers are not permitted under the federal mandate to balance-bill members.

For members of Medicare Advantage plans, CMS issued guidance (https://www.cms.gov/files/document/COVID-19-toolkit-issuers-MA-plans.pdf) that the COVID-19 vaccine administration should be billed by providers to the CMS Medicare Administrative Contractor (MAC) using product-specific codes for each vaccine approved. This will ensure that Medicare Advantage members will not have cost sharing for the administration of the vaccine.

For members of Medicaid plans, Medicaid state-specific rate and other state regulations may apply.

>>>Click here to read past updates

UPDATE - COVID-19 Update 4/28/21. We recently updated the effective date about reimbursement for the administration of the COVID-19 vaccine. The cost of COVID-19 FDA-approved vaccines will initially be paid for by the government. READ MORE

Effective May 1, 2021, for members of our fully-insured employer and individual plans, as well as self-funded plans, Anthem will reimburse for the administration of COVID-19 FDA-approved vaccines at a rate of $40 per administration. Anthem will cover the administration of COVID-19 vaccines with no cost share for in- and out-of-network providers, during the national public health emergency, and providers are not permitted under the federal mandate to balance-bill members.

For members of Medicare Advantage plans, CMS issued guidance (https://www.cms.gov/files/document/COVID-19-toolkit-issuers-MA-plans.pdf) that the COVID-19 vaccine administration should be billed by providers to the CMS Medicare Administrative Contractor (MAC) using product-specific codes for each vaccine approved. This will ensure that Medicare Advantage members will not have cost sharing for the administration of the vaccine.

For members of Medicaid plans, Medicaid state-specific rate and other state regulations may apply.

>>>Click here to read past updates

UPDATE - COVID-19 Update 4/28/21. We recently updated the effective date about reimbursement for the administration of the COVID-19 vaccine. The cost of COVID-19 FDA-approved vaccines will initially be paid for by the government. READ MORE

Effective May 1, 2021, for members of our fully-insured employer and individual plans, as well as self-funded plans, Anthem will reimburse for the administration of COVID-19 FDA-approved vaccines at a rate of $40 per administration. Anthem will cover the administration of COVID-19 vaccines with no cost share for in- and out-of-network providers, during the national public health emergency, and providers are not permitted under the federal mandate to balance-bill members.

For members of Medicare Advantage plans, CMS issued guidance (https://www.cms.gov/files/document/COVID-19-toolkit-issuers-MA-plans.pdf) that the COVID-19 vaccine administration should be billed by providers to the CMS Medicare Administrative Contractor (MAC) using product-specific codes for each vaccine approved. This will ensure that Medicare Advantage members will not have cost sharing for the administration of the vaccine.

For members of Medicaid plans, Medicaid state-specific rate and other state regulations may apply.

>>>Click here to read past updates

UPDATE - COVID-19 Update 4/28/21. We recently updated the effective date about reimbursement for the administration of the COVID-19 vaccine. The cost of COVID-19 FDA-approved vaccines will initially be paid for by the government. READ MORE

Effective May 1, 2021, for members of our fully-insured employer and individual plans, as well as self-funded plans, Anthem will reimburse for the administration of COVID-19 FDA-approved vaccines at a rate of $40 per administration. Anthem will cover the administration of COVID-19 vaccines with no cost share for in- and out-of-network providers, during the national public health emergency, and providers are not permitted under the federal mandate to balance-bill members.

For members of Medicare Advantage plans, CMS issued guidance (https://www.cms.gov/files/document/COVID-19-toolkit-issuers-MA-plans.pdf) that the COVID-19 vaccine administration should be billed by providers to the CMS Medicare Administrative Contractor (MAC) using product-specific codes for each vaccine approved. This will ensure that Medicare Advantage members will not have cost sharing for the administration of the vaccine.

For members of Medicaid plans, Medicaid state-specific rate and other state regulations may apply.

>>>Click here to read past updates

UPDATE - COVID-19 Update 4/28/21. We recently updated the effective date about reimbursement for the administration of the COVID-19 vaccine. The cost of COVID-19 FDA-approved vaccines will initially be paid for by the government. READ MORE

Effective May 1, 2021, for members of our fully-insured employer and individual plans, as well as self-funded plans, Anthem will reimburse for the administration of COVID-19 FDA-approved vaccines at a rate of $40 per administration. Anthem will cover the administration of COVID-19 vaccines with no cost share for in- and out-of-network providers, during the national public health emergency, and providers are not permitted under the federal mandate to balance-bill members.

For members of Medicare Advantage plans, CMS issued guidance (https://www.cms.gov/files/document/COVID-19-toolkit-issuers-MA-plans.pdf) that the COVID-19 vaccine administration should be billed by providers to the CMS Medicare Administrative Contractor (MAC) using product-specific codes for each vaccine approved. This will ensure that Medicare Advantage members will not have cost sharing for the administration of the vaccine.

For members of Medicaid plans, Medicaid state-specific rate and other state regulations may apply.

>>>Click here to read past updates

UPDATE - COVID-19 Update 4/28/21. We recently updated the effective date about reimbursement for the administration of the COVID-19 vaccine. The cost of COVID-19 FDA-approved vaccines will initially be paid for by the government. READ MORE

Effective May 1, 2021, for members of our fully-insured employer and individual plans, as well as self-funded plans, Anthem will reimburse for the administration of COVID-19 FDA-approved vaccines at a rate of $40 per administration. Anthem will cover the administration of COVID-19 vaccines with no cost share for in- and out-of-network providers, during the national public health emergency, and providers are not permitted under the federal mandate to balance-bill members.

For members of Medicare Advantage plans, CMS issued guidance (https://www.cms.gov/files/document/COVID-19-toolkit-issuers-MA-plans.pdf) that the COVID-19 vaccine administration should be billed by providers to the CMS Medicare Administrative Contractor (MAC) using product-specific codes for each vaccine approved. This will ensure that Medicare Advantage members will not have cost sharing for the administration of the vaccine.

For members of Medicaid plans, Medicaid state-specific rate and other state regulations may apply.

>>>Click here to read past updates

UPDATE - COVID-19 Update 4/28/21. We recently updated the effective date about reimbursement for the administration of the COVID-19 vaccine. The cost of COVID-19 FDA-approved vaccines will initially be paid for by the government. READ MORE

Effective May 1, 2021, for members of our fully-insured employer and individual plans, as well as self-funded plans, Anthem will reimburse for the administration of COVID-19 FDA-approved vaccines at a rate of $40 per administration. Anthem will cover the administration of COVID-19 vaccines with no cost share for in- and out-of-network providers, during the national public health emergency, and providers are not permitted under the federal mandate to balance-bill members.

For members of Medicare Advantage plans, CMS issued guidance (https://www.cms.gov/files/document/COVID-19-toolkit-issuers-MA-plans.pdf) that the COVID-19 vaccine administration should be billed by providers to the CMS Medicare Administrative Contractor (MAC) using product-specific codes for each vaccine approved. This will ensure that Medicare Advantage members will not have cost sharing for the administration of the vaccine.

For members of Medicaid plans, Medicaid state-specific rate and other state regulations may apply.

>>>Click here to read past updates

UPDATE - COVID-19 Update 4/28/21. We recently updated the effective date about reimbursement for the administration of the COVID-19 vaccine. The cost of COVID-19 FDA-approved vaccines will initially be paid for by the government. READ MORE

Effective May 1, 2021, for members of our fully-insured employer and individual plans, as well as self-funded plans, Anthem will reimburse for the administration of COVID-19 FDA-approved vaccines at a rate of $40 per administration. Anthem will cover the administration of COVID-19 vaccines with no cost share for in- and out-of-network providers, during the national public health emergency, and providers are not permitted under the federal mandate to balance-bill members.

For members of Medicare Advantage plans, CMS issued guidance (https://www.cms.gov/files/document/COVID-19-toolkit-issuers-MA-plans.pdf) that the COVID-19 vaccine administration should be billed by providers to the CMS Medicare Administrative Contractor (MAC) using product-specific codes for each vaccine approved. This will ensure that Medicare Advantage members will not have cost sharing for the administration of the vaccine.

For members of Medicaid plans, Medicaid state-specific rate and other state regulations may apply.

>>>Click here to read past updates

UPDATE - COVID-19 Update 4/28/21. We recently updated the effective date about reimbursement for the administration of the COVID-19 vaccine. The cost of COVID-19 FDA-approved vaccines will initially be paid for by the government. READ MORE

Effective May 1, 2021, for members of our fully-insured employer and individual plans, as well as self-funded plans, Anthem will reimburse for the administration of COVID-19 FDA-approved vaccines at a rate of $40 per administration. Anthem will cover the administration of COVID-19 vaccines with no cost share for in- and out-of-network providers, during the national public health emergency, and providers are not permitted under the federal mandate to balance-bill members.

For members of Medicare Advantage plans, CMS issued guidance (https://www.cms.gov/files/document/COVID-19-toolkit-issuers-MA-plans.pdf) that the COVID-19 vaccine administration should be billed by providers to the CMS Medicare Administrative Contractor (MAC) using product-specific codes for each vaccine approved. This will ensure that Medicare Advantage members will not have cost sharing for the administration of the vaccine.

For members of Medicaid plans, Medicaid state-specific rate and other state regulations may apply.

>>>Click here to read past updates

UPDATE - We are extending the process to streamline admissions to long-term acute care hospitals (LTACH) for all Blue Cross and Blue Shield of Alabama members with one or more specified diagnoses. This process extends through June 30, 2021. We will evaluate additional extensions for the admissions process to LTACHs on a monthly basis. READ MORE

4/26/2021 - The U.S. Department of Health and Human Services’ Office of Inspector General has issued an announcement about COVID-19 vaccination administration that includes the following guidance: The vaccine must be administered at no cost to recipients. Providers may not charge an office visit or other fee if the COVID-19 vaccine is the sole medical service provided. Providers may not seek any reimbursement, including through balance billing, from the vaccine recipient. READ MORE 

>>>Click here to read past updates

UPDATE - COVID-19 Telehealth Update. Arkansas Blue Cross and Blue Shield and Health Advantage described a temporary change to our policy in the March issue of Arkansas Blue Cross Providers’ News. We revised that temporary policy on March 24, 2020, making it retroactive to March 16, 2020. READ MORE

>>>Click here to read past updates

UPDATE - Vaccine Update published 5/5/2021. READ MORE 

>>>Click here to read past updates

Blue Cross Blue Shield
Florida

UPDATE - Florida Blue COVID-19 Provider Billing Guidelines - updated 5/25/21. READ MORE 

5/13/2021 - BCBS Florida COVID-19 Provider Billing Guidelines-small update to the guidelines with respect to GatorCare Health Plans. READ MORE 

4/29/2021 - COVID-19 Update 4/29/21. The Florida State of Emergency has been extended through June 26, 2021. READ MORE 
The Federal Public Health Emergency has been extended through July 20, 2021. Florida Blue Commercial/ACA Updates - Extended through the end of the Florida State of Emergency (6/26/21) applicable to the temporary provisions of prescription drugs, and telemedicine. 

>>>Click here to read past updates

UPDATE - In the face of the COVID-19 pandemic, pharmaceutical companies have moved to produce vaccines. READ MORE 
The Food and Drug Administration (FDA) awarded Emergency Use Authorization (EUA) to three pharmaceutical companies for their vaccines: Pfizer  on Dec. 11, 2020 and Moderna  on Dec. 18, 2020 and Janssen Pharmaceutical Companies of Johnson & Johnson  on Feb. 27, 2021. Initially, the federal government will pay for the vaccine. Blue Cross and Blue Shield of Illinois (BCBSIL), or self-funded groups, will cover administration of the vaccine. Coverage will differ depending on if patients are fully insured, in a self-funded employer group, Medicare, or Medicaid. More details available on the website.

>>>Click here to read past updates

UPDATE - Payer is covering telehealth services with a $0 copay for sick and wellness visits. READ MORE

>>>Click here to read past updates

UPDATE - U0005 - Reimbursable for dates of service on or after January 1, 2021 when billed with U0003 or U0004. READ MORE 
Diagnostic tests that run on high-throughput technologies completed within two calendar days of the date and time of the specimen collection are eligible for separate reimbursement when billed with add-on code U0005.

>>>Click here to read past updates

UPDATE - BCBS of Michigan will waive all copays, deductibles, and coinsurance for the administration of COVID-19 vaccines to commercial members. READ MORE

>>>Click here to read past updates

UPDATE - BCBSNE will commit to extending the approval dates for an already approved Pre-Authorization (PA) due to the continued precautions with coronavirus through June 30, 2021. READ MORE 
When this is requested by the ordering provider, BCBSNE will allow an additional six months. Requests to extend the approval dates for previously approved pre-authorizations will not be accepted on or after July 1, 2021.

