Excellus BCBS Updates on COVID-19 (Coronavirus)

Last Updated: 1/19/2021

COVID-19 Information and Resources

We are closely monitoring Novel Coronavirus (COVID-19). Our top priority is the health and well-being of the members that we serve. We are also committed to sharing the information we have when it becomes available to us. Because information is changing and evolving daily, please check back regularly. We are in contact with local, state and federal health and other officials and we will implement applicable orders, regulations,and requirements as they become effective.

Please continue to refer to the following websites for up-to-date health information:
§ U.S. Centers for Disease Control and Prevention
§ New York State Department of Health
§ Your County Health Department

We also encourage you to check our News and Updates regularly for communication updates. Type COVID-19 in the Search area. Keep in mind that you must be logged in with your username and password to access all news updates.

THANK YOU for your patience, understanding and collaboration as we all rally to navigate this new health care landscape.

 

For all products and lines of business, the Health Plan will provide coverage with no member cost-share for COVID-19 diagnostic/viral testing as well as antibody testing. The testing must be medically appropriate for the diagnosis and treatment of an individual by an attending provider as evidenced by an order from the attending provider.  

Attending providers should make individualized determinations regarding whether a test is medically appropriate for each patient based on a personally performed telehealth or face-to-face encounter with their patients, and in accordance with accepted medical standards and practice.  Attending providers are responsible for monitoring medical appropriateness guidance issued by federal and state health authorities. The tests must be approved by the U.S. Food and Drug Administration (FDA) or must be the subject of an emergency use order request and the lab performing the testing must be appropriately certified. 

Testing that is ordered or performed solely for purposes of pandemic control or re-opening the economy, and not based on a determination by an attending provider that the test is medically appropriate for the diagnosis and treatment of an individual member, is not covered.  This includes tests performed on an asymptomatic individual solely to assess health status as required by parties such as an employer, common carrier, school, camp, travel authority/advisory, nursing home (to visit a resident), government/public health agency or research/epidemiologic study, or when ordered upon the request of a member solely to facilitate the member’s desire to self-assess COVID-19 immune status.

The following important information regarding antibody testing and antigen testing should be considered when determining the appropriateness of these tests. 

We also encourage you to review these testing guidelinesOpen a PDF.

Antibody Tests

  • Antibody testing to diagnose acute infection is not recommended. Viral (nucleic acid or antigen) testing to diagnose acute infection is recommended by the  Centers for Disease Control and Prevention.

  • Antibody testing is not recommend for use as the sole basis for diagnosis or to rule out COVID-19. Please refer to the  FDA website and  Infectious Disease Society of America website for additional information.  

  • Please refer to the Infectious Diseases Society of America’s COVID-19 Antibody Testing Primer
    Key points from the Antibody Primer include, but are not limited to:
    • The antibody response in affected patients remains largely unknown and the clinical values of antibody testing have not been fully demonstrated. . 
    • With the rapid release of numerous antibody tests, there are still issues that need to be addressed, including test quality, interpretation, and utility of antibody tests. These numerous antibody tests vary in the viral antigen(s) they target, and it is not yet clear which antibody responses, if any, are protective or sustained.
    • Antibody tests are most useful as surveillance tools to estimate (with surrounding confidence intervals) relative proportions of different populations that have been exposed to SARS CoV2. They have less utility as diagnostic tools for individual patient assessment.

  • Not all marketed serological (antibody) tests have been evaluated by the FDA.  The FDA’s authorized tests, including serological tests, are listed on its  Emergency Use Authorization (EUA) page. Tests being offered under a policy outlined in the FDA’s COVID-19 Diagnostic Policy Guidance are listed on the FDA’s FAQ page. Such tests have not been reviewed by the FDA, unless an EUA has also been submitted and reviewed by the FDA.

  • Antibody testing should only be ordered by clinicians familiar with the use and limitations of the test, along with appropriate pre- and post-test counseling documented in the medical record.    

CDC Interim Guidance for COVID-19 Antibody Testing

On May 23, 2020, the Center for Disease Control and Prevention issued interim guidelines for COVID-19 antibody testing, which include the following: 

  • Serologic testing should not be used to determine immune status in individuals until the presence, durability, and duration of immunity is established.
  • Serologic test results should not be used to make decisions about grouping persons residing in or being admitted to congregate settings, such as schools, dormitories, or correctional facilities
  • Serologic test results should not be used to make decisions about returning persons to the workplace.
  • Additional data are needed before modifying public health recommendations based on serologic test results, including decisions on discontinuing physical distancing and using personal protective equipment.

