We're here to support you and our members

We will continue to update this page to make sure you have the latest information about how we are supporting you and our members during this time.

Updated on May 26, 2020:

• Updated the Pharmacy section to indicate that for members who are on a plan based in Idaho, Oregon or Utah, we are allowing requests for an extended supply of medications through May 31, 2020; For members who are on a Washington-based plan, we are allowing requests for an extended supply of medications through June 3, 2020

Claims payment

Expedited claims payment
We have expedited claims payment to seven days on average.

Medical record requests
If your office is unable to send requested medical records to us via fax or mail, view these steps to submit medical records (PDF) for provider appeals and clinical audits using a secure file transfer protocol (SFTP) site.

For provider appeals, you can also use the SFTP site to upload your appeal request and supporting documentation.

Temporary updates to telehealth

Telehealth expansion

We have temporarily expanded medical and behavioral health telehealth services. This expansion will remain in effect through each state’s emergency declaration.

Watch the short video below to learn how to:

• See your patients virtually
• Submit claims for these services to be paid the same as in-person visits

The visits are considered the same as in-person visits and are paid at the same rate as in-person visits.

Telehealth services can be provided if the services:

• Are safely and effectively delivered via telehealth
• Meet the code definition that is billed when provided via telehealth
• Meet existing coverage criteria, including pre-authorization requirements and medical necessity

• Are conducted using U.S. Department of Health and Human Services’ (HHS’) lead on discretion with respect to HIPAA compliant platform requirements. Pulsara offers a free, HIPAA-compliant, video-enabled platform. Innovaccer also offers a HIPAA-compliant telehealth platform.

Member benefits and claim submission guidelines

• For claims to process correctly and for you to receive reimbursement consistent with an in-office visit, you must use:
  • The place of service (POS) location where the services would have normally occurred (including POS 11; excluding POS 02)
  • Modifier 95 to indicate that the services were rendered via telehealth.
• Telehealth services are covered when conducted via audio or video.

• The member's coinsurance and deductible will apply to telehealth service, if applicable. Note: The telehealth visit related to COVID-19 diagnostic testing to determine if the virus is currently present will be covered at no member cost share. See below for information about coverage and claim submission guidelines for COVID-19 testing and treatment.

Risk adjustment
CMS recently announced that providers can include diagnosis codes on telehealth claims for risk adjustment purposes.

As with face-to-face visits, diagnosis codes included on claims must have sufficient documentation and may be subject to review. Refer to the Risk Adjustment section of our website for additional information about documentation requirements.

Palliative care
As a participating provider, you can conduct advance care planning (ACP) conversations with your patients via telehealth.

There are also free resources available to help you care for and have ACP conversations with your patients. See below for links to the palliative care resources.

Telehealth benefits
We will continue to cover the medical and behavioral health codes for our Individual, group and Medicare Advantage members, as outlined in our Virtual Care (Administrative #132) reimbursement policy. Claims submitted following the guidelines in this policy, including the use of POS 02, will be paid as they have been. View instructions for verifying members' telehealth benefits.

Teledentistry expansion

Teledentistry services can be provided if:

• Your interaction with the member qualifies as a teledentistry visit. Please refer to the American Dental Association’s Policy on Teledentistry for guidance.

Member benefits and dental provider reimbursement:

• Claims performed via teledentistry are considered the same as in-person visits and are paid at the same rate as in-person visits.
• Standard cost shares and plan limitations apply. Any paid amounts will accumulate to the annual maximum, if applicable.
• View the member’s plan benefits on the Availity Web Portal.

Doctor on Demand

Members have access to telehealth services via Doctor on Demand. Doctor on Demand provides medical and reimbursement health video visits.

Advice24

Members also have access to a 24/7 nurse advice line that they can call for answers to questions about common health concerns.

Secure messaging

Ask a Doctor provides routine medical care virtually by secure messaging (that can convert to video) with a board-certified, U.S.-based provider and is an option for members with mild or no symptoms. It is available to Individual, small, mid-size and large group members.

Caring for our members

Care management

To help our members receive the care they need, we are:

• Urging members to contact their provider office or facility before presenting themselves. In addition, we are encouraging members to use their telehealth options, if appropriate, to receive care in the convenience of their home. Our member website includes other information to help our members be prepared and stay informed, including a COVID-19 symptom checker.
  • The COVID-19 symptom checker is a decision tree that asks members if they have any known symptoms of COVID-19, if they have spent time with anyone who has gotten sick and other relevant questions. Upon completion, members will get a suggestion on next steps, such as stay home and rest, connect with a provider or seek immediate emergency care.
• Encouraging members to avoid delays to non-COVID-19-related critical care by seeing their provider using telehealth or by scheduling an in-person visit
• Waiving the cost of COVID-19 recognized treatment for our Individual members through June 30, 2020.
• Reaching out to provide personalized support as we learn of members diagnosed with COVID-19 to help them with food and other needs.
• Proactively contracting high-risk members who are engaged in case management to ensure they have the support they need.