>>>Click here to read past updates

UPDATE - Blue Cross has updated the standard non-RVU fee schedule for COVID-19 testing as follows in accordance with the member’s benefit plan for all lines of business. READ MORE 
• HCPCS U0001: $35.91 – effective 2/4/20 dates of service
• HCPCS U0002: $51.31 – effective 2/4/20 dates of service
• HCPCS U0003: $100.00 – effective 4/14/20 through 12/31/20 dates of service
• HCPCS U0003: $75.00 – effective 1/1/21 dates of service
• HCPCS U0004: $100.00 – effective 4/14/20 dates of service
• HCPCS U0005: $25.00 – effective 1/1/21 dates of service

3/7/2020 - Effective immediately, payer won’t require prior authorization and won’t apply member co-pays or deductibles for testing to diagnose COVID-19 when medically necessary and consistent with Centers for Disease Control guidance. This applies to all members payer insures. With regard to treatment for COVID-19, Blue Cross and Blue Shield of New Mexico plans cover medically necessary health benefits, including physician services, hospitalization and emergency services consistent with the terms of your benefits. READ MORE

UPDATE - Clarification for COVID-19 Vaccine and Monoclonal Antibody Treatment Reimbursement for Commercial and Medicare Advantage Lines of Business.
READ MORE 
In previous communications related to the COVID-19 vaccine and monoclonal antibody treatment, we shared that we would mirror the Medicare rates established by the Centers for Medicare & Medicaid Services (CMS) for Medicare Advantage and commercial products/lines of business.

We wish to clarify that we will use the geographically adjusted Medicare rates (i.e., the rates applicable to upstate NY) to reimburse COVID-19 vaccine administration and the infusion administration for monoclonal antibody treatment. These rates are the same as what you receive for treating Medicare fee-for-service patients.

Our claims system has been updated to reflect the geographically adjusted Medicare rates, including the March 15, 2021, CMS update for COVID-19 vaccine administration rates.

• COVID-19 vaccine administration: We will auto-adjust claims with dates of service on or after March 15, 2021, to reflect the CMS geographically adjusted vaccine administration rates (which are higher than the previous rates). There is no action required on your part to initiate an adjustment and no need to resubmit claims.
• COVID-19 monoclonal antibody infusion administration: Any claims for monoclonal antibody infusion administration processed or adjusted on or after April 4, 2021, will be paid at the updated geographically adjusted rates. We will not adjust previously paid claims to recoup the difference between the higher national CMS rate paid and the geographically adjusted rates.
• Please keep in mind that COVID-19 vaccines administered to Medicare Advantage members by Medicare Advantage contracted providers should be submitted to Original Medicare following the instructions included on the CMS website.

>>>Click here to read past updates

UPDATE - Our cost-sharing waiver for COVID-19-related treatment will expire on June 30, 2021 for customers on the following plans: Fully-insured commercial plans (individual and group plans), Blue Medicare Supplemental plans, Balance funded Administrative Services Only (ASO) plans, and Other ASO plans, unless the employer has opted to extend this waiver. For Medicare Advantage plans offered or administered by Blue Cross and Blue Shield of North Carolina (Blue Cross NC), the COVID-19 treatment cost-sharing waiver will remain in place through the duration of the federal public health emergency (PHE). The PHE is set to expire on June 30, 2021 but may be extended by the federal government.
READ MORE 

5/28/2021 - Effective June 1, 2021, providers and facilities submitting COVID-19 claim inquiries to Blue Cross and Blue Shield of North Carolina (Blue Cross NC) will no longer be able to submit any inquiries via the online Microsoft Form or via the COVID19questions@bcbsnc.com or COVID19claimsfallout@bcbsnc.com mailboxes. READ MORE 

5/24/2021 - Effective June 30, 2021, there will be a change in coverage related to temporary language found in several policies as a result of COVID-19. READ MORE
The temporary language found in these policies will revert back to the coverage/non-coverage that was in place prior to the COVID-19 pandemic. These changes apply to Administrative Services Only (ASO groups), fully insured membership and all commercial lines of business. The temporary language in the following policies will expire on June 30, 2021: "Skilled Nursing Services and Gene Expression Testing for Breast Cancer Prognosis AHS-M2020," and "Skilled Nursing Services."

5/24/2021 - The temporary language in the following policies will be extended to September 30, 2021: "Allergy Immunotherapy (Desensitization)," and "Advanced Illness/Advance Directives." READ MORE 

>>>Click here to read past updates

3/31/2020 - "Blue Care On Demand" is for video or health provider visits for members inside or outside SC without COVID-19 symptoms. Cost is $0 for members when you use code "COVID19." "Doctors Care Anywhere" is for video visits with Doctors Care providers and should be used by members in SC with any acute symptoms. Cost is $0 for members when you use code "INS." "S.C. Department of Health and Environmental Control (DHEC)-Virtual Triage" is for video visits with health providers for members in SC who have specific COVID-19 symptoms. Cost is $0 for members when you use the code "COVID19." READ MORE

UPDATE - BlueCross Tennessee Shares Plan to Cover Costs for COVID-19 Vaccination. READ MORE 
BlueCross BlueShield of Tennessee wants to make members aware that it will cover the administration cost for all coronavirus vaccines that receive Food and Drug Administration (FDA) approval and emergency use authorization. The cost of the vaccine itself is covered by the federal government. BlueCross will cover the fees associated with its administration. If a BlueCross member is charged for any part of their vaccine visit, they can call the Member Services number on the back of their Member ID card for help. As more FDA-approved COVID-19 vaccines are produced and distributed, anyone who wants a vaccine should be able to get one. Members should check BCBSTUpdates.com for answers to vaccine-related questions, and with the Tennessee Department of Health at tn.gov/health for additional information on the state’s vaccine distribution plan.

>>>Click here to read past updates

UPDATE - What You Need to Know About COVID-19 Vaccine Protocols.
READ MORE 
The Pfizer COVID-19 vaccine has received emergency use authorization for children ages 12 and older. By fall, COVID-19 vaccines may be approved for younger children. The CDC recommends the COVID-19 vaccine for everyone ages 12 and older Learn more about third-party links. In updated clinical guidance Learn more about third-party links, the CDC says that other vaccines may be given with the COVID-19 vaccine. It’s no longer necessary to wait 14 days between the COVID-19 vaccine and other vaccines as a precaution. The American Academy of Pediatrics Learn more about third-party links also supports this guidance.

5/13/2021 - Coronavirus (COVID-19) Provider Information for ERS Participants.
READ MORE 
We updated the expiration date to June 30, 2021 for non-COVID-19 related, in-network telemedicine and Virtual Visits through Doctor On Demand and MDLIVE on the Telehealth section.

>>>Click here to read past updates

UPDATE - Update on Billing of U0001. READ MORE 
Updated June 18, 2020 and retroactive to February 4, 2020: Healthcare providers using the Centers for Disease Control and Prevention (CDC) 2019 Novel Coronavirus Realtime RT-PCR Diagnostic Test Panel may bill for that test using this newly created HCPCS code (U0001). It is eligible for reimbursement and does not apply member liabilities. 

3/17/2020 - For BCBSVT members to receive a zero-cost share for the coronavirus testing, services must be provided in an office (place of service 11), or Urgent Care (place of service 20) or Emergency Room (place of service 23) setting. CPT codes U0001, U0002, 87635 and 87631; refer to complete billing details. READ MORE

UPDATE - COVID-19 Update. Question - If I paid out-of-pocket for a COVID-19 test that should be covered, what do I need to do? Answer - Call Customer Service at the number on your member ID card. Customer Service will help you submit your claim if your provider has not submitted it. You will need to show either the provider’s order or proof of your referral for your COVID-19 diagnostic test for your claim to be processed by Blue Shield. READ MORE 

>>>Click here to read past updates

UPDATE - Buckeye Health Plan is closely following advancements in the prevention and treatment of COVID-19, including vaccinations. READ MORE 
As a healthcare provider, you will play an integral role as COVID-19 vaccines become available. We want to update you on important new information about vaccine coverage. To prepare for vaccine administration, the Centers for Medicare and Medicaid (CMS) have published billing guidance (PDF) for Medicaid and Children’s Health Insurance Program (CHIP) providers. Similar to other COVID-19 services, the vaccines will be offered at no cost to your patients. Member liability will be $0. Non-participating provider pre-auth requirements will be waived.

>>>Click here to read past updates

UPDATE: CareFirst BCBS will fully cover all member costs associated with all FDA-approved COVID-19 vaccines, including for members in self-insured plans.
READ MORE

UPDATE - COVID-19: Temporary Change to PA's for Transition to Post-Acute Care Update/Effective 4/1/21. READ MORE 
Earlier during the pandemic, CareSource modified the prior authorization (PA) process to help provide administrative relief in patient throughput and capacity management in the acute environment during COVID pandemic. As the state is no longer experiencing over-capacity in acute care settings, and in order to improve coordination for timely admissions and member discharge planning, CareSource is reestablishing previous workflows. All prior authorization requirements will be effective for dates of service beginning April 1, 2021. Providers are required to obtain prior authorization before administering the applicable health care service(s).For dates of service occurring between January 1 and March 31, 2021, CareSource will waive prior authorization requirements as communicated in the previous network notification. Please note: This notification applies to all Ohio products (Medicaid, MyCare, Medicare, Advantage, D-SNP and Marketplace).

 >>>Click here to read past updates

UPDATED - Centene's Medicaid, Medicare Advantage, and Marketplace members can access COVID-19 vaccines at no cost as they become available to them in accordance with state and federal (CMS) requirements and timelines. READ MORE 

>>>Click here to read past updates

UPDATE - CGS MCR Claims Processing Issues Log. 05/11/2021 Resolved.
READ MORE

• Issue - Claims billed with HCPCS codes U0002 and 87635 with HCPCS modifier QW (CLIA waived lab test) denied in error.
• Status - Closed
• Provider Type Impacted - CLIA waived laboratory providers and suppliers
• Claim Coding Impact - HCPCS codes U0002 and 87635 w HCPCS modifer QW
• MAC Action - CGS will reprocess/adjust all claims denied in error. A system fix was implemented on 5/10/21, and completed on 5/11/21.
• Provider Action - No action is required by you.

5/6/2021 - CGS MCR Claims Processing Issues Log. 05/6/2021 Resolved. READ MORE 

• Issue - Claims submitted with HCPCS code U0005 experienced processing issues. Some were paid but applied to the deductible in error; some denied as routine and for referring physician.
• Status - Closed
• Provider Type Impacted - Part B Providers
• Claim Coding Impact - HCPCS code U0005 MAC Action - Our claims processing system was updated to correct this. Update 3/22/21 - Incorrect denials for CPT modifier 90 have been added to this mass adjustment. Affected claims from Kentucky providers are currently in process. Ohio claims will be adjusted soon.
• Update 5/6/21 - All KY and OH adjustment have completed. Adjustments for incorrect denials were also complete for KY and OH.
• Provider Action - No action is required by you.

5/6/2021 - CGS Medicare Claims Processing Issues Log. 05/06/2021 Resolved.
READ MORE 

• Issue 01/21/2021 Claims submitted for the Pfizer-Biontech Covid-19 Vaccine Administration (First Dose) are denying in error when billed in place of service 60 (Mass Immunization Center).
• Status - Closed
• Provider Type Impacted - Part B Providers
• Claim Coding Impact - CPT codes 0001A and 0002A
• MAC Action - Our claims processing system was updated to correct this. Update 1/29/21 - Mass adjustments have been initiated.
• Update 4/12/21 - A second mass adjustment was initiated for additional denials.
• Update 5/6/21 - All adjustments have been completed.
• Provider Action - No action is required by you.

5/1/2021 - COVID-19 News: Sequestration. READ MORE 
The Coronavirus Aid, Relief, and Economic Security (CARES) Act suspended the payment adjustment percentage of 2% applied to all Medicare Fee-For-Service (FFS) claims from May 1 through December 31, which was then extended to March 31, 2021. An Act to Prevent Across-the-Board Direct Spending Cuts, and for Other Purposes, signed into law on April 14, 2021, extends the suspension period to December 31, 2021. CGS will release any previously held claims with dates of service on or after April 1, and reprocess any claims paid with the reduction applied. No provider action is required. Refer to the CMS Special Edition MLN Connects dated April 16, 2021.

>>>Click here to read past updates

12/3/2020 - CDC Guidance for Expanded Screening/Testing to Reduce Silent Spread of SARS-CoV-2. READ MORE 
This interim guidance is based on what is currently known about the novel coronavirus (SARS-CoV-2) and coronavirus disease (COVID-19) as of the date of posting, December 1, 2020. Guidance from the U.S. Centers for Disease Control and Prevention (CDC) are meant to supplement—not replace—any federal, state, local, territorial, or tribal health guidance. Note: This document is intended to provide considerations for expanding screening testing for SARS-CoV-2, the virus that causes COVID-19 and does not dictate the determination of payment decisions or insurance coverage of such testing, except as may be otherwise referenced (or prescribed) by another entity or federal or state agency. CDC has no regulatory authority over testing; therefore, the information in this document is meant to assist health departments in making decisions rather than in establishing any regulatory requirements.