Recommendations for Use of Serologic/Antibody Testing

  • Serologic assays that have Emergency Use Authorization (EUA) are preferred for public health or clinical use since their test performance data have been reviewed by FDA. 
  • Serologic testing can be offered as a method to support diagnosis of acute COVID-19 illness for persons who present late. For persons who present 9-14 days after illness onset, serologic testing can be offered in addition to recommended direct detection methods such as polymerase chain reaction. This will maximize sensitivity as the sensitivity of nucleic acid detection is decreasing and serologic testing is increasing during this time period.
  • Serologic testing should be offered as a method to help establish a diagnosis when patients present with late complications of COVID-19 illness, such as multisystem inflammatory syndrome in children.

Limitations of Current Antibody Testing

  • Some tests may exhibit cross-reactivity with other coronaviruses, such as those that cause the common cold. This could result in false-positive test results. Some persons may not develop detectable antibodies after coronavirus infection. In others, it is possible that antibody levels could wane over time to undetectable levels. 
  • Definitive data are lacking, and it remains uncertain whether individuals with antibodies (neutralizing or total) are protected against reinfection with SARS-CoV-2, and if so, what concentration of antibodies is needed to confer protection.

Antigen Testing

  • While antigen tests are thought be very specific for the virus, they are not as sensitive as molecular tests and therefore have a higher chance of false negatives; a negative antigen test result does not rule out infection and may need to be confirmed with a molecular test prior to making treatment decisions or to prevent possible spread of the virus due to a false negative. Please review the FDA’s General FAQs section.

Administrative Policy and Coding Guidance for COVID-19 Viral and Antibody Testing

The Health Plan has implemented Administrative Policy 26  ̶  COVID-19 Viral and Antibody Testing, to define the coverage, reimbursement and billing guidelines for COVID-19 viral and antibody testing. This policy applies to participating and non-participating practitioners, facilities, laboratories and pharmacies and all lines of business effective March 13, 2020, the date of the national state of emergency declaration. This retrospective application is intended to capture all relevant testing claims that were addressed in subsequent federal legislation and guidance.

The Health Plan provides coverage in full for diagnostic/viral testing as well as antibody testing that is determined to be medically appropriate for the diagnosis and treatment of an individual by an attending provider as evidenced by an order from the attending provider.  The tests must be FDA approved or the subject of an emergency use order request and the lab performing the testing must be appropriately certified. 

For purposes of commercial or Medicaid Managed Care member testing, attending providers are limited to physicians, nurse practitioners, physician assistants and pharmacists.  For purposes of Medicare Advantage member testing, attending providers include any health care provider who is authorized to order laboratory tests under New York State law.

Provider claims for medically appropriate COVID-19 testing MUST be submitted with one of the following codes: CPT® codes U0001, U0002, U0003, U0004, 0202U, 86328, 87635, and/or 86769. These codes may be billed with diagnoses of B97.29, U07.1, Z03.818, and/or Z20.828 when appropriate. 

Laboratories MUST bill G2023 and G2024 for the purpose of specimen collection of patients at skilled nursing facility or for homebound patients. Again, these codes may be billed with diagnoses of B97.29, U07.1, Z03.818, and/or Z20.828 when appropriate.

Pharmacies providing medically appropriate COVID-19 testing for Commercial and Medicaid members may submit claims using the National Council for Prescription Drug Programs COVID-19 testing billing methodology. For additional information, please refer to the following billing guidance documents:

For Medicaid members: NYS Medicaid COVID-19 Sample Collection and Testing Claims Submission.Open a PDF

For Commercial members: Commercial COVID-19 Sample Collection and Testing Claims Submission.Open a PDF

For additional information, please visit the ESI Pharmacy Resource Center, or contact the ESI Pharmacy Technical Help Desk at 1-800-922-1557.

When the sole purpose of the test is for pandemic control such as testing of asymptomatic individuals to assess health status as required by an employer, school, camp, common carrier, government/public health agency, or research/epidemiologic study,  any submitted testing codes (CPT codes U0001, U0002, U0003, U0004 0202U, 86328, 87635, and/or 86769) MUST be accompanied by EITHER one of these encounter codes - Z02.0, Z02.1, Z02.4, Z02.5, Z02.79, Z02.89 Z02.9, Z56.89, and/or Z56.9, OR modifier-CG.  These testing claims are not ordered by attending providers as medically appropriate for the diagnosis or treatment of an individual(s) and are not covered.

Claims will be reviewed pre-payment and post-payment. Pre-payment review is claim review prior to payment. A pre-payment review results in an initial determination. Post-payment review is claim review after adjudication. A post-payment review may result in no change to the initial determination or a revised determination. Pre- and post-payment reviews are to ensure claim/billing accuracy and completeness and are not medical necessity reviews.

