What you need to know about coronavirus (COVID-19) 

For WellFirst Health providers

WellFirst Health is taking measures to support our valued in-network providers who are caring for our members amid concerns of the coronavirus COVID-19 spreading in our area. Check this web page regularly for updates.

If you have questions contact your Provider Network Consultant directly and email your question to ProviderRelations@wellfirstbenefits.com for a prompt reply.

In alignment with COVID-19-related federal and state regulations, WellFirst Health is:

  • implementing $0 member cost share
  • removing authorization requirements for certain services
  • putting temporary policies into use
  • increasing network adequacy monitoring.

Our intention is to remove potential barriers and delays to COVID-19 testing and treatment across all WellFirst Health product lines. 

Provider communications

As we move toward stabilization of temporary COVID-19 health plan coverage and billing policies, we are discontinuing our weekly COVID-19 communications. We will resume COVID-19 communications when we begin transitioning back to pre-public health emergency policies. We will communicate urgent information in the interim, should the need arise

COVID-19 communications: 7/30/20

COVID-19 communications: 5/21/20

COVID-19 communication: 5/14/20

COVID-19 communication: 5/7/20

COVID-19 communication: 4/23/20

COVID-19 communication: 4/16/20

COVID-19 communication: 4/9/20

COVID-19 communication: 4/2/20: Includes health plan waiver information 

COVID-19 communication: 3/26/20

COVID-19 communication: 3/12/20

Telemedicine information: 3/18/20

WellFirst Health's COVID-19 Policies

Updated 6/4/20
WellFirst Health is waiving copayments and cost sharing for diagnostic screenings and associated evaluation and management (E&M) services related to COVID-19.

WellFirst Health is temporarily expanding $0 cost sharing to include in-network hospitalizations.

WellFirst Health is temporarily expanding $0 cost sharing to include COVID-19 antibody testing with no member out-of-pocket costs. This expanded coverage applies to the SSM Health Employee Health Plan ASO and ACA Individual Plans.

Updated 5/14/20

We are complying with CMS coding guidelines for COVID-19 testing.
Procedure codes
The American Medical Association created new CPT codes effective for dates of service on or after April 10, 2020, to describe COVID-19 antibody testing.

The American Medical Association created a new CPT code effective for dates of service on or after March 13, 2020, to describe COVID-19 testing by amplified probe technique:

  • 87635 - Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique
Previously, CMS released two HCPCS codes effective for dates of service on or after Feb. 20, 2020, available for use on April 1, 2020:
  • U0001 - CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel
  • U0002 - 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19)
Laboratories using the CDC test kit should report U0001. Laboratories not using the CDC test kit should report 87635 if the testing method meets the code description. If your laboratory uses any other method not described by CPT 87635, HCPCS U0002 may be billed. We do not anticipate a need to receive code U0001 at this time as the government is testing at no cost.

The American Medical Association created new CPT codes effective for dates of service on or after April 10, 2020, to describe COVID-19 antibody testing:
  • 86328 - Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative, single step method (e.g., reagent strip); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19])

CPT code 86328 should be reported once per single-step method (e.g., reagent strip) even if multiple antibody classes (IgG and IgM) are tested. If two antibodies are tested in two separate single-step assays, 86328 may be reported twice. Modifier 59 should be appended to the code for the second test to identify that two distinct analyses were performed.
  • 86769 - Antibody; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19])

Similarly, if IgG and IgM are tested in separate assays, 86769 may be reported twice. Modifier 59 should be appended to the code for the second test to identify that two distinct analyses were performed.

With the addition of these two new codes, the guidelines for codes 86602-86804 have been revised to incorporate new CPT code, 86328. A parenthetical note has been added following code 86635 directing users to new codes 86328 and 86769. Lastly, the description for code 86318 has been changed.

Diagnosis codes
Screening for COVID-19 should be reported with the appropriate screening code:
  • Z03.818 – Encounter for observation for suspected exposure to other biological agents ruled out
    • Screening for COVID-19 due to potential exposure, but COVID-19 diagnosis is ruled out
  • Z20.828 – Contact with and (suspected) exposure to other viral communicable diseases
    • Screening for COVID-19 due to contact with and suspected exposure
  • Z11.59 – Encounter for screening for other viral diseases
    • Asymptomatic, no known exposure, results unknown or negative

The implementation date for ICD-10-CM code U07.1 (COVID-19) has been moved up to April 1, 2020, from Oct. 1, 2020. Effective for discharge/dates of service on and after April 1, 2020, diagnosed cases of COVID-19 and presumptive positive COVID-19 tests should be reported with ICD-10-CM code U07.1, except in the case of newborns and obstetrics patients. Appropriate codes for associated medical manifestations should be reported as additional diagnoses.
For discharge/dates of service before April 1, 2020, providers should follow previously communicated guidelines using the ICD-10 code for the condition as the primary diagnosis followed by B97.29 as the secondary diagnosis.

Modifier CS
For dates of service on and after March 18, 2020, WellFirst Health requires modifier CS when billing E&M services related to the administration of a COVID-19 test or to the evaluation of a patient for purposes of determining the need for such a test. Modifier CS will allow us to accurately waive member cost share on services related to COVID-19 testing.