>>>Click here to read past updates

UPDATE - MLN Connects 6/9/21. As part of President Biden’s commitment to increasing access to vaccinations, the Centers for Medicare & Medicaid Services (CMS) today announced an additional payment amount for administering in-home COVID-19 vaccinations to Medicare beneficiaries who have difficulty leaving their homes or are otherwise hard-to-reach. READ MORE 
This announcement further demonstrates continued efforts of the Biden-Harris Administration to meet people where they are and make it as easy as possible for all Americans to get vaccinated. There are approximately 1.6 million adults 65 or older who may have trouble accessing COVID-19 vaccinations because they have difficulty leaving home.

While many Medicare beneficiaries can receive a COVID-19 vaccine at a retail pharmacy, their physician’s office, or a mass vaccination site, some beneficiaries have great difficulty leaving their homes or face a taxing effort getting around their communities easily to access vaccination in these settings. To better serve this group, Medicare is incentivizing providers and will pay an additional $35 per dose for COVID-19 vaccine administration in a beneficiary’s home, increasing the total payment amount for at-home vaccination from approximately $40 to approximately $75 per vaccine dose. For a two-dose vaccine, this results in a total payment of approximately $150 for the administration of both doses, or approximately $70 more than the current rate.

6/3/2021 - MLN Connect 6/3/21. MACs Resume Medical Review on a Post-payment Basis. READ MORE 
Beginning August 2020, Medicare Administrative Contractors (MACs) resumed post-payment reviews of items and services with dates of service before March 2020. MACs may now begin conducting post-payment medical reviews for later dates of service. The Targeted Probe and Educate program (intensive education to assess provider compliance through up to 3 rounds of review) will restart later. The MACs will continue to offer detailed review decisions and education as appropriate.

5/27/2021 - MLN Connects 5/27 - Submit Medicare GME Affiliation Agreements during COVID-19 PHE by January 1, 2022. READ MORE

5/27/2021 - MLN Connects 5/27. Publications - Medicare Diabetes Prevention & Diabetes Self-Management Training — Revised. READ MORE 

5/26/2021 - CMS News 5/26/21. CMS Encourages Companies to Promote Quality, Affordable Health Coverage for Gig Workers. READ MORE 
The Centers for Medicare & Medicaid Services (CMS) is encouraging online platform companies to share information with gig workers on their ability to enroll in affordable, quality, health coverage during the 2021 Marketplace Special Enrollment Period (SEP). Digital platforms – including Delivery Drivers, Inc., DoorDash, Lyft, Postmates, StyleSeat, Uber, and Wonolo – are participating in “Gig Workers’ Week of Action” to promote Marketplace healthcare plans to their workforces.

5/20/2021 - MLN Matters MM12294. Addition of the Shared System CWF to the Business Requirements for the Healthcare Common Procedure Coding System (HCPCS) Codes U0002QW and 87635QW Mentioned in Change Request 11765. READ MORE 

5/13/2021 - MLN Connects 5/13/21. Multimedia - Community Champions Video Launch. READ MORE 
On May 5, as a part of CMS’ ongoing COVID response efforts to support the long term care community, we debuted our first social media videos highlighting staff, also referred to as Community Champions, who moved from being initially uncertain about receiving the COVID-19 vaccine to accepting the vaccine-- and encouraging their peers to do the same. Throughout the COVID-19 pandemic, staff in nursing homes have been providing ongoing care to our nation’s most vulnerable. This social media campaign is intended to help increase vaccine acceptance amongst long-term care staff. Please like and share our Community Champions video. 

5/11/2021 - MLN Connects 5/11/21. Special Edition - CMS Expanding Efforts to Grow COVID-19 Vaccine Confidence and Uptake Amongst Nation’s Most Vulnerable. READ MORE 
As part of the ongoing response to address the COVID-19 pandemic and to improve health care access and reduce the risk of severe illness and death from COVID-19, CMS issued a rule that will ensure long-term care facilities, and residential facilities serving clients with intellectual disabilities, educate and offer the COVID-19 vaccine to residents, clients, and staff. These requirements apply to Long-Term Care (LTC) facilities and Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICFs-IID) and align with existing requirements for influenza and pneumococcal vaccines in LTC facilities.

5/6/2021 - MLN Connects 5/6/21. Special Edition - CMS Increases Medicare Payment for COVID-19 Monoclonal Antibody Infusions. READ MORE 
As part of the ongoing response to address the COVID-19 pandemic, CMS has increased the Medicare payment rate for administering monoclonal antibodies to treat beneficiaries with COVID-19, continuing coverage under the Medicare Part B COVID-19 vaccine benefit. Beneficiaries pay nothing out of pocket, regardless of where the service is furnished – including in a physician’s office, health care facility, or at home.

Effective May 6, the national average payment rate will increase from $310 to $450 for most health care settings. In support of providers’ efforts to prevent the spread of COVID-19, CMS will also establish a higher national payment rate of $750 when monoclonal antibodies are administered in the beneficiary’s home, including the beneficiary’s permanent residence or temporary lodging (e.g., hotel/motel, cruise ship, hostel, or homeless shelter).

The new national payment rate for at-home administration of monoclonal antibodies accounts for increased costs associated with the one-on-one nature of this care model. These higher national average payment rates reflect additional information provided to CMS about the costs of providing these services in a safe and timely manner, such as clinical staff and personal protective equipment. This action also means Medicare payments to providers and suppliers will be more aligned to their costs to administer these products.

MLN Connects 5/6/2021. (1) New Program: HRSA COVID-19 Coverage Assistance Fund. READ MORE 
On May 3, HHS, through the Health Resources and Services Administration (HRSA), announced the HRSA COVID-19 Coverage Assistance Fund (CAF). This program covers the cost of administering COVID-19 vaccines to patients enrolled in health plans that either don’t cover vaccination fees or cover them with patient cost-sharing.

“After securing enough COVID-19 vaccines for all adults, the Biden-Harris Administration is elevating work to boost access to them,” said HHS Secretary Becerra. “We listened to our health care providers on the frontlines of the pandemic. On top of increasing reimbursement rates tied to administering the shots, we are closing the final payment gap that resulted as vaccines were administered to underinsured individuals. No health care provider should hesitate to deliver these critical vaccines to patients over reimbursement cost concerns.”

(2) Ground Ambulance Services: Waiver for Treatment in Place. READ MORE 
Effective March 1, 2020, where the following criteria are satisfied, Medicare pays for ground ambulance services without a transport during the COVID-19 Public Health Emergency (PHE):

^^ The ground ambulance service was furnished in response to a 911 call (or the equivalent in areas without a 911 call system); and
^^ The patient would have been transported to a destination permitted under Medicare regulations, but the transport did not occur as a result of community-wide emergency medical service protocols due to the COVID-19 PHE; and
^^ The patient’s condition required the level of service provided and would normally require transport by ambulance, absent the community-wide EMS protocols (in other words, any other means of transportation would have been contraindicated).

>>>Click here to read past updates, MLN Newsletters, Webinar recordings, etc.

OHA (Ohio Hospital Association) presentation 5/19/2020 w ODM (Ohio Department of Medicaid) clarification. READ MORE

UPDATE - The cost-share waiver for COVID-19 diagnostic testing and related office visits is in place until the end of Public Health Emergency (PHE) period, currently through July 20, 2021. READ MORE 

>>>Click here to read past updates

Add-on procedure code U0005 will be added to the laboratory fee schedule and priced at $25.00. The add-on code U0005 was created to be billed in combination with procedure codes U0003 or U0004 only when providers meet the specific criteria outlined by CMS. READ MORE

* Providers must meet specific criteria in order to bill procedure code U0005.

COVID-19 News. Effective Date: February 11, 2021, U0005 should be listed separately in addition to either HCPCS code U0003 or U0004. READ MORE 

Empire BCBS will cover the cost of the COVID-19 vaccine. Empire members won’t have out-of-pocket costs for the vaccine during the national public health emergency. This applies to all members, regardless of the type of health plan they have, or which doctor or healthcare professional they choose to visit for COVID-19 vaccinations. READ MORE 

UPDATE - The initial supply of COVID-19 monoclonal antibodies will be provided free of charge by the federal government. The Health Plan will provide reimbursement for infusion of the antibody treatments only. Please do not bill for the monoclonal antibody products you receive for free. READ MORE 

5/4/2021 - The NYS Emergency Regulation on Telehealth has been extended to 6/4/2021. This extends specifically to COVID-19 and non-COVID-19-related telehealth services. READ MORE 

>>>Click here to read past updates

Effective March 01, 2020, providers are responsible to ensure any copays, coinsurance, or deductible charges are waived for Fidelis Care members at the time of an office visit, urgent care visit, clinic, or emergency room visit when the purpose of that visit is testing for COVID-19.  Claims with correct coding will be adjusted to reflect provider payments with $0 member liability upon processing. Updating claiming systems to be able to receive new codes by April 1, 2020. Will add Healthcare Common Procedure Coding System (HCPCS) codes to system.  READ MORE

UPDATE - Billing News 5/26/21. Providers in Primary Care Alliance ACO not receiving reimbursement on certain SNF claims. READ MORE 
Some providers participating in the All-Inclusive Population Based Payment (AIPBP) in the Primary Care Alliance Accountable Care Organization (ACO) (V304) are indicating they are not getting reimbursed on skilled nursing facility (SNF) claims for beneficiaries who have COVID-19 claims, either from Medicare or the ACO.

The ACO is NOT withholding payment under AIPBP. The claims are not paid by Medicare because the beneficiary has exhausted their coverage, so the ACO cannot reimburse the provider for these claims.

Review of Medicare coverage rules - - Claims from providers participating in the AIPBP (benefit enhancement indicator 5) with the B no pay code (0 reimbursement) and no AIPBP reduction applied are not paid because the beneficiary has exhausted their Medicare benefits. Even if the claim was for a beneficiary with COVID-19, the regular Medicare coverage applies:

• CMS did not change all spell of illness rules for COVID-19 to allow more than the 60/30 – 20/80 days.
• A beneficiary is allowed 60 full hospital days, 30 co-insurance hospital days, 60 hospital lifetime days, 20 full SNF days, and 80 co-insurance SNF days.

Regardless if the claim is eligible for coverage, when a beneficiary is out of benefit days, the claim will be non-covered by Medicare. 

Background
Providers in the Next Generation ACO (NGACO) Model that select AIPBP agree to have eligible claims reduced by 100% in exchange for payments made from the ACO entity. Providers will receive $0 payment from Medicare, and instead will be reimbursed by the ACO. For additional information on the AIPBP, please see MLN Matters Special Edition article SE17011.

5/7/2021 - 2021 Payment Rates for COVID-19 Vaccine and Monoclonal Administration. READ MORE 
CMS established national payment allowances for the administration of COVID-19 vaccines and monoclonal antibodies. These allowances will be geographically adjusted for many providers. The First Coast allowances for jurisdiction N (JN) for administration of COVID-19 vaccines and monoclonal antibodies for 2021 are broken down into three categories:

^^ Payment rates for dates of service (DOS) January 1 through March 14th,

^^ Payment rates for dates of service (DOS) March 15th through May 5th,

^^ Payment rates for dates of service (DOS) May 6th through December 31, 2021.

5/13/2021 - First Coast Medicare Processing Issues. Allowance of QW Modifier on Codes U0002 and 87635. Part B. READ MORE 
Issue - Effective for dates of service on and after March 2, 2020, CMS added the QW modifier (Clinical Laboratory Improvement Amendments Act {CLIA} waived tests) to procedure codes 87635 and U0002. However, the Common Working File (CWF) wasn't updated to accommodate this request. A recent update has been made to the system.

Resolution - Claims impacted will be reprocessed for dates of service on and after March 2, 2020, that were denied when the QW modifier was reported on 87635 and U0002.

Status/date resolved - Open.

Provider action - No provider action is needed.

5/3/2021 - First Coast Medicare Processing Issues. Revised editing for ordering/referring providers on lab claims. READ MORE 
Issue - Because of the COVID-19 public health emergency (PHE), CMS previously amended regulations to remove the requirement that certain diagnostic tests are covered only when ordered by the treating physician. With this revised policy, Medicare beneficiaries may receive coverage for one COVID-19 and related test without the order of a physician or non-physician practitioner.

This revised policy includes the following codes: U0001-U0004, 87635, 86769, 86328, 87275, 87276, 87279, 87400, 87501-87503, 87631, 87804, 87280, 87420, 87634, and 87807.