These services are subject to audit and policy updates at the Health Plan’s discretion. Commercial members will be held liable for claims that deny based upon this policy. Providers will bear responsibility for testing claim denials of Medicare Advantage, Medicaid Managed Care and Health and Recovery Plan members.

You can access this administrative policy in its entirety under the Policies & Guidelines tab. You must log in with your username and password to access our administrative policies.

Reminders

  • Viral testing to rule out an active COVID-19 infection in patients prior to elective procedures is considered a component of pre-admission testing and is not reimbursed separately.  
  • Viral testing during an inpatient hospital stay prior to transfer to post-acute care (skilled nursing facility or long-term care) is considered part of the hospital DRG.

Resources

CDC Interim Guidelines for COVID-19 Antibody Testing:
https://www.cdc.gov/coronavirus/2019-ncov/lab/resources/antibody-tests-guidelines.html#anchor_1590264293982

American Medical Association’s Serological Testing for SARS-CoV-2 Antibodies: 
https://www.ama-assn.org/delivering-care/public-health/serological-testing-sars-cov-2-antibodies

Infectious Diseases Society of America’s IDSA COVID19 Antibody Testing Primer:
https://www.idsociety.org/globalassets/idsa/public-health/covid-19/idsa-covid-19-antibody-testing-primer.pdf

Association of Public Health Laboratories and Council of State and Territorial Epidemiologists, Public Health Considerations: Serologic Testing for COVID-19,   Version 1 – May 7, 2020: 
https://www.aphl.org/programs/preparedness/Crisis-Management/Documents/Serologic-Testing-for-COVID-19.pdf

PLEASE NOTE: During the state of emergency, state and federal governments are issuing frequent COVID-19-related guidance. Our Health Plan’s policies and communications are subject to change accordingly.
 

The following information outlines the steps that we are taking to address state requirements and guidance. We have also included information on the additional efforts we are taking as a health plan to ensure member access to care and the reduction in administrative burden on our participating providers, hospitals and facilities.

Complying with Regulatory Guidance

(Please refer to NYS Dept of Financial Services Supplement No. 2 to Insurance Circular Letter No. 8 and our communication dated July 6, 2020)

  • The Health Plan will resume retrospective review for non-COVID-related services for inpatient and outpatient hospital, mental health and substance use disorder treatment facilities provided on and after June 19, 2020. We are committed to ensuring that our request for medical records in support of these reviews will be reasonable.
  • The Health Plan will not deny emergency department and/or inpatient hospital services as not medically necessary on retrospective review if the services were provided to our members to diagnose or treat COVID-19 during the declared state of emergency.
  • We continue to work diligently to ensure that hospital claims processing is completed expeditiously, while following all required steps and processes to confirm member eligibility, coverage and cost-share responsibility.
  • While the prompt pay provisions of New York’s Insurance Law allow health plans 30 days to process electronic claims and 45 days to process paper claims, we are making good faith efforts to reduce these processing time frames during the state of emergency.

Health Plan Efforts During the COVID-19 State of Emergency  

The Health Plan is taking the following steps to ensure member access to care and assist in alleviating some of the burden on our participating providers, hospitals and facilities during the State of Emergency. 

  • Increasing payment levels for and expanding telehealth services. (Please refer to our March 20, 2020 mailed communication. Contact your Provider Relations representative to request a copy.)
  • Waiving member cost-share responsibility for telehealth services.
  • Extending the time frame to submit an initial clinical editing dispute and a second level grievance.  The initial dispute time frame will change from 120 days to 210 days.  The second level grievance time frame will change 90 days to 180 days.  Please remember to attach medical records with your initial submission to avoid additional submission requests.
  • Facility claim recovery audits for both inpatient and outpatient claims will be suspended for 90 days.  Claims currently in the appeal process will be extended 90 days.
  • Physician claim audit appeal time frames will be extended to 90 days.
  • Suspending timely filing requirements for claims with dates of service from March 16, 2020 through September 16, 2020.
  • Suspending medical record requests for HEDIS reviews for our commercial and Medicaid members.
  • Providers who can bill for evaluation and management services and feel that an at-home visit with a member is necessary can bill CPT codes 99341-99350 for all health plan members. Reimbursement rates for CPT codes 99341-99350 are included in the physician fee schedules posted on our website.
  • During the State of Emergency, the health plan is suspending the credentialing requirement that a physician be licensed in New York state if he/she is licensed in another state. The health plan reserves the right to recommend to our Credentialing Committee certain individuals be accepted for temporary participation during the State of Emergency on a fast-track basis.
  • Voluntarily electing not to pass through the New York State Medicaid 1% sequestration payment reductions for affected services at this time.
  • Health plan-employed clinicians registering to volunteer their time and expertise to assist during the State of Emergency.