Providers may submit corrected claims to include modifier CS if member cost share was applied to a service related to COVID-19 testing on a previously-processed claim.

Telemedicine billing
Telehealth service (either temporary or standard) is provided via Zoom or similar audio/visual technology
  • Modifier:  ’95 - indicating that the service rendered was actually performed via telehealth
  • Place of Service:  Equal to what it would have been had the service been furnished in-person (eg, 11, 20, 21, 22)

Telehealth service (either temporary or standard) is provided via traditional method involving originating site and distant practitioner
  • Modifier:  None  (Medicaid requires ‘GT - Via interactive A/V telecommunication systems)
  • Place of Service : ’02’ – telehealth

Communication technology-based services
Communication technology-based services (CTBS) are furnished via telecommunications technology but are not considered telehealth services. Examples include telephone services (CPT 99441-99443, 98966-98968), online E/M services (99421-99423, G2061-G2063).

Because these are not considered telehealth services, a telehealth modifier is not required. The Place of Service should be ‘11’ or other applicable site of the practitioner’s normal office location.

Codes and travel allowance for specimen collection
For dates of service on and after March 1, 2020, WellFirst Health accepts the following codes for COVID-19 specimen collection:
  • G2023 — Specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), any specimen source
  • 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

The laboratory technicians must personally draw the sample and collect the specimen from a homebound or nursing home patient. Enlisting a messenger service for a specimen pick up does not qualify.

A travel allowance may be provided to laboratory technicians collecting specimens for COVID-19 testing from a non-hospital inpatient or homebound patients under existing codes P9603 and P9604.

Specimen collection code for hospital outpatient clinic visit
Effective for dates of service on and after March 1, 2020, CMS established a new Level II HCPCS code for COVID-19 specimens collected during a hospital outpatient clinic visit:
  • HCPCS C9803 - Hospital outpatient clinic visit specimen collection for severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]), any specimen source

Effective May 1, 2020, specimen collections reported with HCPCS codes G2023 and G2024 for hospital outpatient clinic visits instead of C9803 will be returned.

COVID-19 testing using high throughput technologies
Effective on and after March 18, 2020, COVID-19 testing that uses high throughput technologies will be paid in accordance with CMS’ recently-released guidance. A high throughput technology is defined as a platform capable of automated processing of more than two hundred specimens per day. The highly sophisticated equipment requires more intensive processes and technician training to ensure quality and warrants a change in reimbursement.

Examples of high throughput technology as of April 14, 2020, include, but are not limited to, the following technologies:
  • Roche cobas 6800 System
  • Roche cobas 8800 System
  • Abbott m2000 System
  • Hologic Panther Fusion System
  • GeneXpert Infinity System
  • NeuMoDx 288 Molecular

HCPCS U0003 is used to report the high throughput version of tests that would otherwise be identified with CPT 87635. HCPCS U0004 is used to report the high throughput version of tests that would otherwise be identified with U0003. Neither U0003 nor U0004 should be used for tests that detect COVID-19 antibodies.
Updated 7/30/20

Waiving authorizations

Diagnostic services related to COVID-19 testing
WellFirst Health is waiving authorizations for diagnostic services related to COVID-19 testing. 

Outpatient services
WellFirst Health is waiving authorization requirements for outpatient services directly for and related to COVID-19. Providers must bill for these services using the COVID-19 ICD-10 codes to appropriately bypass authorization requirements for services that qualify for the waiver.

Chest scans
Effective for dates of service on and after Sept. 1, 2020, WllFirst Health is reinstating the prior authorization requirement  for chest CT scans.

Antibody testing
WellFirst Health does not require prior authorization for antibody testing; however, we do expect that all antibody tests be physician-ordered. Because of the variety of testing options available on the market currently, we encourage providers to know the efficacy of the antibody tests they are ordering.

Extending authorization date spans

WellFirst Health is extending authorization date spans for the following services:
  • Outpatient dental anesthesia — extending to a one-year timeframe, for one procedure
  • Out-of-network and in-network outpatient services/surgery in an outpatient or ambulatory surgical center (ASC) setting — extending an additional six months for all previously approved date spans that were less than 12 months
  • Approved out-of-network specialist visits — extending for six months for all previously approved services that were originally allowed a three-month date span.

WellFirst Health’s partner Magellan Healthcare is also extending authorization date spans to 120 days on authorization requests for the following services:
  • Musculoskeletal Care Management (MSK) Surgeries
  • Physical Therapy and Occupation Therapy
  • Radiology.

