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 your Provider Network Consultant directly or email your question to DHP.PNCInquiry@deancare.com for a prompt reply.
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: 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.
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:
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.
The Wisconsin Department of Health Services encourages providers to be enrolled in the Wisconsin COVID-19 Vaccine Program, if they meet the requirements.
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.
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.
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.
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 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 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.
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.
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.
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.
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:
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:
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.
Additionally, a new POS code 10 has been created.
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.
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)