A telehealth visit is an option for initial screenings when an in-office visit is not an option. Telehealth services are covered under all product lines.

In-network telehealth visits will be covered with no member cost-share when the services would have been covered under the member’s policy if delivered in-person, including behavioral health treatment. To be covered as an office visit, the telehealth consultation must include all elements necessary for the service to be considered an office visit.

Please refer to our telehealth coding guidance gridOpen a PDF for assistance with the appropriate modifier and place of service code to use for the service rendered.  This grid will be updated as needed, so please check back regularly.

We also encourage you to visit our Telehealth Resources page.

Member Cost-Share for Telehealth Services

For Medicare Advantage members, we will continue to cover both COVID-19 and non-COVID-19 related telehealth services with no member cost-share through the end of the public health emergency, currently set to expire April 21, 2021. This date may be extended based on NYS and/or federal requirements. 

COVID-19-Related Telehealth Services

Under federal guidance, COVID-19-related telehealth services will remain covered in full with no member cost-share through the end of the federal public health emergency (which is currently set to expire April 21, 2021) for all lines of business. 

Non-COVID-19-Related Telehealth Services

In accordance with the NYS emergency regulation, for members covered by commercial fully insured products and members enrolled in self-funded groups that have opted in to waive member cost-share, all telehealth services (COVID-19 and non-COVID-19) must be covered in full with no member cost-share through the expiration of the NYS emergency regulation (which is currently set to expire on March 5, 2021; date subject to change). For these members, we will re-institute the customer cost-share responsibility under the member’s benefit for non-COVID-19 telehealth services when the NYS emergency regulation expires. 

It’s important to note that some of our self-funded groups have opted out of waiving member cost-share for non-COVID-related telehealth services. Please review the listOpen a PDF before providing non-COVID-related telehealth services to our members. (secure login required to access list)

Reimbursement

We will continue to reimburse all telehealth services at the same rate as the corresponding face-to-face CPT/HCPCS code.  This applies to all lines of business and may be extended for some or all programs based upon NYS and/or federal requirements. We provide advance written notice of any reimbursement updates for telehealth services.

We are closely monitoring the supply of medications that are available during the COVID-19 outbreak.

We have implemented early refill overrides for prescription medications. Pharmacists can make the override at the point of sale.

We are increasing access to prescription medications by waiving early medication refill limits on 30-day prescription maintenance medications (consistent with a member’s benefit plan).

Members are also encouraged to use their 90-day mail order benefit for prescription medications.

We will ensure formulary flexibility if shortages or access issues do occur. Emergency prescription drug overrides are also available as part of our standard exception process on an individual member basis.

On August 5, 2020, the New York State Department of Financial Services (“DFS”) issued Circular Letter No. 14 (2020) regarding charges for personal protective equipment (“PPE”) by health care and dental care providers. The Circular Letter addresses complaints received from some individuals who have been charged for PPE used by their health care/dental care provider and reminds providers that they are limited to collecting applicable patient health plan cost-sharing and prohibited from balance billing.

The Circular Letter also advises health care and dental care providers that they must refund health plan members for any fees collected for PPE. To review the Circular Letter, please visit the DFS website.

The Health Plan has not changed its reimbursement policy related to PPE, supplies or materials; they are not covered and are considered inclusive to the service provided.

To ensure that you are ready to order, receive and administer the COVID-19 vaccine, please refer to the Center for Medicare & Medicaid Services website. This site provides important information related to provider vaccine reporting requirements and other resources that will be critical to your practice or facility as you prepare to vaccinate against COVID-19. The New York State Department of Health website also provides information critical to ordering, receiving and administering the vaccine.

Provider Billing, Reimbursement and Cost-Share Information

We encourage you to review our December 29, 2020 communication for additional information related to COVID-19 vaccine billing, cost-share and reimbursement information.

Pharmacy Claims Billing Information

Pharmacies providing COVID-19 vaccinations approved under the FDA Emergency Use Authorization and Advisory Committee on Immunization Practices (ACIP) for Commercial and Medicaid members may submit claims using the National Council for Prescription Drug Programs COVID-19 vaccine billing methodology. COVID-19 vaccine claims for Medicare members must be billed to the CMS Medicare Administrative Contractor (MAC), which is the beneficiary’s original Medicare Fee-for-Service program. For additional information, please refer to the pharmacy billing guidance