Resolution - CMS has revised this editing to remove the ordering requirement from additional codes. This revised editing will be applicable to the following codes for dates of service on or after March 1, 2020: U0005, 86408, 86409, 86413, 87426, 87811, 0224U, 0226U, 87428, 87636, 87637, 0240U, 0241U, G2023, and G2024. The relaxation of the referring provider for the listed codes is effective for dates of service on or after March 1, 2020. The referring/ordering provider NPI will be required for procedure codes 87632 and 87633 effective for claims processed on or after May 4.

Status/date resolved - Open

Provider action - If you think your claim denied in error due to missing ordering provider, includes one of the codes listed above, and is for a date of service on or after March 1, 2020, you can request a history correction reopening using the Claim Reopening Gateway. 

>>>Click here to read past updates

UPDATE - COVID-19 update 6/8/21. The White House, the U.S. Department of Health and Human Services (HHS) Office of the Assistant Secretary for Preparedness and Response and the U.S. Food and Drug Administration (FDA) today released a series of policy recommendations to address the vulnerabilities in U.S. pharmaceutical supply chains. Led by HHS, the White House report and its recommendations have been accepted by President Biden. READ MORE 

6/4/2021 - COVID-19 Update 6/4/21. On June 1, the FDA approved an abbreviated new drug application for albuterol sulfate inhalation aerosol 90 mcg (base)/actuation. READ MORE 
Albuterol sulfate inhalation aerosol is used for the treatment or prevention of bronchospasm (narrowing of the airways) in patients four years of age and older with reversible obstructive airway disease (such as asthma) and for the prevention of exercise-induced bronchospasm in patients four years of age and older. The most common side effects associated with albuterol sulfate inhalation aerosol are headache, dizziness, tachycardia (rapid heart rate), chest pain, pharyngitis (sore throat), and rhinitis (runny nose).

The FDA recognizes the increased demand for certain products during the COVID-19 public health emergency and has prioritized the review of generic drug applications for potential treatments and supportive therapies for patients with COVID-19. We remain deeply committed to facilitating access to safe and effective medical products to help address critical needs of the American public.

** On June 3, the FDA posted an update to the SARS-CoV-2 Viral Mutations: Impact on COVID-19 Tests web page to share the latest information. The update added new information about a potential impact on the performance of the Mesa Biotech Inc. Accula SARS-CoV-2 Test due to a genetic mutation at positions 28877-28878 (AG to TC) in patient samples. ** The FDA reissued the Letter of Authorization for REGEN-COV (Casirivimab and Imdevimab) treatment for COVID-19 to authorize:
^ ^ ^ A dosage change from 1200 mg of casirivimab and 1200 mg of imdevimab to 600 mg of casirivimab and 600 mg of imdevimab;
^ ^ ^ A new coformulation presentation that contains 600 mg of casirivimab and 600 mg of imdevimab in a single vial, and
^ ^ ^ Addition of subcutaneous (under-the-skin) injection as an alternative route of administration when intravenous (administered into a vein) infusion is not feasible and would lead to delay in treatment.

6/1/2021 - COVID-19 Update: The FDA issued a safety communication to warn the public to stop using the Lepu Medical Technology SARS-CoV-2 Antigen Rapid Test Kit and the Leccurate SARS-CoV-2 Antibody Rapid Test Kit (Colloidal Gold Immunochromatography) because the FDA has serious concerns about the performance of the tests and believes there is likely a high risk of false results when using these tests. READ MORE 
Neither test has been authorized, cleared, or approved by the FDA. The FDA has identified this issue as a class I recall, which is the most serious type of recall. The FDA is aware that these unauthorized tests were distributed to pharmacies to be sold for at-home testing by consumers, as well as offered for sale directly to consumers.

5/26/2021 - COVID-19 Update: The U.S. Food and Drug Administration issued an emergency use authorization (EUA) for the investigational monoclonal antibody therapy sotrovimab for the treatment of mild-to-moderate COVID-19 in adults and pediatric patients (12 years of age and older weighing at least 40 kilograms [about 88 pounds]) with positive results of direct SARS-CoV-2 viral testing and who are at high risk for progression to severe COVID-19, including hospitalization or death. This includes, for example, individuals who are 65 years of age and older or individuals who have certain medical conditions. READ MORE 

The safety and effectiveness of this investigational therapy continues to be evaluated for treatment of COVID-19. Sotrovimab is not authorized for patients who are hospitalized due to COVID-19 or require oxygen therapy due to COVID-19. This treatment has not shown benefit in patients hospitalized due to COVID-19 and monoclonal antibodies may be associated with worse clinical outcomes when administered to hospitalized patients requiring high flow oxygen or mechanical ventilation.

5/25/2021 - COVID-19 Update: The FDA updated its guidance, Emergency Use Authorization for Vaccines to Prevent COVID-19, to include a new section that clarifies how the agency intends to prioritize review of EUA requests for the remainder of the COVID-19 public health emergency. READ MORE 
As noted in the guidance, for the remainder of the current pandemic, the FDA may decline to review and process further EUA requests other than those for vaccines whose developers have already engaged with the agency as described in the agency’s guidance, “Emergency Use Authorization Vaccines to Prevent COVID-19.”

* * Today the FDA issued a report that describes some of the approaches used by the South Korean government to address COVID-19, particularly regarding development, authorization and use of diagnostic tests. Numerous sources around the world declared South Korea’s response strategy had successfully “flattened the curve” of COVID-19. As South Korea’s experience may be informative for future considerations, the FDA reviewed information, including reports in the press and information made publicly available by the South Korean government, about their COVID-19 response strategy.

5/21/2021 - The FDA issued a reminder to health care providers to give clear, step-by-step instructions to patients who, in a health care setting, self-collect anterior nasal samples for SARS-CoV-2 testing. Without proper instructions, patients may not collect an adequate sample for testing, which may decrease the sensitivity of the test. READ MORE 

* * The FDA issued a safety communication to remind health care providers and the public that results from currently authorized SARS-CoV-2 antibody tests should not be used to evaluate a person’s level of immunity or protection from COVID-19 at any time, and especially after the person received a COVID-19 vaccination. The FDA also updated the Serology/Antibody Tests: FAQs on Testing for SARS-CoV-2 and the Antibody (Serology) Testing for COVID-19: Information for Patients and Consumers web pages to provide updated information on the use of SARS-CoV-2 antibody test results.

* * The FDA updated the definition of high risk for COVID-19 to include additional medical conditions and factors associated with increased risk for progression to severe disease. This update applies to the emergency use authorizations (EUAs) for REGEN-COV (Casirivimab and Imdevimab) and Bamlanivimab and Etesevimab.

5/19/2021 - FDA Authorizes Longer Time for Refrigerator Storage of Thawed Pfizer-BioNTech COVID-19 Vaccine Prior to Dilution, Making Vaccine More Widely Available. READ MORE Additional Information:

^^ Based on a review of recent data submitted by Pfizer Inc. today, the U.S. Food and Drug Administration is authorizing undiluted, thawed Pfizer-BioNTech COVID-19 Vaccine vials to be stored in the refrigerator at 2°C to 8°C (35°F to 46°F) for up to 1 month. Previously, thawed, undiluted vaccine vials could be stored in the refrigerator for up to 5 days.

^^ Pfizer Inc. submitted data to the FDA to demonstrate that undiluted, thawed vials of its COVID-19 vaccine are stable at refrigerator temperatures for up to 1 month.

^^ The updated Fact Sheet for Healthcare Providers Administering Vaccine (Vaccination Providers) is intended to help frontline workers understand the revised storage time. The Fact Sheet is available on the FDA’s web site.

5/11/2021 - COVID-19 Update 5/11/2021. READ MORE 
On May 10, the FDA issued a press release about FDA’s expansion of the emergency use authorization for the Pfizer-BioNTech COVID-19 Vaccine to include individuals 12 through 15 years of age.

In addition, the FDA added a question, “What data did the FDA evaluate to support Emergency Use Authorization of Pfizer-BioNTech COVID-19 Vaccine in individuals 12 through 15 years of age?”, to the Pfizer-BioNTech COVID-19 Frequently Asked Questions webpage. The FDA is currently working on translating the updated Fact Sheet for Recipients and Caregivers in multiple languages.

>>>Click here to read past updates

READ MORE

UPDATE - HHS Secretary Xavier Becerra to Insurers & Providers: COVID-19 Vaccines and Testing Must be Free for Patients. READ MORE 
Below is a letter sent by U.S. Department of Health and Human Services (HHS) Secretary Xavier Becerra to insurers and providers following recent reports of ongoing concerns about Americans facing costs associated with COVID-19 vaccinations or testing.

To COVID-19 vaccination and testing providers and insurers: Since we took office, the Biden-Harris administration has made combatting the COVID-19 pandemic our top priority. Central to our national plan to protect Americans and end the pandemic has been increasing testing and vaccinations. In light of recent reports of consumer cost concerns exit disclaimer icon, I am reminding health care providers of their signed agreements to cover the administration of COVID-19 vaccines free-of-charge to patients, and group health plans and health insurers of their legal requirement to provide coverage of COVID-19 vaccinations and diagnostic testing without patients shouldering any cost.

COVID-19 vaccines and their administration are free for any individual living in the United States, regardless of their insurance or immigration status. Currently, all providers administering COVID-19 vaccines are required to sign the Centers for Disease Control and Prevention (CDC) COVID-19 Vaccination Program Provider Agreement. Among other requirements, this agreement states that providers must administer COVID-19 vaccines at no out-of-pocket cost to patients. Furthermore, to ensure no surprise billing, providers may not require that patients have additional medical services to receive their COVID-19 vaccination – nor can they charge any type of fee if COVID-19 vaccination is the sole medical service provided.

5/25/2021 - HHS to Dedicate $4.8 Billion from American Rescue Plan to COVID-19 Testing for the Uninsured. READ MORE 
The US Department of Health and Human Services (HHS), through the Health Resources and Services Administration (HRSA), is announcing that it is dedicating $4.8 billion from the American Rescue Plan (ARP) to support the HRSA COVID-19 Uninsured Program. This funding will allow the program to continue reimbursing health care providers for testing uninsured individuals for COVID-19. As of May 19, 2021, the program has issued nearly $4 billion in testing reimbursements to providers. There are approximately 29 million uninsured individuals living in the United States. While this administration has been focused on decreasing the uninsured rate, as evidenced by the more than 1 million people who have enrolled into quality health coverage through the Special Enrollment Period (SEP), much work remains. By ensuring programs like the HRSA COVID-19 Uninsured Program remains adequately funded, this administration is removing cost impediments so anyone exposed to COVID-19 may seek appropriate testing and care.

The funding announced today is dedicated to COVID-19 testing. HRSA also helps uninsured individuals’ access COVID-19 treatment and vaccinations through the COVID-19 Uninsured Program. The program reimburses providers at national Medicare rates for providing these services. As of May 19, 2021, the program has issued over $2.5 billion toward reimbursing providers for delivering COVID-19 treatment and over $85 million for vaccinating the uninsured.

5/20/2021 - HHS Announces $14.2 Million from American Rescue Plan to Expand Pediatric Mental Health Care Access. READ MORE 
The U.S. Department of Health and Human Services (HHS), through the Health Resources and Services Administration (HRSA), announced the availability of $14.2 million from the American Rescue Plan to expand pediatric mental health care access by integrating telehealth services into pediatric primary care.

The funding will expand Pediatric Mental Health Care Access (PMHCA) projects into new states and geographic areas nationwide, including tribal areas. These new state and regional networks of pediatric mental health care teams will provide teleconsultations, training, technical assistance and care coordination for pediatric primary care providers to diagnose, treat and refer children and youth with mental health conditions and substance use disorders. Currently, there are 21 PMCHA projects in the country. Research demonstrates an increased need for pediatric mental and behavioral health care. In the United States, about 22 percent of children ages 3 to 17 are currently affected by some type of mental, emotional, developmental, or behavioral condition. Only about 20% of children with mental, emotional, or behavioral disorders receive care from a specialized provider.

5/11/2021 - HHS Awards $40 Million in American Rescue Plan Funding to Support Emergency Home Visiting Assistance for Families Affected by the COVID-19 Pandemic. READ MORE 
These funds will be used to provide services and emergency supplies, such as diapers, food, water, and hand sanitizer. Families who cannot access home visiting services due to the pandemic will be provided technology to participate in virtual home visits. Funds will also be used to train home visitors on emergency preparedness and response planning for families and on how to safely conduct virtual intimate partner violence screenings.

