Until further notice, the vaccine costs will be funded by the federal government for our medical plan members across all lines of business. However, reimbursement for administering the vaccine will vary by line of business.

TennCare will cover the cost to administer the vaccines to the following members through their Pharmacy Benefit Manager (PBM):

• BlueCare Tennessee and CoverKids members, when administered by a pharmacist.

(CoverKids folded under BlueCare effective Jan. 1, 2021, so the same provisions apply for these members.)

We’ll cover the cost to administer the vaccines to:

• BlueCare Tennessee members, including CoverKids members, when in a hospital setting.
• Commercial members in most cases. Grandfathered employer self-funded health plans (those which existed before the Affordable Care Act) can make their own decisions as to what should be covered.
• Medicare Advantage and BlueCare Plus members, effective Jan. 1, 2022

Claims for vaccines funded by the federal government should not be filed with BlueCross. If you’re an immunizing provider, please file your claims as follows:

Medicare Advantage and BlueCare Plus:

• Hospitals: Submit administration claims to us according to your regular hospital contract.
• Health Departments: Submit administration claims according to your regular health department contract.
• Pharmacies: If pharmacy coverage is through BlueCross, submit claims through the BlueCross PBM.
• Other (Mobile Units, Group Practices): Submit administration claims according to your regular professional services contract.

• Hospitals: Submit administration claims to us according to your regular hospital contract.
• Health Departments: Submit administration claims according to your regular health department contract.
• Pharmacies: Submit claims to TennCare’s Pharmacy Benefit Manager (PBM).
• Other (Mobile Units, Group Practices): Submit administration claims according to your regular professional services contract.

• Hospitals: Submit administration claims to us according to your regular hospital contract.
• Health Departments: Submit administration claims according to your regular health department contract.
• Pharmacies: If pharmacy coverage is through BlueCross, submit claims through the BlueCross PBM.
• Other (Mobile Units, Group Practices): Submit administration claims according to your regular professional services contract.

Until further notice during the COVID-19 emergency, our reimbursement for vaccine administration will be consistent with the current CMS rates. Please use the following codes when submitting claims:

• Pfizer
  • 91300 (Effective Dec. 11, 2020)
  • 0001A (Effective Dec. 11, 2020)
  • 0002A (Effective Dec. 11, 2020)
  • 0003A (Effective Aug. 12, 2021)
  • 0004A (Effective Sept. 22, 2021)
  • 91305 (Effective Oct. 29, 2021)
  • 0051A (Effective Oct. 29, 2021)
  • 0052A (Effective Oct. 29, 2021)
  • 0053A (Effective Oct. 29, 2021)
  • 0054A (Effective Oct. 29, 2021)
  • 91307 (Effective Oct. 29, 2021)
  • 0071A (Effective Oct. 29, 2021)
  • 0072A (Effective Oct. 29, 2021)
  • 0073A (Effective Jan. 3, 2022)
  • 91308 (Effective Feb. 1, 2022)  
  • 0081A (Effective Feb. 1, 2022)
  • 0082A (Effective Feb. 1, 2022)
  • 0083A (Effective June 17, 2022)
  • 91312 (Effective Aug. 31, 2022)
  • 0124A (Effective Aug. 31, 2022)
  • 91315 (Effective Aug. 31, 2022)
  • 0154A (Effective Aug. 31, 2022)
• • 91317 (Effective Dec. 8, 2022)
  • 0173A (Effective Dec. 8, 2022)

• Moderna
  • 91301 (Effective Dec. 18, 2020)
  • 0011A (Effective Dec. 18, 2020)
  • 0012A (Effective Dec. 18, 2020)
  • 0013A (Effective Aug. 12, 2021)
  • 91306 (Effective Oct. 20, 2021) 
  • 0064A (Effective Oct. 20, 2021)
  • 91309 (Effective March 29, 2022)
  • 0094A (Effective March 29, 2022)
  • 91313 (Effective Aug. 31, 2022)
  • 0134A (Effective Aug. 31, 2022)
  • 91314 (Effective Aug. 31, 2022)
  • 0144A (Effective Aug. 31, 2022)
  • 91316 (Effective Dec. 8, 2022)
  • 0164A (Effective Dec. 8, 2022)

• Janssen (Johnson & Johnson)
  • 91303 (Effective Feb. 27, 2021)
  • 0031A (Effective Feb. 27, 2021)
  • 0034A (Effective Oct. 20, 2021)

• In-Home Administration (for use with the applicable vaccine administration code above when a vaccine is given in a patient’s home)
  • M0201 (Effective June 8, 2021)

• Novavax
  • 91304 (Effective July 13, 2022)
  • 0041A (Effective July 13, 2022)
  • 0042A (Effective July 13, 2022)
  • 0044A (Effective Oct. 19, 2022)

Please note: We’re currently processing claims for the administration of the vaccines listed above. As more vaccines become approved, we’ll add their codes to this list. If you have questions about these vaccines, please refer to the CDC website.

No, our dental providers should not bill for vaccine administration. Claims received from dental offices for COVID-19 vaccine administration will be denied.

No. Member cost-share for COVID-19 vaccines and the vaccine administration should be covered by BlueCross, or the member’s PBM if pharmacy coverage is not through BlueCross, or the Provider Relief Fund, depending on the member’s coverage. Members enrolled in Commercial grandfathered employer self-funded health plans (plans that existed before the Affordable Care Act was enacted) might not have coverage for the vaccine and its administration.

