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Claims payment

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

CMS suspending sequestration payment adjustment
As part of the Coronavirus Aid, Relief and Economic Security (CARES) Act, the Centers for Medicare & Medicaid Services (CMS) is suspending the 2% sequestration payment adjustment for Medicare claims for dates of service from May 1 to December 31, 2020. Therefore, we are suspending the sequestration payment adjustment for our Medicare Advantage claims with dates of service during this time period.

CMS applying a 20% increase to the MS-DRG weight for discharges of an individual diagnosed with COVID-19
As part of the CARES Act, CMS is applying a 20% increase to the Medicare Severity Diagnosis Related Group (MS-DRG) weight for discharges of an individual diagnosed with COVID-19 for discharges beginning on or after January 27, 2020. Therefore, we are applying this increase for our Medicare Advantage claims for discharges beginning on this date.

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.

The emergency declaration end dates are:

• Idaho: To be determined
• Oregon: July 6, 2020
• Utah: June 30, 2020

• Washington: To be determined

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.

Individual and group members

• 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) where the services would have normally occurred (including POS 11; excluding POS 02).
  • Modifier 95 to indicate that the services were rendered via telehealth.  (This update was made to align to the most recent guidance from CMS.)
• Telehealth services are covered for our Individual and group (including administrative only services groups who have opted in to the telehealth expansion) members when conducted via audio or video. View instructions for verifying ASO groups who will temporarily cover virtual services to replace in-person visits.

• The member's coinsurance and deductible will apply to the 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.

Medicare Advantage members
To align with the most recent CMS guidance:

• 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.
    • Note: For Medicare Advantage claims that were previously submitted with modifier GT, please rebill these claims using the type of bill that indicates a corrected claim with modifier 95.
• For the encounter to meet the Medicare telehealth face-to-face requirement, telehealth visits with your Medicare Advantage patients must be conducted using real-time via audio and video, and the use of audio and video must be documented in the patient’s chart note.
• The member's copay, coinsurance and deductible will apply to the 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.

• Telehealth services can be provided to Medicare Advantage PPO members by out-of-network providers.

Risk adjustment
CMS recently announced that providers can include diagnosis codes on telehealth claims for risk adjustment purposes. The hierarchical condition category (HCC) coding accepted by CMS will count toward gap closures in our Regence Medicare Quality Incentive Program (QIP).

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.

BlueCard members
BlueCard members’ telehealth benefits are based on the member’s home plan.

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.

Telehealth vendors

In addition to local providers, most members have access to one of two national telehealth vendors that can help assess a member’s condition and determine the necessary next steps of care:

• MDLIVE provides medical and behavioral health care via video or phone visits. It is available to Medicare Advantage members and as a buy up for fully insured large group and administrative services only (ASO) group members. Note: For Medicare Advantage all visits with MDLIVE will be at the member’s primary care provider (PCP) copay.

• Doctor on Demand provides medical and behavioral health video visits. It is available to Individual, small group, mid-size group and Uniform Medical Plan (UMP) members. It is also offered as a buy up for large and ASO group members.

When members login to their account, they can view their telehealth benefits and access their telehealth vendor.

Note: If a patient’s symptoms might be indicative of COVID-19, the member would still need to be seen in person and tested for the disease.

Advice24

Most 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.

House calls

DispatchHealth and Heal provide house calls in certain areas.

DispatchHealth
DispatchHealth serves as a mobile urgent care service that provides care in the home setting. It is an option for members who do not have COVID-19 symptoms and are concerned about the risk of exposure in a clinic setting. Note: During the triage process, if DispatchHealth identifies a patient at risk for COVID-19, DispatchHealth will direct the patient to the appropriate testing site.

View the complete list of the conditions and symptoms they treat.

Regence small, mid-size and large group, UMP, ASO and Medicare Advantage plan members have access to DispatchHealth in Idaho (Boise area), Oregon (Portland area) and Washington (Seattle, Tacoma and Olympia areas). View DispatchHealth’s service area and verify access using a ZIP code. Note: The program may not apply to all UMP Plus plans.