5/4/2021 - HHS Announces Nearly $1 Billion from American Rescue Plan for Rural COVID-19 Response. READ MORE 

HHS Announces $250 Million from American Rescue Plan to Develop and Support a Community-Based Workforce to Increase COVID-19 Vaccinations in Underserved Communities. READ MORE 

FACT SHEET: President Biden to Announce Goal to Administer at Least One Vaccine Shot to 70% of the U.S. Adult Population by July 4th. READ MORE 

5/3/2021 - HHS Launches New Reimbursement Program for COVID-19 Vaccine Administration Fees not Covered by Insurance. READ MORE 

>>>Click here to read past updates

UPDATE - Coronavirus (COVID-19) Update: FDA Revokes Emergency Use Authorization for Monoclonal Antibody Bamlanivimab. READ MORE

4/15/2021 - Message from HHS-OIG Leadership on the COVID-19 Vaccination Program and Provider Compliance. READ MORE 
As COVID-19 vaccinations continue to be administered nationwide, the Office of Inspector General (OIG) reminds vaccine providers and the public that this vaccine is being provided by the Federal Government and must be administered at no cost to recipients. Providers participating in the Centers for Disease Control and Prevention's (CDC's) COVID-19 Vaccination Program are obligated to comply with the terms of that program.

Regarding the COVID-19 Vaccination Program, CDC has explained:
The COVID-19 Vaccine Is Provided at 100% No Cost to Recipients. All organizations and providers participating in the CDC COVID-19 Vaccination Program:

^^ must administer COVID-19 Vaccine with no out-of-pocket cost to the recipient;
^^ may not deny anyone vaccination based on the vaccine recipient's coverage status or network status;
^^ may not charge an office visit or other fee if COVID-19 vaccination is the sole medical service provided;
^^ may not require additional medical services to receive COVID-19 vaccination;
^^ may seek appropriate reimbursement from a program or plan that covers COVID-19 Vaccine administration fees for the vaccine recipient, such as:
** vaccine recipient's private insurance company
** Medicare or Medicaid reimbursement
** HRSA COVID-19 Uninsured Program for non-insured vaccine recipients; and
^^ may not seek any reimbursement, including through balance billing, from the vaccine recipient.

12/10/2020 - FAQs–Application of OIG's Administrative Enforcement Authorities to Arrangements Directly Connected to the Coronavirus Disease 2019 (COVID-19) Public Health Emergency. READ MORE 
The Office of Inspector General (OIG) recognizes that, in the current public health emergency resulting from the outbreak of the COVID-19, the health care industry must focus on delivering needed patient care.

1. As part of OIG's mission to promote economy, efficiency, and effectiveness in HHS programs, we are committed to protecting patients by ensuring that health care providers have the regulatory flexibility necessary to adequately respond to COVID-19 concerns. Therefore, OIG is accepting inquiries from the health care community regarding the application of OIG's administrative enforcement authorities, including the Federal anti-kickback statute and civil monetary penalty (CMP) provision prohibiting inducements to beneficiaries (Beneficiary Inducements CMP).
2. If you have a question regarding how OIG would view an arrangement that is directly connected to the public health emergency and implicates these authorities, please submit your question to OIGComplianceSuggestions@oig.hhs.gov. In your submission, please provide sufficient facts to allow for an understanding of the key parties and terms of the arrangement at issue.3 OIG will update the FAQ site as we respond to additional frequently asked questions.

UPDATE - The following codes may be used when collecting specimens for the diagnostic purposes of COVID-19. Reimbursement for specimen collection will, in general, only be separately reimbursed if it is the ONLY code billed on the claim. If billed with another code, such as an E&M code, no separate reimbursement will be allowed. 99000, 99001, 99211, C9803, G2023, G2024. READ MORE 

MEMBER COVERAGE - - ** ACA and Commercial Members: Highmark member cost-sharing (deductibles, coinsurance and copayments) for outpatient, in-network Virtual Visits and covered Telemedicine Services provided by our approved national vendors (American Well, Doctor On Demand, and Teladoc) will be waived for dates of service from March 13 through June 30, 2021 regardless of medical diagnosis.

** Medicare Advantage Members: Highmark member cost-sharing (deductibles, coinsurance and copayments) for outpatient, in-network or out-of-network Virtual Visits and covered Telemedicine Services provided by our approved national vendors (American Well, Doctor On Demand, and Teladoc) will be waived for dates of service from March 13 through June 30, 2021 regardless of medical diagnosis.

** FEP and Self-Insured Employer Group Members: The telehealth cost share waiver does not apply to FEP or any self-insured employer group that has opted out of the cost share waiver. Members should contact Member Services (using the number on the back of their card) to see if this applies to their plan.

** CHIP Members: Highmark member cost sharing (copays) for outpatient, in-network Virtual Visits and covered Telemedicine Services provided by our approved national vendors (American Well, Doctor On Demand, and Teladoc) does not apply. There is no cost for these services. 

>>>Click here to read past updates

Horizon
Blue Cross Blue Shield
New Jersey

UPDATE - Effective January 1, 2021 and throughout the period of public health emergency, Horizon BCBSNJ shall consider an additional add-on payment (U0005) for COVID-19 diagnostic testing run on high throughput technology, when billed with procedure code U0003 or U0004, and when the following conditions are met.
READ MORE

•  U0003 or U0004 COVID-19 testing is completed in two (2) calendar days or less for the specific test billed, and
• The laboratory can certify that 51% of the previous months U0003 and U0004 COVID-19 diagnostic testing was completed within two (2) calendar days or less.
  

3/6/2020 - Effective March 6, 2020:

◦ Waiving prior authorizations for a visit to a primary care physician, urgent care center, or emergency room for evaluation of upper respiratory symptoms, fever, shortness of breath or other conditions that may represent COVID-19.
◦ Waiving prior authorizations for diagnostic tests and for covered services that are medically necessary and consistent with CDC guidance if diagnosed with COVID-19.
◦ Waiving prior authorization for lab studies or diagnostic testing required during an ER evaluation or inpatient hospital stay.  Horizon will cover the full cost of the COVID-19 test. 
◦ Horizon members will have no cost, 24/7 access to licensed nurses who can assess and assist members with symptoms that are consistent with suspected COVID-19 infection.  READ MORE

UPDATE - HRSA eNews 6/3/21: HHS to Dedicate $4.8 Billion from American Rescue Plan to COVID-19 Testing for the Uninsured. READ MORE 
The US Department of Health and Human Services (HHS), through the Health Resources and Services Administration (HRSA), is announcing that it is dedicating $4.8 billion from the American Rescue Plan (ARP) to support the HRSA COVID-19 Uninsured Program. This funding will allow the program to continue reimbursing health care providers for testing uninsured individuals for COVID-19. As of May 19, 2021, the program has issued nearly $4 billion in testing reimbursements to providers.

HRSA Announces $50 Million in Funding to Optimize Use of Virtual Care in Health Centers. We announced the availability of up to $50 million for HRSA-funded health centers to further efforts to advance virtual care. This competitive, one-time funding opportunity will support health centers in optimizing the use of virtual care to increase access and improve clinical quality for medically underserved communities and vulnerable populations.
Application Due Date:
* Friday, July 16, 11:59 p.m. ET in Grants.gov
* Tuesday, August 17, 5 p.m. ET in HRSA’s Electronic Handbooks (EHBs)

Visit the fiscal year (FY) 2022 Optimizing Virtual Care technical assistance (TA) webpage for the Notice of Funding Opportunity, pre-recorded TA webinar, and other resources. New Rural Health Clinic Vaccine Confidence (RHCVC) Funding Opportunity Now Available. We released a Notice of Funding Opportunity for the Rural Health Clinic (RHC) Vaccine Confidence Program to expand access to vaccines and ensure equity in COVID-19 response in rural communities.

The new funding will support eligible RHCs to increase vaccine confidence, improve health care in rural areas, and reinforce key messages about prevention and treatment of COVID-19 and other infectious diseases.
Interested RHCs must complete three registrations before applying for a HRSA grant.

Application Due Date: Wednesday, June 23, 11:59 p.m. ET.

5/20/2021 - More Than 10 Million COVID-19 Vaccine Doses Administered by Community Health Centers. READ MORE 
May 19 - The U.S. Department of Health and Human Services (HHS) announced that Health Resources and Services Administration (HRSA) Health Center Program-funded health centers and Health Center Program look-alikes (LALs) have administered more than 10 million COVID-19 vaccine doses nationwide—with 61% provided to racial and ethnic minorities. Community health centers, which largely serve the nation’s underserved and most vulnerable communities. HHS Coordinates New Effort to Vaccinate Migratory and Seasonal Workers in the Food and Agriculture Sectors - the Department of Health and Human Services (HHS), through the Health Resources and Services Administration (HRSA), the Centers for Disease Control and Prevention (CDC), and the Food and Drug Administration (FDA), is coordinating efforts to support COVID-19 vaccination of migratory and seasonal agricultural workers including workers in the food sector.

These workers, including workers in the food sector, are often at heightened risk of COVID-19 infection as a result of multiple common factors, such as living in congregate housing, using shared transportation, and close working conditions. HHS Awards $40 Million in American Rescue Plan Funding to Support Emergency Home Visiting Assistance for Families Affected by the COVID-19 Pandemic - HHS), through the Health Resources and Services Administration (HRSA), awarded approximately $40 million in emergency home visiting funds to states, territories, and the District of Columbia to support children and families affected by the COVID-19 pandemic. The Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program supports the delivery of coordinated and comprehensive, high quality, voluntary, evidence-based home visiting services to children and families living in communities at risk for poor maternal and child health outcomes. These funds will be used to provide services and emergency supplies, such as diapers, food, water, and hand sanitizer. Families who cannot access home visiting services due to the pandemic will be provided technology to participate in virtual home visits. Funds will also be used to train home visitors on emergency preparedness and response planning for families and on how to safely conduct virtual intimate partner violence screenings.

5/19/2021 - HRSA COVID-19 Coverage Assistance Fund. READ MORE 
The HRSA COVID-19 Coverage Assistance Fund (CAF) is a program established by and administered by the Health Resources and Services Administration (HRSA), using funds appropriated by Congress under the Provider Relief Fund (PRF). Contractor support is provided by the SSI Group (SSI). The CAF reimburses eligible health care providers for claims associated with COVID-19 vaccine administration provided to underinsured individuals, who are defined for this purpose as having a health plan that either does not include COVID-19 vaccine administration as a covered benefit or covers COVID-19 vaccine administration but with cost-sharing.

** The HRSA COVID-19 Coverage Assistance Fund reimburses providers for claims for COVID-19 vaccine administration provided to individuals who have health insurance, but whose health plan either does not include COVID-19 vaccination as a covered benefit or covers COVID-19 vaccine administration but with cost-sharing. In contrast, the HRSA COVID-19 Uninsured Program reimburses providers who have conducted COVID-19 testing, provided COVID-19 treatment and/or administered Food and Drug Administration (FDA) authorized COVID-19 vaccines under an Emergency Use Authorization (EUA) or FDA-licensed COVID-19 vaccines under a Biologics License Application (BLA) to individuals who did not have any health care coverage at the time the service was rendered. Both programs work toward the goal of supporting providers in increasing access to COVID-19 vaccines for individuals living in the United States. Because claims for underinsured individuals require additional coordination with insurers, however, separate portals have been established for each patient population. 

5/6/2021 - HRSA eNews 5/6/21. READ MORE 
May 5 - U.S. Health and Human Service (HHS) Secretary Xavier Becerra and U.S. Housing and Urban Development (HUD) Secretary Marcia L. Fudge today announced a joint-agency effort to increase access to COVID-19 prevention and treatment services, including testing and vaccinations, among disproportionately affected communities, including among HUD-assisted households and people experiencing homelessness. This program will leverage the Health Center COVID-19 health Vaccine Program which currently provides a direct supply of vaccines to nearly 800 health centers across the country. HHS and HUD expect the effort will reach over 6,000 multifamily housing properties, 6,700 homeless shelters, and approximately 7,500 public housing properties across the country to respond to and stop the spread of COVID-19.

5/6/2021 - HRSA eNews 5/6/21. READ MORE 
May 3 – The US Department of Health and Human Services, through the Health Resources and Services Administration (HRSA) is announcing a new program covering costs of administering COVID-19 vaccines to patients enrolled in health plans that either do not cover vaccination fees or cover them with patient cost-sharing. Since providers cannot bill patients for COVID-19 vaccination fees, this new program, the COVID-19 Coverage Assistance Fund (CAF), addresses an outstanding compensation need for providers on the front lines vaccinating underinsured patients.

“After securing enough COVID-19 vaccines for all adults, the Biden-Harris Administration is elevating work to boost access to them,” said HHS Secretary Becerra. “We listened to our healthcare providers on the frontlines of the pandemic. On top of increasing reimbursement rates tied to administering the shots, we are closing the final payment gap that resulted as vaccines were administered to underinsured individuals. No healthcare provider should hesitate to deliver these critical vaccines to patients over reimbursement cost concerns."