• Partnering with Alacura Medical Transportation Management LLC (Alacura) for air ambulance services. Alacura can be used for non-emergent (requires pre-authorization) and urgent facility-to-facility transport for members, including COVID-19 patients. For more information, visit Alacura’s website or call Alacura at 1 (844) 425-2287.

Pre-authorizations

To help support patient care:

• We are available to support discharge needs, including removing barriers to quickly discharge our members to alternate settings, to accommodate care needs of critical patients.
  • Please contact our Care Management team if you are encountering any discharge barriers at 1 (866) 543-5765 from 7 a.m. to 5 p.m. Monday through Friday and one of our case management nurses will assist you. (See below for more information.)
• If your patient has services that are delayed, we will extend pre-authorizations for elective inpatient admissions or outpatient elective services. Please contact us to request an extension for your expiring pre-authorization request.
• AIM Specialty Health (AIM) and eviCore healthcare (eviCore) are extending authorizations for six months. Requests for AIM and eviCore will automatically be extended.
• Urgent and emergent transport does not require pre-authorization.

• Any emergency room visit that results in an in-patient admission, directly related to COVID-19, does not require a pre-authorization.

Discharging members to post-acute settings
During this challenging time, we are committed to supporting our hospital partners in removing barriers to quickly discharge our members to alternate settings to accommodate care needs of critical patients related to the COVID-19 pandemic.

Effective immediately, if hospitals need to transfer a patient quickly due to the COVID-19 impact and do not have time to secure pre-authorization for post-acute care settings or home-based care (i.e., skilled nursing facilities, long-term acute care hospitals and inpatient rehabilitation), we will waive the pre-authorization requirements and instead require notification by both the discharging and receiving facility/provider within 24 hours for care coordination and concurrent review authorization.

We will continue to monitor the needs of our hospital partners and re-evaluate an extension beyond May 31, 2020, as needed.

Quality and incentive programs

CMS recently announced that providers can include diagnosis codes on telehealth claims for risk adjustment purposes. See the telehealth visits for more information.

We are pausing Healthcare Effectiveness Data and Information Set (HEDIS®) - related medical record retrieval.

We will communicate any impact to our quality programs at a later date.

Credentialing providers

Temporary providers and expedited credentialing
During this health emergency, we are allowing exceptions to our locum tenens policy and expediting credentialing to help meet emerging demands for health care providers and to ensure that our members have access to care. Please contact Provider Relations for more information.

Pharmacy pre-authorization and medication refills

Pre-authorizations
All drug pre-authorizations that are due to expire between March 23, 2020, and June 30, 2020, will be extended six months from the current expiration date to alleviate work by the provider’s offices. Members will be notified via letter that their pre-authorization has been extended with the new expiration date. We will evaluate any pre-authorizations that expire after this period at a later date.

Early prescription medication refills
Our prescription medication refill policies have been updated to:

• Adjust our “refill too soon” policy for all medications, except opioids.
  • For members who are on a plan based in Idaho, Oregon or Utah, we are allowing requests for an extended supply of medications through May 31, 2020.
  • For members who are on a Washington-based plan, we are allowing requests for an extended supply of medications through June 3, 2020.
• Allow for a 90-day refill on medications used for chronic conditions, such as multiple sclerosis, diabetes, asthma and heart disease
  • Note: Some drugs are not eligible for extended day supply, including controlled substances and certain specialty drugs. Drugs listed on our formularies in the Narcotics and section marked SP are not eligible for an extended supply.
  • Members can order home-delivery prescriptions through the AllianceRx Walgreens Prime website or by calling 1 (844) 765-2894.

Therapeutic options for patients with COVID-19

There are no U.S. Food and Drug Administration (FDA)-approved drugs specifically for the treatment of patients with COVID-19. At present clinical management includes infection prevention and control measures and supportive care, including supplementary oxygen and mechanical ventilatory support when indicated. An array of drugs approved for other indications, as well as several investigational drugs, are being studied in several hundred clinical trials that are underway across the globe.

View the CDC’s information about therapeutic options for patients with COVID-19.

Expanded access to alternative medications for albuterol inhalers

Albuterol inhalers are in short supply across the country, due to increased prescribing related to COVID-19 symptom treatment. We are expanding access to and removing pre-authorization for alternative medications through June 30, 2020, to allow pharmacies to use available stock to meet members' needs. Alternative medications include the generic of Proair HFA, brand Proventil HFA, and the authorized generics of Proventil HFA and Ventolin HFA. These medications will be covered at the same cost share for members as abuterol.