You can refer a patient to care by calling the Regence-specific phone number for any of the locations below at 1 (833) 652-0539 or by calling the following phone numbers dedicated to each area:

• Boise, ID: (208) 298-9893
• Portland, OR: (503) 917-4904
• Seattle, WA: (425) 651-2473
• Tacoma, WA: (253) 341-4072

• Olympia, WA: (360) 836-4855

Heal
Heal provides primary and urgent care home visits by a physician and laboratory technician. Heal will see members who are suspected of having COVID-19 in their home. Heal may test for COVID-19 and is working with the Washington Health Department to order the test. Heal may also work with our participating labs to order the test. Members can make appointments from 8 a.m. to 8 p.m., seven days a week, 365 days a year. It is currently available to Individual, small, mid-size and large group, UMP (except UMP Plus plans), ASO and Medicare Advantage members in only the greater Seattle, Washington area.

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 fully insured and Medicare Advantage members through June 30, 2020.
  • We are working with self-funded partners to implement similar cost share arrangements when directed.
• 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.

• Oxygen concentrators used by Medicare Advantage members for more than 90 days will require pre-authorization effective August 1, 2020. (We previously indicated this change was effective July 1, 2020.)

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 August 1, 2020, as needed.

These changes do not apply to BlueCard and BCBS FEP members.

Quality and incentive programs

CMS recently announced that providers can include diagnosis codes on telehealth claims for risk adjustment purposes. The hierarchical condition category (HCC) coding accepted by CMS will count toward gap closures in our Medicare Quality Incentive Program (QIP). See the telehealth visits section for more information.

We are pausing outbound and inbound care gap calls, Healthcare Effectiveness Data and Information Set (HEDIS®) - related medical record retrieval and quality-related home visits.

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

Credentialing providers

Temporary providers and expedited credentialing

During this health emergency, we are allowing an exception 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.

Locum tenens
We are making the following exceptions to our Locum tenens policy to allow a provider to identify and authorize care for his or her patients by another provider, during this pandemic:

• The use of a locum tenens provider by a participating provider has been expanded to 180 days during this emergency.

• A locum tenens can have a valid license in a different state than the one in which they are practicing in.

Expedited credentialing
If your practice has been directly impacted by COVID-19, please:

• Complete the credentialing application.
• Contact Provider Relations to request expedited credentialing.

• Note: This process does not apply to routine requests.

View information below regarding temporary updates to telehealth.

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 alternative medications through June 30, 2020, to allow pharmacies to use available stock to meet members' needs.

• Individual and group members: We are removing the pre-authorization for alternatives, including 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 albuterol.
• Medicare Advantage members: The authorized generics and generics from ProAir HFA will be covered at the same cost share as Proair HFA, Proair RespiClick and Ventolin HFA.

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 can test for COVID-19. Our provider networks include one or both of these labs. You can verify your patient's 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.)

By including the correct COVID-19 diagnosis codes and modifier CS on your claims:

• The COVID-19 diagnostic test to determine if the virus is currently present and associated office visit will be covered at no member cost share.

• COVID-19 recognized treatment will be covered at no member cost share for our fully insured and Medicare Advantage members diagnosed with the disease through June 30, 2020. We are working with our administrative services only (ASO) group partners to implement similar cost share arrangements when directed.

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, group (including ASO group) and Medicare Advantage 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 Individual and group (including fully insured, HSA plan and ASO group) members, we will cover one antibody test per year, per member with no cost share. 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.

For Medicare Advantage members, there is not a limit on the number of antibody tests a member can receive.

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:

• For Individual and group members (including fully insured, HSA plan and ASO group members): The test must be ordered by the member’s attending provider and be part of appropriate medical care.
• For Medicare Advantage: The test must be ordered by a licensed health care professional and be 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.

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 policies
  • Commercial
  • Medicare Advantage
• COVID-19 Antibody Testing (Laboratory #74) medical policy

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
• TriWest’s Community Providers COVID-19 Resource
• 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)