Provider Resources

• COVID-19 Vaccine Talking Points for Providers (PDF)

Coronavirus disease 2019 (COVID-19) is an emerging illness.  Many details about this disease are still unknown, such as treatment options, how the virus works, and the total impact of the illness.  New information, obtained daily, will further inform the risk assessment, treatment options and next steps.  We always rely on our provider partners to ensure the health of our members, and we want you to be aware of the tools available to help you identify the virus and care for your patients during this time of heightened concern.

Guidance:

• Know the warning signs of COVID-19. Patients with COVID-19 have reported mild to severe respiratory symptoms. Symptoms include fever, cough, and shortness of breath. Other symptoms include fatigue, sputum production, and muscle aches.  Some individuals have also experienced gastrointestinal symptoms, such as diarrhea and nausea, prior to developing respiratory symptoms.  
• However, be aware that infected individuals can be contagious before symptoms arise. Symptoms may appear 2-14 days after exposure.
• Instruct symptomatic patients to wear a surgical or isolation mask and promptly place the patient in a private room with the door closed.
• Health care personnel encountering symptomatic patients should follow contact precautions, airborne with N95 precautions, and wear eye protection and other personal protective equipment.
• Refer to the CDC’s criteria for a patient under investigation for COVID-19.  Notify local and/or state health departments in the event of a patient under investigation for COVID-19.  Maintain a log of all health care personnel who provide care to a patient under investigation.
• Monitor and manage ill and exposed healthcare personnel.
• Safely triage and manage patients with respiratory illness, including COVID-19.  Explore alternatives to face-to-face triage and visits as possible, and manage mildly ill COVID-19 cases at home, if possible. 

Take Action:

• Be alert for patients who meet the criteria for persons under investigation and know how to coordinate laboratory testing.
• Review your infection prevention and control policies and CDC's recommendations  for healthcare facilities for COVID-19.
• Know how to report a potential COVID-19 case or exposure to facility infection control leads and public health officials.  Contact your local and/or state health department to notify necessary health officials in the event of a person under investigation for COVID-19.
• Refer to the Centers for Disease Control and Prevention (CDC) and the World Health Organization for the most up-to-date recommendations about COVID-19, including signs and symptoms, diagnostic testing, and treatment information.
• Be familiar with the intended scope of available testing and recommendations from the FDA.    

This guidance is in response to the current COVID-19 pandemic and may be retired at a future date

PROVIDER BILLING GUIDANCE FOR COVID-19 TESTING

We are closely monitoring and following all guidance from the Centers for Medicare and Medicaid as it is released to ensure we can quickly address and support the prevention, screening, and treatment of COVID-19. The following guidance can be used to bill for services related to COVID-19 testing, screening and treatment services. This guidance is in response to the current COVID-19 pandemic and may be retired at a future date. For additional information and guidance on COVID-19 billing and coding, please visit the resource centers of the Centers for Medicare and Medicaid (CMS) and the American Medical Association (AMA).  

COVID-19 Testing Services

• Providers performing the COVID-19 test can bill us for testing services that occurred after February 4, 2020, using the following newly created HCPCS codes:
  • HCPCS U0001 - For CDC developed tests only - 2019-nCoV Real-Time RT-PCR Diagnostic Panel.
  • HCPCS U0002 - For all other commercially available tests - 2019-nCoV Real-Time RT-PCR Diagnostic Panel.
  • CPT 87635 - Effective March 13, 2020 and issued as “the industry standard for reporting of novel coronavirus tests across the nation’s health care system.”
    Please note:  It is not yet clear if CMS will rescind the more general HCPCS Code U0002 for non-CDC laboratory tests that the Medicare claims processing system is scheduled to begin accepting starting April 1, 2020.
• These codes should not be used for serologic tests that detect COVID-19 antibodies.         
• All member cost share (copayment, coinsurance and/or deductible amounts) will be waived across all products for any claim billed with the new COVID-19 testing codes.
• We have configured our systems to apply $0 member cost share liability for those claims submitted utilizing these new COVID-19 testing codes.
• In addition to cost share, authorization requirements will be waived for any claim that is received with these specified codes.
• Providers billing with these codes will not be limited by provider type and can be both participating and non-participating.
• We will temporarily waive requirements that out-of-state Medicare and Medicaid providers be licensed in the state where they are providing services when they are licensed in another state.