COVID-19 specimen collection

The CDC has information caring for patients with a possible COVID-19 infection. View the CDC’s recommendations for reporting, testing and specimen collection.

CMS created two new HCPCS codes representing COVID-19 specimen collection. These codes are billable by clinical diagnostic laboratories.

The codes are effective for claims with dates of service on or after March 1, 2020:

• HCPCS G2023: Specimen collection for severe acute respiratory syndrome coronavirus 2, any specimen source
• HCPCS G2024: Specimen collection for severe acute respiratory syndrome coronavirus 2 from an individual in a skilled nursing facility (SNF) or by a laboratory on behalf of a home health agency (HHA), any specimen source

Order tests from participating labs

LabCorp and Quest Diagnostics are participating labs on our provider networks. These labs can test for COVID-19 and are typically a lower cost option for our members whose network includes LabCorp and/or Quest Diagnostics. You can verify your patients' coverage using our provider search tool, Find a Doctor.

Note: Individuals seeking testing for COVID-19 should not visit a LabCorp or Quest Diagnostics location to request a test. Tests must be ordered by a physician or other authorized health care provider.

LabCorp, our preferred lab

Providers can order the COVID-19 test the same way that other tests are ordered from LabCorp. If you are not already registered, create an account on LabCorp’s website.

More information about COVID-19, including answers to frequently asked questions, is available on LabCorp’s website.

Quest Diagnostics

Providers can order the test the same way that other tests are ordered from Quest Diagnostics. If you are not already registered, create an account on Quest Diagnostic’s website.

For more information, including a link to a Healthcare Provider Fact Sheet, visit Quest Diagnostic’s website.

Claims submission for the COVID-19 test and related services

For COVID-19 testing and recognized treatment, the correct diagnosis codes must be included on claims in the first position:

• For dates of service from March 1 through March 31, 2020: B97.29, Z03.818 or Z20.828 must be included.
• For dates of service beginning on April 1, 2020: U07.1, Z03.818 or Z20.828 must be included.

• Modifier CS must be added to each line item for COVID-19-related testing or treatment. (For telehealth claims, both modifier 95 and modifier CS must be included.)

If you previously submitted claims with incorrect COVID-19 diagnosis codes and the member's benefits were not applied correctly, please rebill these claims using the:

• Type of bill that indicates a corrected claim
• Correct COVID-19 diagnosis codes (as shown above)

• Modifier CS must be added to each line item for COVID-19-related testing or treatment. (For telehealth claims, both modifier 95 and CS must be included.)

This ensures we process our members’ benefits correctly, including no member cost share for COVID-19 diagnostic testing and the associated office visit. COVID-19 recognized treatment will be covered at no member cost share for our members diagnosed with the disease through June 30, 2020.

For dates of service before April 1, 2020, view the CDC's ICD-10-CM Official Coding Guidelines - Supplement Coding encounters related to COVID-19 Coronavirus Outbreak (PDF). For dates of service beginning on April 1, 2020, view the CDC’s ICD-10-CM Official Coding and Reporting Guidelines

Note: We will not cover the cost of personal protective equipment (PPE) for medical or dental services as a separate reimbursable expense.

COVID-19 testing codes

The Centers for Medicare and Medicaid Services (CMS) and the American Medical Association (AMA) have established codes for COVID-19 testing to allow for better tracking of the public health response for this virus to help protect people from the spread of this infectious disease.

We will reimburse COVID-19 testing in accordance with applicable law, including the Coronavirus Aid, Relief and Economic Security (CARES) Act and the Family First Coronavirus Response Act (FFCRA).

Please ensure you bill the appropriate code based on which test was used.

Diagnostic testing
To ensure our members have access and coverage for diagnostic (antigen) testing, we are:

• Not requiring pre-authorization for COVID-19 diagnostic testing to determine if the virus is currently present when ordered by a physician or other qualified health care provider.
• For Individual members, we will cover the cost of the COVID-19 diagnostic test and an associated office visit with no cost share, if a provider determines a test is appropriate. We will cover the cost of the COVID-19 diagnostic test if it is provided prior to a procedure.
• For Medicare Supplement members, only the diagnostic test is covered at no cost share.
• Reimbursing COVID-19 diagnostic testing conducted at drive-up testing sites with no cost share, if a provider determines a test is necessary. Claims for tests conducted at drive-up sites should be submitted using POS 15.