>>>Click here to read past updates

UPDATE - Humana Claims Payment Policy - COVID-19 Related Coding Revised 04/2021. READ MORE 

>>>Click here to read past updates

As we continue to monitor the status of COVID-19 cases and review procedure data in Michigan, Humana is implementing changes to authorization requirements. READ MORE 
Humana is reinstating authorization requirements for Medicare Advantage and commercial lines of business for skilled nursing facilities (SNFs) for dates of service on or after May 15, 2021.

a. This return to our standard authorization policy applies to participating/in-network and nonparticipating/out-of-network providers.

b. You will need to submit supporting documentation for your authorization and can expect responses to be provided in normal processing timeframes. Please plan accordingly.

Provider Alert - Repricing Hospital Outpatient Claims Billed with COVID-19 Diagnosis and Procedure Codes. READ MORE 
This notice informs hospitals that certain outpatient claims containing COVID-19-related coding will be reprocessed. The information below applies specifically to traditional Medicaid fee-for-service claims; however, for managed care claims, the managed care plans will also identify any claims impacted by these changes and automatically reprocess them. Hospitals do not need to take any action on these claims.

UPDATE - Independence Blue Cross is waiving all cost-sharing for the administration of the COVID-19 vaccine to commercial group and individual members. For Medicare Advantage members, the cost of the COVID-19 vaccine and its administration will be covered by Medicare. READ MORE

UPDATE - New Telehealth Code Added to EWC for FQHC/RHC Providers. READ MORE
Effective retroactively for dates of service on or after March 4, 2020, the Every Woman Counts Program (EWC) has added HCPCS code G0071 as a benefit to align with the Medi-Cal Payment for Telehealth and Virtual/Telephonic Communications Relative to the 2019-Novel Coronavirus (COVID 19) guidelines.

An Erroneous Payment Correction (EPC) will be implemented to reprocess denied claims with dates of service on or after the effective date of this billing policy, that were appropriately submitted based on the guidance published in this article, but erroneously denied because Medi-Cal had not yet implemented the system changes to support appropriate adjudication. Providers may also elect to use this updated billing policy to correct and resubmit previously denied claims as described in the CIF Submission and Timeliness Instructions section of the Provider Manual. EWC services rendered using telehealth modalities and the above HCPCS code should be billed with an appropriate ICD-10-CM code(s) listed in tables 1a, 1b, 2a and 2b in the Every Woman Counts section of the Provider Manual.

6/7/2021 - Broadband Benefit for Medi-Cal Beneficiaries. READ MORE 
The Department of Health Care Services (DHCS) has identified a potential funding opportunity for Medi-Cal recipients seeking to use telehealth services as the COVID-19 pandemic continues. Providers are encouraged to inform Medi-Cal recipients of this opportunity as soon as possible to ensure that they can benefit from the limited offering.

All Medi-Cal recipients are eligible for the Emergency Broadband Benefit (EBB) program which provides up to $50 of assistance a month to help cover the cost of internet access. The monthly discounted internet service will be available until EBB funds are used up, or up to six months after the end of the COVID-19 pandemic, whichever is sooner.

5/24/2021 - Effective Date Correction to Previous EPC Letter of Retroactive Rate Adjustment for COVID-19 Diagnosis Claims. READ MORE 
An Erroneous Payment Correction (EPC) letter entitled, Retroactive Rate adjustment for COVID-19 Diagnosis Claims(Reference Number P42709), was mailed to select providers on May 15, 2021. Providers who received the letter were informed that retroactive provider reimbursement rates for HCPCS codes U0003 and U0004 would be implemented for dates of service on or after March 25, 2021. This effective date, March 25, 2021, is incorrect. The correct effective date is January 1, 2021. Providers affected will receive a corrected letter prior to the implementation of the EPC. All other instruction and information within the EPC letter are correct.

5/18/2021 - Temporary Increased COVID-19 DME Oxygen and Respiratory Rates. READ MORE 
Effective for dates of service on or after March 1, 2020 and updated effective January 1, 2021, Durable Medical Equipment (DME) Oxygen and Respiratory rates are temporarily increased due to the ongoing coronavirus disease 2019 (COVID-19) Public Health Emergency (PHE).

5/14/2021 - COVID-19 Uninsured Group User Guide Now Available. A step-by-step user guide for the Coronavirus (COVID-19) Uninsured Group Web Application Web Portal is now available on the Medi-Cal Provider website. READ MORE 

On March 18, 2020, House Resolution 6201 (Families First Coronavirus Response Act, Section 6004) authorized State Medicaid Programs to provide access to COVID-19 diagnostic testing and testing-related services at no cost to the individual.

This program will be available to individuals with no insurance; who currently have private insurance that does not cover COVID-19 diagnostic testing, testing-related services, and treatment services; who do not qualify for any Medi-Cal programs (with the exception of individuals who have not met a Medi-Cal Share of Cost obligation); and who are a California resident.

5/12/2021 - New Age Restriction for Pfizer-BioNTech COVID-19 Vaccine. 
READ MORE 
The Food and Drug Administration (FDA) approved an amended Emergency Use Authorization (EUA) from Pfizer-BioNTech, to allow their COVID-19 vaccine to be administrated to individuals 12 years of age or older. Effective for dates of service on or after May 10, 2021, Medi-Cal will accept and adjudicate claims for either dose of the Pfizer-BioNTech vaccine, that are administered to any individual 12 years of age or older. The Pfizer-BioNTech COVID-19 Vaccine web page is updated to reflect this change. All other billing policy remains unchanged.

5/5/2021 - New NDC for Moderna COVID-19 Vaccine. READ MORE 
Moderna has introduced a new National Drug Code (NDC), 80777027315, for their coronavirus disease 2019 (COVID-19) vaccine. Medi-Cal will accept and adjudicate pharmacy claims for dates of service on or after April 1, 2021, that use this NDC when billing for the administration of either dose of the Moderna COVID-19 vaccine. The Moderna COVID-19 Vaccine web page is updated to reflect this change. All other billing policy, regardless of NDC billed, remains unchanged.

>>>Click here to read past updates

UPDATE - Effective Nov. 18, 2020, Medical Mutual temporarily suspended skilled nursing facility (SNF) prior authorizations for all hospitals. This prior authorization suspension ends on Apr. 2, 2021. READ MORE 

>>>Click here to read past updates

The Michigan Department of Health and Human Services (MDHHS) has suspended the ability to scan paper claims received by U.S. postal mail. Providers can submit HIPAA 837P,837I or 837D electronic claims. If you currently do not have the ability to send electronic claims, please contact your Quadax Account Executive. READ MORE

MLO Medical Laboratory Observer

UPDATE - MLO Infectious Disease News 7/27/2020. READ MORE

7/10/2020 - Disease/Infectious Disease - WHO:  Aggressive Action Needed to Turn COVID-19 Around. READ MORE

UPDATE - Effective 1/1/2021, only submitters of U0003 or U0004 that also include code U0005 will earn the higher payment of $100 per test. Submitters unable to support the additional code of U0005 high throughput tests will receive a lesser CMS payment of $75 per test. READ MORE

>>>Click here to read past updates

UPDATE - NGS Medicare Production Alerts. READ MORE 

• Resolved 5/14/2021 - CLIA Waived Tests CPTs 87635 and U0002 with Modifier QW - CARC B7 Denials.
• Issue - An update in the April 2021 release is creating claim denials for CPTs 87635 and U0002 when billed with the QW modifier.
• Claim Coding Impact - Incorrect denials for current procedural terminology (CPT) codes 87635 and U0002.
• Reason Code is CARC B7.
• Provider Type(s) Impacted - Jurisdiction K and Jurisdiction 6 Part B providers.
• NGS Action - The CWF will be updating editing to allow these codes with Modifier QW, with the CLIA cert type 2 or 4. When CWF completes the update to allow these claims to process correctly, NGS will perform a mass adjustment to allow previously denied claims. Adjustments were completed on 5/14/2021.
• Provider Action - No provider action is needed.
• Proposed Resolution/Fix - Adjustments were completed on 5/14/2021.
• Status - Closed Date Reported - 4/23/2021.

>>>Click here to read past updates

UPDATE - NOTE Practitioner and Ordered Ambulatory claims submitted prior to June 1, 2021 for dates of service on or after April 1, 2021 that were paid at $13.23 will be automatically reprocessed at the new $40.00 administration fee. Providers do not need to submit claim adjustments.

NOTE: Pharmacy claims for dates of service on or after April 1, 2021 that were submitted prior to June 1, 2021 and were paid $13.23 will be automatically reprocessed by eMedNY and will pay the $40.00 administration fee. Providers do not need to submit claim adjustments. READ MORE 

>>>Click here to read past updates

UPDATE - Noridian Update: Addition of the Shared System CWF to the Business Requirements for the HCPCS Codes U0002QW and 87635QW Mentioned in Change Request 11765. READ MORE

MLN Matters Number: MM12294
Related CR Release Date: May 20, 2021
Related CR Transmittal Number: R10798OTN
Related Change Request (CR) Number: 12294
Effective Date: March 20, 2020
Implementation Date: July 6, 2021 - (fast tracked-May 10, 2021)

CR 12294 tells you about a revision to CR 11765 This link will take you to an external website. that requires changes to Medicare’s Common Working File (CWF) for Healthcare Common Procedure Coding System (HCPCS) codes U0002QW and 87635QW. All other information in CR 11765 is unchanged and there shouldn’t be any impact on you. 

5/11/2021 - Noridian Alert. Denials for U0002QW and 87635QW. READ MORE 
Provider/Supplier Type(s) Impacted: Clinical Laboratory Improvement Amendment (CLIA) waived laboratory providers.

Reason Codes: Not applicable

Claim Coding Impact: U0002QW and 87635QW

Description of Issue: An issue was identified for claims billed with HCPCS Codes U0002QW or 87635QW for dates of service on/after 03/20/20. Claims processed on/after 05/05/20 may be receiving incorrect denials stating the provider was not certified/eligible to be paid for this procedure/service. The remark codes that will appear on the remit are CO-B7 and N570.

Noridian Action Required: Noridian will adjust any claims that are impacted and will provide updates as they are available.

Provider/Supplier Action Required: No provider action is needed.

Proposed Resolution/Solution: The Common Working File (CWF) is implementing a correction to its programming, effective 05/10/21, to allow the QW modifier to be billed with HCPCS Codes U0002 and 87635. Noridian will identify and adjust any claims that may have denied incorrectly stating the provider was not eligible to perform the service. No action is needed from the provider.

Date Reported: 05/11/21

>>>Click here to read past updates

UPDATE - Important Updates to the COVID-19 Vaccine and Monoclonal Antibody (mAb) Infusions. READ MORE
Effective with claims received on and after June 8, 2021, a new add-on payment code M0201 (COVID-19 vaccine home administration code) has been developed and can be added to COVID-19 vaccine administration codes: 0001A, 0002A, 0011A, 0012A, and 0031A.

New mAb infusion codes M0247 (Intravenous infusion, sotrovimab, includes infusion and post administration monitoring) M0248 (Sotrovimab infusion home administration and Q0247 (Injection, sotrovimab, 500 mg) have been developed effective with dates of service on and after May 26, 2021. Refer to the reimbursement articles below for the updated rates. Additionally, an update has been made to the diagnosis reporting for the mAb infusion therapy administration.

Travel Allowance for Collection of Specimens. READ MORE 
Medicare pays a specimen collection fee when it is medically necessary for a clinical laboratory technician to draw a specimen for a clinical diagnostic laboratory test. In addition, when a technician travels to a nursing facility or homebound patient and a specimen collection fee is payable. Medicare provides for payment of a travel allowance “to cover the transportation and personnel expenses for trained personnel to travel to the location of an individual to collect the sample.” The place of service for travel allowance should be reported based on the location of the patient encounter. Prior Office of Inspector General (OIG) work found that travel allowances have the potential to be overpaid when some clinical laboratories claimed travel mileage in excess of the actual miles traveled. Please our review proper billing article.

5/10/2021 - Novitas Claim Issues for Part B. CLIA waived codes 87635 & U0002. Reported 5/10/2021. READ MORE 
Issue - Effective with dates of service on and after March 2, 2020 CMS added the QW modifier (CLIA waived laboratory tests) to procedure codes 87635 and U0002. However, the Common Working File wasn’t updated to accommodate this request. A recent update has been made to the system.

Providers Impacted - JH/JL Providers

Workload Impacted - Clinical Laboratory Services

Proposed Resolution/Fix/Action Required - Claims impacted will be reprocessed for dates of service on and after March 2, 2020 that were denied when the QW modifier was reported on 87635 and U0005.

