The provider communications and information on this page are intended for our valued in-network providers caring for our members throughout the public health emergency. If you have questions, contact a Provider Network Consultant at ProviderRelations@wellfirstbenefits.com.
COVID-19 communication: 4/2/20: Includes health plan waiver information
As WellFirst Health has communicated, effective July 1, 2021, member cost share amounts were reinstated and members are responsible for payment of their out-of-pocket costs for facility stays under the terms of their health care coverage.
WellFirst Health is temporarily expanding $0 cost sharing to include COVID-19 antibody testing with no member out-of-pocket costs.
WellFirst Health is waiving copayments and cost sharing for diagnostic screenings and associated evaluation and management (E&M) services related to COVID-19.
In adherence to requirements in the Families First Coronavirus Response Act (FFCRA) and Coronavirus Aid, Relief, and Economic Security (CARES) Act for diagnostic test cash pricing transparency, WellFirst Health expects that any provider who performs a COVID-19 diagnostic test make public the cash price, defined as the charge that applies to an individual who pays cash (or cash equivalent), for the test.
We are complying with CMS coding guidelines for COVID-19 testing. The CDC is a reliable source for current testing information. As with any claim submission to the Health Plan, it is important that claims for COVID-19 testing be submitted with an accurate diagnosis code.
In most cases, the Health Plan does not cover COVID-19 testing when requested by a member or third party for reasons such as for employment, school admission, entertainment, or travel. Claims submitted for COVID-19 testing requested by a member or third party should include the appropriate diagnosis code from Z02.0 through Z02.9 as the primary diagnosis.
There is no copayment, coinsurance, or deductible for medically necessary COVID-19 tests when ordered by a provider during the public health emergency. Medically necessary testing includes tests for members with known or suspected symptoms or known or suspected exposure. It also includes tests for members entering a medical facility for services.
Effective October 1, 2021, the ICD-10 CM code used to report COVID-19 testing for asymptomatic and symptomatic patients with actual or suspected exposure to COVID-19 is Z20.822 – Contact with and (suspected) exposure to COVID-19. Per the ICD-10-CM Official Guidelines for Coding and Reporting, a screening code such as Z11.52 – Encounter for screening for COVID-19 is generally not appropriate during the COVID-19 pandemic.
For dates of service on and after March 18, 2020, Dean Health Plan 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.
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
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, Dean Health Plan accepts the following code for COVID-19 specimen collection:
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:
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:
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.
To receive and administer COVID-19 vaccines and supplies, organizations or individual providers are required to enroll in a federal vaccine distribution program through state immunization programs. (The exceptions to this enrollment requirement are providers who are part of a national chain that registered directly with the Centers for Disease Control [CDC]).
Note: We recommend that providers check with their organization before enrolling as some organizations may be registered as an organization in lieu of having their individual providers enroll.
For state-specific enrollment information:
WellFirst Health has released communications linked from this page regarding federal recommendations, emergency use authorizations (EUAs), approvals, and applicable Health Plan processes regarding COVID-19 vaccines and administration.
The Health Plan covers FDA EUA and approved COVID-19 vaccine administration with no member cost-sharing, per the CARES Act requirements.
See our April 13, 2022, provider communication regarding a second COVID-19 booster shot for certain immunocompromised individuals and people ages 50 years and older who received an initial booster dose at least four months ago.
See our Nov. 29, 2021, provider communication regarding booster and third dose vaccine information.
Effective Nov. 19, 2021, The FDA expanded EUA to include COVID-19 booster shots for all adults who received either the Moderna or Pfizer-BioNTech COVID-19 vaccine at least six months ago.
The Johnson and Johnson COVID-19 vaccine booster was authorized to be administered at least two months after completion of the single-dose primary regimen to individuals 18 years of age and older. Providers should use the applicable current procedural terminology (CPT) code on claims for booster dose vaccine administration, listed below.
On Oct. 20, 2021, the FDA amended EUAs for Moderna and Pfizer-BioNTech COVID-19 vaccines to allow for a single booster dose to specific populations to be administered at least six months after completion of the primary vaccination regimen.
Additionally, the FDA authorized the use of a heterologous (or “mix and match”) booster dose with currently available (i.e., FDA-authorized or approved) COVID-19 vaccines.
See our Aug. 30, 2021, COVID-19 communication regarding the FDA amended EUAs for both the Pfizer-BioNTech and the Moderna COVID-19 vaccines to allow a third dose to immunocompromised individuals on Aug. 12, 2021. Use the following CPT codes for a third dose vaccine administration:
See our August 5, 2021, COVID-19 communication regarding in-home COVID-19 vaccine administration. Use HCPCS code M0201 for in-home COVID-19 vaccine administration.
Vaccine EUAs and approvals for adults
See our Aug. 30, 2021, communication regarding the FDA full approval of the Pfizer-BioNTech COVID-19 vaccine for individuals 16 years of age and older on Aug. 23, 2021.
See our March 18, 2021, communication regarding the FDA EUA for the single-dose Janssen (Johnson & Johnson) COVID-19 vaccine on Feb. 27, 2021.
See our November 24, 2020, communication regarding the FDA issued EUAs for the Pfizer-BioNTech COVID-19 vaccine on December 11, 2020, and the Moderna COVID-19 vaccine on December 18, 2020.
Vaccine EUAs for children
See our Nov. 29, 2021, provider communication regarding COVID-19 vaccines for children.
On Oct. 29, 2021, the FDA issued EUA for the Pfizer-BioNTech COVID-19 vaccine for children 5 through 11 years of age.
This is to be administered as a two-dose primary series, three weeks apart, at a lower dose (10 micrograms) than that used for individuals 12 years of age and older (30 micrograms).
Providers should use the applicable CPT code on claims specific to the first or second dose vaccine administration, listed below.
Pfizer-BioNTech; 0071A - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 10 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation; first dose
Pfizer-BioNTech; 0072A - Second dose
On Jan. 3, 2022, the FDA amended the EUA for the Pfizer-BioNTech COVID-19 vaccine to expand the use of a single booster dose to include individuals 12 through 15 years of age.
Additionally, the EUA shortens the time between the completion of the primary Pfizer-BioNTech COVID-19 vaccination and a booster dose to at least five months and allows for a third primary series dose for certain immunocompromised children 5 through 11 years of age.
The FDA issued EUA for AstraZeneca’s EVUSHELD (tixagevimab co-packaged with cilgavimab) for the pre-exposure prophylaxis (prevention) of COVID-19 in certain adults and pediatric patients (12 years of age and older weighing at least 88 pounds).
EVUSHELD is intended for the highest risk immunocompromised individuals who are not expected to have an effective response to vaccination. EVUSHELD is indicated for pre-exposure prophylaxis only and not for treatment of patients with COVID-19. It is not intended as a replacement for COVID-19 vaccines or boosters.
Changes for Medicare Advantage claims
Effective Jan. 1, 2022, claims for the administration of COVID-19 vaccines and monoclonal antibody products to members enrolled in a Medicare Advantage plan must be submitted to the health plan.
As the public health emergency stabilizes, the Health Plan is determining appropriate timing for resumption of pre-COVID-19 operations.
Postponing elective surgeries and non-essential proceduresOn 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: