What you need to know about coronavirus

Updated 6/14/21
As Prevea360 Health Plan 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.

Prevea360 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 following products: Commercial (fully-insured, including ACA) and Medicaid. 

Prevea360 Health Plan is waiving copayments and cost sharing for in-network diagnostic screenings and associated evaluation and management (E&M) services related to COVID-19.There will be no member out-of-pocket costs for all products, including Commercial, Medicare and Dean Administrative Services Only (ASO) self-funded groups.

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, Prevea360 Health Plan 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.

To receive and administer COVID-19 vaccines and supplies, organizations or individual providers must be enrolled in a federal vaccine distribution program which is being coordinated 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.

The federal government will procure and distribute the vaccine at no cost to enrolled organization and providers. The Advisory Committee on Immunization Practices (ACIP) and the CDC will be issuing future guidance on vaccine distribution based on available supply and priority populations.

Wisconsin COVID-19 vaccine program enrollment

The Wisconsin Department of Health Services encourages providers to be enrolled in the Wisconsin COVID-19 Vaccine Program, if they meet the requirements.

Updated 4/13/22

Prevea360 Health Plan has released communications linked from this page regarding federal recommendations, emergency use authorizations (EUAs), approvals and our applicable 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.

Booster dose

See our Nov. 29, 2021, provider communication regarding booster and third dose vaccine information. 

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.

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.

• Pfizer-BioNTech; 0004A

• Moderna; 0064A

• Janssen; 0034A

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 6 months after completion of the primary vaccination regimen.

• 65 years of age and older

• 18 through 64 years of age at high risk of severe COVID-19

• 18 through 64 years of age with frequent institutional or occupational exposure to SARS-CoV-2

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.

Third dose

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: 

• Pfizer-BioNTech; 0003A

• Moderna; 0013A

 

In-home administration

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.

Vaccine EUAs and approvals for adults

See our Aug. 5, 2021, COVID-19 communication regarding in-home COVID-19 vaccine administration. Use HCPCS code M0201 for in-home COVID-19 vaccine administration.

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 Nov. 24, 2020, communication regarding the FDA issued EUAs for the Pfizer-BioNTech COVID-19 vaccine on Dec. 11, 2020, and the Moderna COVID-19 vaccine on Dec. 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

 

Booster

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.

EVUSHELD 

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.

Updated 1/17/22
Prevea360 Health Plan continues to monitor monoclonal antibody therapy updates.

The FDA approved Veklury (remdesivir) for use in adults and pediatric patients (12 years of age and older and weighing at least 88 pounds) for the treatment of COVID-19 requiring hospitalization. CMS created a HCPCS code for VEKLURY (remdesivir) antiviral medication when administered in an outpatient setting — J0248 injection, remdesivir, 1 mg.

The FDA issued EUA for the prescription oral antiviral medication, ritonavir-boosted nirmatrelvir (Paxlovid). The EUA for Paxlovid is for the treatment of mild-to-moderate COVID-19 in adults and children (12 years of age and older weighing at least 88 pounds) who have tested positive for the virus, are within five days of symptom onset and at high risk for progression to severe COVID-19.

The FDA issued EUA for another prescription oral antiviral medication, molnupiravir. The EUA for molnupiravir is for the treatment of mild-to-moderate COVID-19 in adults who have tested positive for the virus, are within five days of symptom onset, at high risk for progression to severe COVID-19, and for whom alternative authorized COVID-19 treatment options are not accessible or clinically appropriate. Molnupiravir is not authorized for use in patients younger than 18 years of age.

These medications are not replacements for COVID-19 vaccines or boosters.

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.

Updated 6/14/21

As the public health emergency stabilizes, the Health Plan is determining appropriate timing for resumption of pre-COVID-19 operations.

Waiving authorizations
Outpatient services
Prevea360 Health Plan 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.

Antibody testing
Prevea360 Health Plan 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.

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.

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:

• State Lab
• Quest Diagnostics
• LabCorp
• BioReference Laboratories

Updated 2/23/22

Telehealth
We are referring to the CMS Medicare Telemedicine Health Care Provider Fact Sheet for our telemedicine coverage guidance. 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. Prevea360 Health Plan 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. Dean Health Plan is adopting the increased reimbursement rates for these codes on claims with dates of service on and after March 1, 2020, across all Dean Health Plan products.

Place of service codes for telehealth
Effective Jan. 1, 2022, the description for POS 02 changed to distinguish that the patient is not located in their home when receiving health services or health related services through telecommunication technology.

• New description for POS 02 – Telehealth provided other than in patient’s home (replaced old description of POS 02 – Telehealth)

Additionally, a new POS code 10 has been created.

• New POS 10 – Telehealth Provided in Patient’s Home

POS codes for commercial plans
On claims for members in a commercial benefit plan, providers may submit POS 10 or a POS code equal to what it would have been had the service been furnished in-person (e.g., 11, 20, 21, 22).

Regardless of what POS code is used on a commercial claim for telehealth, a telehealth modifier is also required.

• 93 – Synchronous telemedicine service rendered via telephone or other real-time interactive audio-only telecommunications system
  • Effective Jan. 1, 2022, modifier 93 should be used for audio-only visits.
• 95 - Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system

POS codes for Medicare Advantage
CMS does not require telehealth POS codes 02 and 10 on Medicare claims during the public health emergency and instructs their providers to continue billing according to current applicable rules. While POS 10 will be accepted on Medicare claims, CMS has advised that these claims will be processed and reimbursed as if POS 02 was billed which is typically a lower rate.

Refer to the CMS MLN Matters article, number MM12427, titled “New/Modifications to the Place of Service (POS) Codes for Telehealth,” for more information.

Telehealth services through 2023
CMS has extended some telehealth services, that were added on a temporary basis in response to the public health emergency, to remain in place through 2023. Refer to the CMS MLN Matters article, number MM 12549, titled “CY2022 Telehealth Update Medicare Physician Fee Schedule," for more information.

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.