Postponing elective surgeries and non-essential procedures

On March 18, 2020, CMS released a recommendation that all elective surgeries, non-essential medical, surgical, and dental procedures be delayed during the COVID-19 outbreak for the preservation of personal protective equipment, beds, and ventilators. In response, Utilization Management is evaluating all approved prior authorizations on file for elective inpatient admissions with a surgery/admit date on or before March 16, 2020, to determine if the surgery was rendered:
  • If the surgery has been performed, we will process the applicable provider claims using our standard process.
  • If the surgery was not performed, we will change the admit/start date on the prior authorization to a future date. We will continue to do so, as necessary, during the COVID-19 public health emergency. Authorizations with a changed start/admit date will be denoted by a COVID-19 statement in the Provider Portal authorization summary.
Providers do not need to obtain a new prior authorization for any already-approved surgeries. Once CMS lifts its recommendation and the surgery is scheduled, providers will need to call our Customer Care Center to report the date of surgery, as required by our current process.

Moving patients from out-of-network to in-network facility
WellFirst Health is suspending requiring members to be transferred from an out-of-network facility to an in-network facility unless transfer is explicitly requested by the out-of-network facility.

Retrospective review
WellFirst Health will allow providers two weeks after the date of service to submit authorization requests for retrospective review for any service that requires prior authorization.

Providers who are not equipped to handle COVID-19 patient inquiries or collect specimens for testing can contact us for the nearest in-network provider at DHP.PNCInquiry@deancare.com.

Providers who do not have access to a qualifying laboratory for COVID-19 testing can contact one of the following in-network FDA-approved laboratories:
  • The State Lab
  • Quest Diagnostics
  • LabCorp
Updated 5/14/20

We are referring to the CMS Medicare Telemedicine Health Care Provider Fact Sheet for our expanded telemedicine coverage guidance effective for dates of service beginning March 6, 2020. Our expanded coverage will remain in effect until further notice.

To support needed provider network adequacy, protect members and providers, and promote access to care, we are offering Zoom meeting licensure to providers without the ability to conduct telemedicine services during the COVID-19 public health emergency. Providers may contact their Provider Network Consultant if they are interested in obtaining a Zoom license to provide telehealth services.

To accommodate Medicare beneficiaries who don’t have access to or are hesitant to use the interactive audio-video technology required for telehealth services, the Centers for Medicare & Medicaid (CMS) is waiving the video requirement for certain telehealth services. WellFirst Health is adopting this waiver for all products during the public health emergency to allow members to receive these services via telephone (audio-only). The services that can be rendered via telephone have been added to CMS’s List of Medicare Telehealth Services .

Because practitioners are providing audio-only services in instances that would have been provided as in-person or telehealth visit under non-COVID-19 circumstances, CMS established new Relative Value Units (RVUs) for audio-only assessment and management services. The RVUs are based on crosswalks to the most analogous office/outpatient evaluation and management (E&M) services resulting in increased reimbursement for CPT codes 99441, 99442, and 99443. WellFirst Health is adopting the increased reimbursement rates for these codes on claims with dates of service on and after March 1, 2020, across all WellFirst Health products.

In alignment with CMS guidance, these temporary services should be billed with the Place of Service (POS) equal to what would have been billed if not for the public health emergency.

Modifier 95 should be appended to indicate that the service rendered was actually performed via telehealth. Traditional telehealth services performed using an originating-site facility and distant-site practitioner, should continue to be billed with POS ‘02’.

Communication technology-based services
Communication technology-based services (CTBS) are furnished via telecommunications technology but are not considered telehealth services. Our coverage of CTBS services includes:

Telephone Services (for all health plan products)
  • 99441, 99442, and 99443 (telephone services) 
  • 98966, 98967, 98968 (telephone services by qualified non-physician providers) 

Online evaluation and management or assessment and management
  • 99421, 99421, 99423 (Online digital evaluation and management service)
  • G2061, G2062, G2063 (online assessment and management, by qualified non-physician providers)

Evaluation of recorded video/image and virtual check in.
  • G2010 (remote evaluation of recorded video or image)
  • G2012 (Brief communication technology-based service, e.g., virtual check-in)

During this public health emergency, Medicare is relaxing rules for HCPCS G2010 and G2012 to include practitioners such as licensed clinical social workers, clinical psychologists, physical therapists, occupational therapists, and speech-language pathologists. Services described in G2010 and G2012 are considered “sometimes therapy” services and would require a GN, GO, or GP modifier when furnished by the private practice occupational therapist, physical therapist, and speech-language pathologist.

CMS has also clarified that several types of practitioners are already allowed to bill procedure codes G2061, G2062, and G2063. These include licensed clinical social worker services, clinical psychologist services, physical therapist services, occupational therapist services, or speech language pathologist services.

These services may temporarily be furnished to both new and established patients. Member consent to receive these services must be received, but can be documented by Auxiliary staff under general supervision.

Providers should continue to only bill codes that are on their fee schedules. If you need assistance verifying the codes on your fee schedule or have specific questions on allowable codes other than those listed within our guidelines, contact your Provider Network Consultant.
WellFirst Health will not be amending contracts for COVID-19 measures. We will add applicable COVID-19 codes to all appropriate fee schedules.
WellFirst Health will regularly poll providers to monitor network adequacy related to provider availability for needed COVID-19 diagnosis and treatment. We ask for your prompt response to these inquiries.

Please notify your Provider Network Consultant immediately of any site closures or if you are deploying practitioners to other locations.

Are you a WellFirst Health member?