Status - Open

>>>Click here to read past updates

Ohio Governor Mike DeWine announced the Ohio Bureau of Workers' Compensation (BWC) is deferring the due date for employers to pay their June, July, and August premium installments until Sept.1. READ MORE

UPDATE - ANTIGEN TESTING UPDATE. Governor DeWine discussed the Ohio Department of Health aligning with the Center of Disease Control and Prevention’s (CDC) current case definition. READ MORE 

>>>Click here to read past updates

UPDATE - Governor Mike DeWine signed Executive Order 2020-38D, which authorizes the Ohio Department of Medicaid to temporarily and substantially increase hospital-specific cost coverage add-ons, or CCAs. READ MORE 
Citing hardships hospitals have faced during the COVID-19 public health emergency and recognizing the need to mitigate the imbalance between managed care capitation rates and hospital rates in the executive order, ODM will increase hospital-specific CCAs to prospectively address CCA shortfalls. This temporary rate increase is equal to $145.1 million.

UPDATE - Ohio Governor Mike DeWine today announced that Ohio Department of Health Director Stephanie McCloud signed the following orders regarding COVID-19 testing frequency of residents and staff at assisted living facilities and nursing homes and opening of Senior Centers and Older Adult Day Services Centers.  
READ MORE

>>>Click here to read past updates

NEW - COVID-19 Updates. Here are some of the steps we have taken to help providers and members. READ MORE 

- We are waiving the cost of diagnostic COVID-19 tests, related respiratory labs, and any visits associated with that test for both in-network and out-of-network facilities. Diagnostic testing included PCR and antigen tests used to inform patient treatment for COVID-19 or related complications, including serology testing for multi systemic inflammatory syndrome in children. Most non-diagnostic tests, including serology testing, testing for return to work, and public health surveillance testing, are not covered.

- We are waiving the cost of treatment related to COVID-19 delivered by in-network providers through at least September 30, 2020 for those testing positive. Prior authorization is required for all out-of-network care, including COVID-19 treatment, except for emergency care and COVID-19 testing (see above).

- We have expanded our telemedicine coverage policies in many states, including waiving the cost of any medically necessary care (related and unrelated to COVID-19, depending on the state) COVID-19 care delivered through telemedicine for our providers.

- We are supporting members with resources such as a risk assessment survey, testing site locator and answers to their most common questions at hioscar.com/covid19.

>>>Click here to read past updates

UPDATE - Retroactive to March 1, 2020, for those impacted by COVID-19, Medicare Fee-For-Service operations will implement the following policies and procedures for all claims, not just for the COVID-19 diagnoses: Additional Documentation Requests that have already been issued, Medicare contractors will release the claims for payment and not issue claim denials. Any claims auto-denied for non-response of an ADR from March 1, 2020, until March 26, 2020, will have the denial reversed and allow payment if an appeal has not been filed. If an appeal has been filed, normal appeals processes will be followed. As of March 26, 2020, future ADRs will not be sent until further notice from CMS. READ MORE

UPDATE - Claim Payment Issues Log. Resolved - Telehealth Procedure Codes and Skilled Nursing Facility Consolidated Billing edits. Issue - During the COVID-19 Public Health Emergency CPT codes 99441, 99442 and 99443, are not excluded from File 1 (Part A Stay – Physician Services) on the Skilled Nursing Facility Consolidated Billing (SNF CB) Part B file. As these three codes have now been added to the list of covered codes under the telehealth waiver during the COVID-19 PHE, they would also qualify for SNF CB exclusion and, thus, would be separately billable under Part B when furnished to a SNF’s Part A resident.  Status 7/29/20 -  Part B Medicare Administrative Contractors (MACs) will reprocess claims for CPT codes 99441, 99442 and 99443, with dates of service on or after March 1, 2020, until notified that changes made for the PHE are to be discontinued.  If you have already received payment from the SNF for these services, that payment should be returned to the SNF once your claims have been reprocessed. Status 9/10/20 - Resolved: Adjustments have been completed. READ MORE                        

3/20/2020 Temporary Provisional Medicare Billing Privileges - Allows physicians and non-physician practitioners to initiate temporary provisional Medicare billing privileges via telephone and address questions regarding provider enrollment flexibilities afforded by the COVID-19 waiver. READ MORE

UPDATE - How long does a Public Health Emergency (PHE) declaration last?
READ MORE 
Answer - A PHE declaration lasts until the Secretary of Health and Human Services declares that the PHE no longer exists or upon the expiration of the 90-day period beginning on the date the Secretary declared a PHE exists, whichever occurs first. The Secretary may extend the PHE declaration for subsequent 90-day periods for as long as the PHE continues to exist and may terminate the declaration whenever the Secretary determines that the PHE has ceased to exist. The declaration was most recently extended on April 15, 2021.

Palmetto GBA provides directions received from CMS on the Palmetto GBA website and through email update messaging. More questions and answers regarding the PHE are available on the U.S. Department of Health and Human Services Public Health Emergency Declaration Q&A webpage.

5/12/2021 - Palmetto GBA Claims Payment Issus Log. CLIA Waived Modifier.
READ MORE 

Issue Description - On March 20, 2020, CMS added the "QW" HCPCS modifier (CLIA waived lab test) as applicable to the HCPCS code U0002 and CPT code 87635. An issue has been identified indicating these laboratory services are denying incorrectly when the "QW" HCPCS modifier was appended. On May 10, 2021, CMS implemented a system fix to address this issue. CMS has instructed Medicare Administrative Contractors to reprocess and adjust affected claims incorrectly denied with dates of service on or after March 20, 2020.

Provider Action - No provider action is needed.

Status - Issue identified.

Date Reported - 05/06/2021

>>>Click here to read past updates

UPDATE - To support people and communities facing unprecedented challenges, Regence health plans announced an extension of coverage for coronavirus (COVID-19) treatment without any out-of-pocket costs for fully insured members through December 31, 2020. This extends the previously announced coverage period through June 30, 2020.
READ MORE

3/24/2020 - Claims can be submitted with CPT 87635 for DOS on and after 3/1/2020. READ MORE 

UPDATE - COVID-19 Vaccines - With the emergency use authorization and distribution of the COVID-19 vaccine, our members will likely be looking to you, their health care provider, for direction. Updates and changes are happening quickly, and Select Health is closely monitoring guidance from local and federal officials to learn the most up-to-date information. READ MORE 

COVID-19 testing - First Choice will cover all medically necessary services required to facilitate testing and treatment of COVID-19 for its eligible members, in accordance with federal and state guidance. No prior authorization is required for COVID-19 testing. READ MORE

4/26/2021 - First Choice by Select Health of South Carolina has been closely monitoring the Centers for Disease Control and Prevention (CDC) for the latest information about the coronavirus (COVID-19), and has been engaged in making the necessary plans based on guidance from the CDC. First Choice recommends that providers follow CDC, Centers for Medicare & Medicaid Services, and state-specific guidance with regard to COVID-19 evaluation, testing, diagnosis, treatment, and reporting. READ MORE 

Select Health of South Carolina covers telehealth visits for our members in accordance with state and federal policy. Similar to Medicare, many states are adopting expanded or interim policies related to the originating site, payment for telephonic visits, and expanded licensure. READ MORE 

Use of certified out-of-network and/or out-of-state providers will be allowed for medically necessary services. READ MORE 
For more resources and guidance, please access the CDC COVID-19 homepage or South Carolina's Department of Environmental Control (SCDHEC).

>>>Click here to read past updates

UPDATE - SCDHHS’ COVID-19 website also includes additional resources for providers including previously released fee schedules for telehealth services, information about federal resources and policy changes, and guidance the agency has issued in preparation and response to the COVID-19 pandemic. READ MORE 
Providers should continue to submit questions and feedback regarding COVID-19 to COVID@scdhhs.gov. Thank you for your continued support of the South Carolina Healthy Connections Medicaid program. SCDHHS looks forward to continuing its partnership with health care providers and all those involved in the health care delivery system to maintain access to the high-value, evidence-based services that are available to Healthy Connections Medicaid members during this unprecedented public health emergency.

>>>Click here to read past updates

UPDATE - Coverage of telehealth services extended through July 26, 2020. Also allowing early refills of prescriptions through July 26, 2020. SummaCare is temporarily suspending a 2% sequestration reduction in claims reimbursements to providers in fee-for-service arrangements in Medicare Advantage plans. The suspension aligns with the CARES Act legislation requiring all health plans to suspend the -2% sequestration payment adjustment in claims with dates of service from May 1, 2020 through December 31, 2020. READ MORE

>>>Click here to read past updates

UPDATE - June 16th NF COVID-19 Webinar with HHSC, LTCR and DSHS. READ MORE 
NF Provider Webinar
June 16, 2021
2:30 – 4 p.m.

Nursing facility providers are strongly encouraged to attend this and all weekly COVID-19 webinars with HHSC Long-term Care Regulation and the Department of State Health Services. LTCR and DSHS will provide the latest information on the COVID-19 pandemic and take live questions from participants. Provider attendance is critical to staying current with COVID-19 requirements and guidance.

June 7th ICF COVID-19 Webinar Rescheduled to June 14th. If you have already registered for the June 7 webinar you do not need to register again. READ MORE 

6/1/2021 - New COVID-19 Vaccine Authority Emergency Rule for Home Health and Hospice Providers. READ MORE 
HHSC Long-term Care Regulation has published Vaccine Authority for Home Health and Hospice Agencies (PDF). The emergency rule allows HCSSA providers to purchase, store, and transport the COVID-19 vaccine for the purposes of vaccinating clients and staff.

6/1/2021 - COVID-19: Provider Enrollment Revalidation Due Dates Extended.
READ MORE 
As directed by the Texas Health and Human Services Commission (HHSC) , Blue Cross and Blue Shield of Texas (BCBSTX) Medicaid will extend provider revalidation due dates through June 30, 2021 to prevent provider disenrollment/disruption. Providers can view the revalidation status on the Provider Information Management System (PIMS).

The following revalidation due dates have been extended:
Original due date March 2020
Extended due date June 30, 2021

What actions are required by providers?
Per HHSC, providers should submit revalidation applications before the deadline to avoid disenrollment. As a reminder, providers can submit their revalidation application up to 90 days before the due date.

6/1/2021 - COVID-19: Claims for Telephone Medical Services (Audio Only).
READ MORE 
In continued response to COVID-19, the Children with Special Health Care Needs (CSHCN) Services Program is extending the authorization of the below procedure codes through June 30, 2021. We are authorizing providers to bill the following procedure codes for medical evaluation and management services delivered by a physician by telephone
(audio only):

Description of Services Procedure Codes

Evaluation and Management (E/M) 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215

When is this effective?
Providers can bill the above procedure codes for telephone (audio only) medical (physician delivered) evaluation and management services delivered March 20, 2020 through June 30, 2021 (previously May 31, 2021).

Note: End date is subject to change. We are continuing to evaluate the evolving state and federal legislative and regulatory landscape relating to COVID-19 and will continue to update our practices accordingly.

The telephone call is considered part of the next office visit and cannot be submitted using the e/m codes if:
• The call is less than 24 hours after an in-person or telemedicine (video) visit
• The call follows the next available appointment

The telephone call is considered part of the previous office visit and cannot be billed separately if:
• The call is less than seven days after an office visit for the same diagnosis

Should a modifier be billed?
Yes, providers should use the 95 modifier and place of service (POS) 02 to indicate the occurrence of remote delivery when delivering service.

5/28/2021 - Multiple Medicaid COVID-19 Flexibilities Extended Through June 30th, 2021. READ MORE 
The following Medicaid and Children’s Health Insurance Plan (CHIP) COVID-19 flexibilities have been extended through June 30, 2021:

“Correction to ‘COVID-19 Guidance: Targeted Case Management Through Remote Delivery’”
“Waiver Extension for DME Certification and Receipt Form”
“Claims for Telephone (Audio-Only) Behavioral Health Services”
“Claims for Telephone (Audio-Only) Medical Services”
“RHC Reimbursement for Telemedicine and Telehealth Services”
“SHARS Services Provided Through Telemedicine or Telehealth”
“Claims for Telehealth Service for Occupational, Physical, and Speech Therapy”
“Claims for Telephone (Audio-Only) Early Childhood Intervention Specialized Skills Training”
“Claims for Telephone (Audio-Only) Nutritional Counseling Services”
“Texas Health Steps Checkup Guidance Extended Through July 31, 2020”

5/28/2021 - COVID-19 Guidance for New and Initial CSHCN Prior Authorizations. This is an update to the article titled, “Guidance for Providers regarding New and Initial Prior Authorizations,” which was published July 2, 2020, on this website.
READ MORE 

To help ensure continuity of care during the COVID-19 (coronavirus) response, the Texas Health and Human Services Commission has directed TMHP to move forward with processing new and initial prior authorization requests, including recertification requests, by relaxing document submission timeframes for providers that are unable to provide certain required documentation during the COVID-19 emergency. This direction will remain in effect through June 30, 2021. This guidance applies to all Children with Special Health Care Needs (CSHCN) Services Program services requiring prior authorization.