High-Throughput Technology Testing Services

• Providers performing high production COVID-19 diagnostic testing via high-throughput technology can bill us for testing services that occurred after February 4, 2020, using the following newly created HCPCS codes:
  • HCPCS U0003 - Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique, making use of high throughput technologies as described by CMS-2020-01-R.
  • Please note: U0003 should identify tests that would otherwise be identified by CPT code 87635 but for being performed with these high throughput technologies.
  • HCPCS U0004 -2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC, making use of high throughput technologies as described by CMS-2020-01-R.
  • Please note: U0004 should identify tests that would otherwise be identified by U0002 but for being performed with these high throughput technologies.
• Neither U0003 nor U0004 should be used for tests that detect COVID-19 antibodies.
• We have configured our systems to apply $0 member cost share liability for those claims submitted utilizing these codes to indicate high production testing.
• Providers billing with these codes will not be limited by provider type and can be both participating and non-participating.

COVID-19 Specimen Transfers

• For specimen transfer related claims, the following codes can be used:
  • G2023 - Spec Clct for SARS-COV-2 COVID 19 ANY SPEC SRC
  • G2024 - SP CLCT SARS-COV2 COVID19 FRM SNF/LAB ANY SPEC
  • C9803 - Hospital outpatient clinic visit specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), any specimen source. This is effective for services provided on or after March 1, 2020.
• Providers billing with these codes will not be limited by provider type and can be both participating and non-participating.

COVID-19 Screening Services

• All member cost share (copayment, coinsurance and/or deductible amounts) will be waived for COVID-19 screening visits and if billed alongside a COVID-19 testing code.
• If no testing is performed, providers may still bill for COVID-19 screening visits for suspected contact using the following Z codes:
  • Z20.828 – Contact with a (suspected) exposure to other viral communicable diseases
  • Z03.818 – Exposure to COVID-19 and the virus is ruled out after evaluation
• This applies to services that occurred as of February 4, 2020.
• Providers billing with these codes will not be limited by provider type.

COVID-19 Treatment Services

• We will waive prior authorization requirements and member cost sharing for COVID-19 treatment for all members.
• For dates of service from February 4, 2020 through March 31, 2020 providers should use the ICD-10 diagnosis code:
  • B97.29 – Confirmed Cases – other coronavirus as the cause of diseases classified elsewhere
• For dates of service of April 1, 2020 and later, providers should use the ICD-10 diagnosis code:
  • U07.1 – 2019-nCov Confirmed by Lab Testing
• As a reminder, only those services associated with screening and/or treatment for COVID-19 will be eligible for prior authorization and member liability waivers.  For screening or treatment not related to COVID-19 normal copayment, coinsurance, and deductibles will apply.

Reimbursement Rates for COVID-19 Services for All Provider Types

• We are complying with the rates published by CMS for the following codes:
  • U0001 = $35.91
  • U0002 = $51.31
  • U0003 = $100.00
  • U0004 = $100.00
  • G2023 = $23.46
  • G2024 = $25.46
• Commercial products will reimburse COVID-19 services in accordance with our negotiated commercial contract rates.
• We will follow these CMS published rates except where state-specific Medicaid rate guidance should supersede.
• Any additional rates will be determined by further CMS and/or state-specific guidance and communicated when available.

In order to ensure that all of our members have needed access to care, we are increasing the scope and scale of our use of telehealth services for all products for the duration of the COVID-19 emergency.  These coverage expansions will benefit not only members who have contracted or been exposed to the novel coronavirus, but also those members who need to seek care unrelated to COVID-19 and wish to avoid clinical settings and other public spaces.

Effective immediately, the policies we are implementing include:

• Continuation of zero member liability (copays, cost sharing, etc.) for care delivered via telehealth*.
• Any services that can be delivered virtually will be eligible for telehealth coverage.
• All prior authorization requirements for telehealth services will be lifted for dates of service from March 17, 2020 through December 31, 2020.
• Telehealth services may be delivered by providers with any connection technology to ensure patient access to care.

*Please note: For Health Savings Account (HSA)-Qualified plans, IRS guidance is pending as to deductible application requirements for telehealth/telemedicine related services. 

Providers who have delivered care via telehealth should reflect it on their claim form by following standard telehealth billing protocols in their state. For further billing and coding guidance for telehealth services, we recommend following what is being published by:

• Centers for Medicare and Medicaid (CMS)
• Department of Health and Human Services (HHS)
• American Medical Association (AMA)

We believe that these measures will help our members maintain access to quality, affordable healthcare while maintaining the CDC’s recommended distance from public spaces and groups of people. 

This guidance is in response to the current COVID-19 pandemic and may be retired at a future date.

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• Prior Authorization Guide (PDF)
• Quick Reference Guide (PDF)
• Secure Provider Portal (PDF)
• Provider Orientation Deck (PDF)
• Provider Newsletter December (PDF)

• Payment Policy
• Clinical Policies
• Updated Policies

• Provider Model of Care Training (PDF)

• Quality Assurance

• Quick Reference Guide (PDF)

• Provider Newsletter, October 2021 (PDF)
• Provider Newsletter, December 2021 (PDF)
• Provider Newsletter, February 2022 (PDF)
• Provider Newsletter, April 2022 (PDF)