Antibody testing
For antibody (serology) testing, we will cover one antibody test per year, per member at no cost to members. This includes members who have a health savings account (HSA) plan.

The test will be covered when performed on or after April 10, 2020, through the end of the public health emergency, when the following criteria are met:

• The test must be ordered by the member’s attending provider and part of appropriate medical care.
• For tests submitted by labs: The test must be performed at a Clinical Laboratory Improvement Amendments- (CLIA-) certified laboratory and the referring/ordering provider’s NPI or TIN must be included.

• For tests submitted by the provider: The manufacturer of the test must be approved or authorized by the FDA or have been approved for FDA-Emergency Use Authorization- (EUA-) for the COVID-19 pandemic.

  • The manufacturer’s name must be included on the electronic professional claim, 837P, in the NTE02 segment, either at claim level or line level. If the manufacturer’s name is not included on the claim, the provider will receive a letter requesting this information.

AMA’s COVID-19 Coding and Guidance page includes a CPT Assistant Guide with information about CPT 86328 and 86769, effective April 10, 2020, for use as the industry standard for reporting of novel coronavirus antibody tests.

Additional antibody tests will be covered to identify COVID-19 antibodies when medical necessity criteria have been met per the COVID-19 Antibody Testing (Laboratory #74) medical policy.

Note: Antibody tests used to evaluate community health (surveillance testing), tracking or for employment purposes are not covered. We believe surveillance testing is the responsibility of the public health system.

For more information, view the Temporary COVID-19 Antibody Testing (Administrative #137) reimbursement policy.

Process for testing for COVID-19

• View information about the process for testing for COVID-19 on Idaho.gov.
• View the Oregon Health Authority’s Provisional Guidance for Health Systems Regarding COVID-19 Testing, under the information for HealthCare Providers, EMS, PSAPs and Clinical Laboratories.
• View information about testing for patients of COVID-19 on Utah.gov.
• View information about testing patients for COVID-19 on the Washington Department of Health’s website.

Contact information for the state health department

Providers should notify both infection control personnel at their health care facility and their local or state health department in the event of a person under investigation (PUI) for COVID-19.

Financial resources for providers during COVID-19

Congress just passed new legislation to provide help during this crisis. Include below is information on new and expanded resources to assist you as both a provider and a small business employer.

New grants for frontline support
A new Public Health and Social Services Emergency Fund includes an initial $100 billion for unreimbursed health care-related expenses or lost revenues that are attributable to COVID-19, as well as for personal protective equipment.

More details will be released soon by the Assistant Secretary for Preparedness and Response at the U.S. Department of Health and Human Services (HHS).

HHS is expected to review applications and make payments on a rolling basis, and the application process likely will require a statement of need and a valid tax identification number (TIN).

Tax relief for wages and benefits
Under the new law, physician group practices, clinics and even non-profit community health centers may be able to take advantage of tax credits.

Businesses forced to suspend operations or that have seen gross receipts fall by 50% from the previous year are eligible. Many practices are seeing a loss of revenue as appointments are delayed or even canceled due to concerns around COVID-19.

View the IRS Coronavirus Tax Relief page or speak with your accountant or financial advisor for more information and to see whether your practice or center is eligible.

Loan assistance
Businesses with fewer than 500 employees (including sole proprietors, independent contractors and anyone otherwise self-employed) can apply for “paycheck protection” loans to meet payroll and cover certain other expenses like rent and utilities.

If employers maintain their payroll, borrowers can apply for loan forgiveness (PDF). This provision is retroactive to February 15, 2020, to help bring workers who may have already been laid off back onto payrolls.

The new loans are available through private financial institutions (i.e., banks, credit unions) that participate in the U.S. Small Business Administration’s (SBA’s) lending network.

You can download a U.S. Department of Treasury’s application for borrowers (PDF). Visit SBA’s website to find a local partner near you to learn more about this and other programs.

Other resources

For more information, refer to the following resources:

• CDC COVID-19
• WHO COVID-19
• CDC travel notice
• Pulsara – Free, HIPAA-compliant, video-enabled platform
• Healthwise Coronavirus Resource Center – Information to share with patients
• CMS Answers to Frequently Asked Questions to Assist Medicare Providers
• Oregon Health Authority Emerging Respiratory Disease
• Idaho Department of Health and Welfare
• Utah Department of Health

• Washington State Department of Health

Palliative care resources

• CAPC COVID-19 Response Resources – Crisis communication and symptom management protocols for all clinicians, and guidance to help palliative care teams address high levels of volume and stress
• VitalTalk’s COVID-19 Communication Skills – How to talk about difficult topics related to COVID-19
• VitalTalk’s Outpatient COVID-19 Talking Maps (PDF)