5/272021 - Telemedicine and Telehealth Extended Through June 30th, 2021. This is an update to the article titled “Telemedicine (Physician Delivered) and Telehealth (Non-Physician Delivered) Extended Through May 31, 2021,” which was posted on this website on April 30, 2021. READ MORE 

5/20/2021 - What You Need to Know About COVID-19 Vaccine Protocols. READ MORE
The Pfizer COVID-19 vaccine has received emergency use authorization for children ages 12 and older. By fall, COVID-19 vaccines may be approved for younger children. The CDC recommends the COVID-19 vaccine for everyone ages 12 and older. In updated clinical guidance the CDC says that other vaccines may be given with the COVID-19 vaccine. It’s no longer necessary to wait 14 days between the COVID-19 vaccine and other vaccines as a precaution. The American Academy of Pediatrics also supports this guidance.

5/4/2021 - COVID-19: Provider Enrollment Revalidation Due Dates Extended.
READ MORE 
As directed by the Texas Health and Human Services Commission (HHSC) , Blue Cross and Blue Shield of Texas (BCBSTX) Medicaid will extend provider revalidation due dates through May 31, 2021 to prevent provider disenrollment/disruption. Providers can view the revalidation status on the Provider Information Management System (PIMS).

5/3/2021 - COVID-19: Claims for Telephone Medical Services (Audio Only)
READ MORE 
In continued response to COVID-19, the Children with Special Health Care Needs (CSHCN) Services Program is extending the authorization of the below procedure codes through May 31, 2021. We are authorizing providers to bill the following procedure codes for medical evaluation and management services delivered by a physician by telephone (audio only):
Description of Services Procedure Codes -
Evaluation and Management (E/M) 99201, 99202, 99203, 99204, 99205, 99211, 99212,
99213, 99214, 99215

5/3/2021 - COVID-19: Rural Health Clinics (RHC) and Telehealth/Telemedicine. READ MORE

• What is changing? Effective December 14, 2020, per the Texas Health and Human Services Commission (HHSC) , we are amending the end date in continued response to COVID-19. The RHC telehealth and telemedicine reimbursement is extended through May 31, 2021. We are continuing to evaluate the evolving state and federal legislative and regulatory landscape relating to COVID-19 and will continue to update our practices accordingly.
• Will RHCs be reimbursed for telehealth/telemedicine? Yes, per the Health and Human Services Commission Blue Cross and Blue Shield of Texas (BCBSTX) Medicaid will reimburse RHCs as telemedicine and telehealth distant site providers statewide for service dates from March 20, 2020 through May 31, 2021.
• How should RHCs bill for reimbursement? RHCs should submit claims using current RHC procedure codes T1015 and 99381.
• Should a modifier be billed? Yes, providers should use the 95 modifier with place of service 02 to indicate the occurrence of remote delivery when delivering service.

5/3/2021 - COVID-19: THSteps Remote Delivery of Medical Checkups. READ MORE

• What is changing? Per the Texas Health Steps (THSteps) and Texas Health and Human ServicesCommission (HHSC) , we are extending the end date for remote delivery of medical checkups for THSteps through May 31, 2021. During this time, telemedicine and telephone delivery for certain components of THSteps checkup are allowed. This applies only to children over 24 months of age. Providers must use their own judgment to determine which checkup component(s) are appropriate for telemedicine or telephone delivery.

5/3/2021 - COVID-19: Office Visit Co-Payments Reimbursement Process for Children's Health Insurance Program (CHIP). READ MORE

• What is new? Per the Texas Health and Human Services Commission , we are extending the end date for waiving medical office visit co-payments for all CHIP members for services provided from March 13, 2020, through May 31, 2021.

5/3/2021 - Durable Medical Equipment (DME) Client Signature Waived During COVID-19. READ MORE 
The Texas Health and Human Services Commission (HHSC) is extending the signature requirement waiver for the DME Certification and Receipt Form through May 31, 2021.

5/4/2021 - DSHS Urges Providers to Order More COVID-19 Vaccine as Needed.
READ MORE 

>>>Click here to read past updates

UPDATE - Telemedicine: TRICARE covers the use of interactive audio/video technology to provide clinical consultations and office visits when appropriate and medically necessary. READ MORE 
These services are subject to the same referral and authorization requirements and include, but are not limited to:

• Clinical consultation
• Office visits
• Telemental health (individual psychotherapy, psychiatric diagnostic interview examination and medication management)

>>>Click here to read past updates

UPDATE - The COVID-19 vaccine is covered in accordance with Centers for Disease Control and Prevention (CDC) recommendations. READ MORE 
TRICARE currently covers the following COVID-19 vaccines: effective May 14, 2021, for ages 12 through 15.TRICARE-covered vaccines are available at no cost to the beneficiary. An approval from Health Net Federal Services, LLC is not required.

>>>Click here to read past updates

UPDATE - UnitedHealthcare will cover medically appropriate COVID-19 testing during the national public health emergency period (currently scheduled to end July 19, 2021), at no cost share, when ordered by a physician or appropriately licensed health care professional for purposes of the diagnosis or treatment of an individual member.* READ MORE 

UnitedHealthcare will cover testing for employment, education, public health or surveillance purposes when required by applicable law. Benefits will be adjudicated in accordance with a member’s benefit plan; health benefit plans generally do not cover testing for surveillance or public health purposes. We continue to monitor regulatory developments during emergency periods.

** Tests must be FDA authorized to be covered without cost sharing (copayment, coinsurance or deductible). FDA-authorized tests include tests approved for patient use through pre-market approval or emergency use pathways, and tests that are developed and administered in accordance with FDA specifications or through state regulatory approval. This coverage applies to members enrolled in Medicare Advantage, Medicaid and Individual and Group Market health plans. Please do not collect upfront payment from the member. Benefits will be otherwise adjudicated in accordance with the member’s health plan. We will reimburse COVID-19 testing in accordance with applicable law, including the CARES Act and UnitedHealthcare’s reimbursement requirements. State variations and regulations may apply during this time.
** UnitedHealthcare is requesting all physicians and health care professionals who perform and bill for COVID-19 antibody tests to register the test(s) that will be used for our members.
** Licensure requirements vary by state. In some states, a pharmacist or other health care professional, such as a nurse practitioner, may have the appropriate licensure to order a test. Please refer to state-specific licensure requirements for appropriate guidance.
** UnitedHealthcare will reimburse appropriate claims for telehealth services in accordance with the member’s benefit plan. For certain markets and plans, UnitedHealthcare is continuing its expansion of telehealth access, including temporarily waiving the Centers for Medicare & Medicaid Services (CMS) originating site requirements. Additional telehealth information may vary by network plan, so please review each section carefully for details.

5/14/2021 - COVID-19 Vaccine Administration in Urgent Care Facilities. READ MORE 
Effective April 15, 2021, UnitedHealthcare will reimburse the appropriate COVID-19 vaccine administration codes listed below for in-network urgent care facilities that are contracted on an all-inclusive Per Case, Per Diem, Per Visit, Per Unit, etc. contract rate.

We will pay 100% of the CMS allowable rate for the following COVID-19 codes and new codes approved by the AMA CPT:

• 00001A
• 00002A
• 0011A
• 0012A
• 0021A
• 0022A
• 0031A

Note:
^^ This is applicable for Individual and Group Market health plans only.
^^ If a health care professional bills a case rate on the same date of service as COVID-19 vaccine administration code for the same patient, UnitedHealthcare will deny the vaccine administration code
^^ We will not adjust rates for payment on claims submitted before the April 15, 2021, date of service.

>>>Click here to read past updates

UPDATE - Physical Health Providers/COVID-19 Resources - Apple Health Medicaid Clinical Policy and Billing Facts for COVID-19 (updated 9/23/20) READ MORE

The Health Care Authority revised the Facts sheet and the following changes were made:

• Clarified billing requirements for providers who usually receive an enhanced rate for services
• Added billing for services provided via email to HCPCS code G2012
• Expanded the services allowed to be billed with GE modifier to include CPT® codes 99421-23, 99441-43, and HCPCS code G2012
  
• Added CPT code 86413 SARS-CoV2/COVID-19 antibody, quantitative to the list
• Ended coverage of CPT code 99001 for drive up/drive through COVID-19 specimen collection, effective 10/15/2020. Added HCPCS codes G2023, G2024, and C9803 to align with Medicare when billing for specimen collection.
  
• Added information that aligns with CMS guidance regarding payment for counseling patients at the time of the COVID-19 testing.

>>>Click here to read past updates

UPDATE - We intend to cover COVID-19 testing and screening services for Medicare members and are waiving all associated member cost share amounts for COVID-19 testing and screening. READ MORE 
To ensure that our members receive the care they need as quickly as possible, WellCare will not require prior authorization, prior certification, prior notification or step therapy protocols for these services. Waiving cost-sharing for COVID-19 treatments in doctor’s offices or emergency rooms and services delivered via telehealth. Waiving prescription refill limits. Relaxing restrictions on home or mail delivery of prescription drugs. Expanding access to certain telehealth services.

>>>Click here to read past updates

UPDATE - Wellmark BCBS will cover COVID-19 vaccinations with no member cost-sharing payments, deeming it a preventive service under the ACA. READ MORE 

3/19/2020 - Wellmark will be waiving copays, coinsurance and deductibles for virtual visits with dates of service from March 16 to June 16, 2020. Wellmark will pay the allowed amount for telehealth services in full. Services that are not a covered benefit, not medically necessary, experimental or investigational are excluded from the member’s copay or other cost-shares that are being waived. This is only applicable to in-network providers. More information on testing and which codes to use for testing to come. READ MORE

UPDATE - Due to COVID-19 impacts, WPS reports they are suspending Provider Enrollment revalidations at this time. They will not deactivate billing privileges and will notify Providers who were set to revalidate when they can do so. READ MORE

UPDATE - COVID-19 News 6/1/21. 2021 Annual Direct Data Entry (DDE) Recertification. Jurisdictions: J8A, J5A. Due to the COVID-19 Pandemic, the 2021 DDE Recertification is delayed until further notice. READ MORE 

In the interim, in order to better assist WPS with determining which Authorized Signer should receive the 2021 DDE Recertification for their PTAN(s) please take the following actions: 
^ If there is more than one Authorized Signer that has a DDE Submitter ID for the PTAN(s)

** Meet with all Authorized Signers and determine which Authorized Signer should receive the 2021 Annual DDE Recertification email for the PTAN(s).
** Contact the DDE Department by phone (866) 518-3295 or email medicare.dde.analysts@wpsic.com.

^ If an Authorized Signer is no longer employed with the PTAN(s)

** Contact the DDE Department at (866) 518-3295 or email medicare.dde.analysts@wpsic.com so that the DDE Submitter ID Record will be deactivated.

^ If there are PTAN(s) in which a Change of Ownership took place over 12 months from the current date

** It is the Authorized Signer (DDE Submitter) responsibility to submit the DDE Submitter ID Request Form with the request type “Remove PTANs”
** The DDE Submitter ID Record will be updated.

^ To add a PTAN to the Authorized Signer DDE Submitter ID

** Confirm there is a DDE EDI Form on file for the PTAN.
** Contact the DDE Department at (866) 518-3295 or email at medicare.dde.analysts@wpsic.com.

Continue to check the website for any updates regarding the 2021 DDE Recertification.

5/24/2021 - June 2021 Local Coverage Determination (LCD) and Billing & Coding/Policy Article Updates. READ MORE 
Please note: Our LCDs and coverage articles will reflect these changes on May 27, 2021. Revised Policies/Articles include: Billing and Coding: MolDX: Multiplex Nucleic Acid Amplified Tests for Respiratory Viral Panels (MCD#/LCD/Article A57579) effective date 4/1/2021. 

This revision is due to the Q2 2021 CPT/HCPCS Code Update and is effective for dates of service on or after April 1, 2021.

5/11/2021 - MCS Claims Processing Alerts. READ MORE

• Description/Claims Coding Impact - Procedure codes U0002-QW and 87635-QW were being denied incorrectly when billed as CLIA waived tests.
• Proposed Resolution/Fix/Action Required - The system was updated on 5/10/2021. Adjustments will be completed on claims denied in error. Providers do not need to take any action.
• Status - Open
• Last Updated - 5/11/2021
• Provider Type Impacted - All
• Date Issue Reported - 4/21/2021

5/10/2021 - MCS Claims Processing Alerts. READ MORE 

• Description/Claims Coding Impact - COVID-19 vaccine, monoclonal antibody, and administration codes may have been denied or paid incorrectly when the beneficiary was covered by Hospice, a Medicare Advantage Plan, or during a SNF stay.
• Proposed Resolution/Fix/Action Required - The system has been updated. Adjustments will be completed for any claims processed incorrectly retroactive back to the effective date of the procedure code. Providers do not need to take any action.

>>>Click here to read past updates