If a member’s plan doesn’t cover the vaccine or its administration, please file your claim with the Provider Relief Fund to receive payment for administering the vaccine.

In April 2020, the TDH began contacting all licensed physicians and pharmacists in Tennessee, including providers, pharmacies and urgent care sites on the Tennessee Immunization Information System (TennIIS) list. You can find details about the TDH’s continued recruitment efforts on their COVID-19 vaccine distribution website. This site also includes the TDH’s draft vaccination plan, currently under review with the CDC.

In addition to state efforts, the federal government has also announced requirements for providers. To receive free supplies of the COVID-19 vaccine(s), providers must sign an agreement with the CDC, agree to vaccinate individuals regardless of the type of coverage they have and not balance bill the patient. The providers also need to meet storage and record-keeping requirements.

The TDH is working to make sure there’s an equitable distribution of vaccination sites across all 95 counties, especially in rural counties and areas with high concentrations of people in vulnerable populations. Providers who wish to administer the COVID-19 vaccine may find more information online at on the TDH website.

Please continue to work with your state and local health department for the latest information on vaccine distribution and availability in your community.

We’re prepared to quickly credential and enroll all immunizing pharmacists during the COVID-19 emergency. Providers should submit a Provider Enrollment Form (PEF) using Availity and declare the need for an expedited enrollment. You can find information about enrollment on our provider website.

When filling out the PEF, please use the Notes section to provide additional information about the expedited request, including the date the practitioner will begin providing services. Once you submit your form, we also recommend you send an email to your Network Manager with the subject line “COVID-19 Request.” That way, they can help prioritize your request with our enrollment team. Please include your expected start date and the PEF number you receive from your application.

Please note, pharmacies still need to manage enrollment through the Pharmacy Benefit Manager (PBM) for each line of business.

Adults age 18 and older are eligible for the Pfizer, Moderna and Novavax vaccine. All U.S. residents age 5 and older are now eligible for the vaccine. Children age 6 months and older are eligible for the Moderna and Pfizer vaccines and adolescents between the ages of 12 and 17 are eligible for the Novavax vaccine. The FDA has also authorized COVID-19 booster shots for all adults age 18 and older. Pfizer and Moderna have released new boosters that are authorized for children ages 5 and up and 6 and up, respectively.

For more information about booster shots and patient eligibility, review the CDC guidance here.

Your patients can check with their local health department or visit VaccineFinder.org to find vaccine locations. The U.S. Department of Health and Human Services has also created a national hotline to help connect people with disabilities to information about the COVID-19 vaccine. The Disability Information and Access Line (DIAL) can help callers find vaccine locations, schedule appointments and access community services, like transportation. Your patients can reach the hotline by calling 1-888-677-1199 or emailing DIAL@n4a.org. Calls are answered Monday through Friday between 8 a.m. and 9 p.m. ET.

Several websites offer helpful information about COVID-19 vaccines, including availabilty and care recommendations.

For news at the state level, the TDH regularly updates information about vaccine development and plans for administration on their COVID-19 website. They also post frequent webinars to keep providers up to speed. If you want the latest news by email, you can subscribe for updates at the bottom of this page.

Likewise, the Tennessee Hospital Association (THA) website has a number of communications guides designed to help providers talk to their patients about the vaccines. This includes recorded webinars with medical experts, presentations, vaccine toolkits and more. You can access the THA materials at tha.com.

For news at the federal level, you may want to visit the CDC COVID-19 vaccination site and the FDA COVID-19 site. The Centers for Medicare & Medicaid Services (CMS) have also issued toolkits to help providers prepare for vaccination administration once the vaccines become available.

As always, we’ll continue to provide updates on this BCBSTupdates site as we receive new information.

As your patients’ trusted source for health-related information, it’s essential that you and your staff are prepared to speak to concerns they may have about the virus and vaccines. The CDC offers helpful information to guide discussions with patients here.

Yes. Effective March 15, 2022, until the end of the federal public health emergency, we’ll cover COVID-19 vaccine counseling for our Commercial members, even if the patient chooses not to receive the vaccine. You may receive reimbursement for vaccine counseling during preventive health visits, when providing acute care, refills or other services, or when COVID-19 vaccine counseling is the sole reason for the visit.

To receive reimbursement, please bill CPT^® code 99401 with a CR modifier to indicate a public health emergency code. The following coding criteria also apply:

• If vaccine counseling was provided at the same time as an office visit for acute care, to address diagnosed illness or for medication refills, include modifier -25 with the office visit evaluation and management code.
• Include CR and GT modifiers if provided during a telehealth visit.
• Include CR and KX modifiers if provided telephonically.
• Only one code may be billed per day.

Please note: To qualify for reimbursement, this service must be provided by a professional with MD/DO, NP, PA or CNM credentials. If a member receives vaccine counseling from an eligible provider in a local health department, federally qualified health center or a rural health clinic, the payment will be outside the prospective payment system rate. This does not apply to our members with Medicare Advantage plans.

Since mid-November 2020, the Tennessee Department of Health has been shipping monoclonal antibody products to Tennessee providers and infusion centers that agreed to administer the treatment. In many cases, they’ve been supplied by the government and are free of charge. Providers should only bill BlueCross for administering the treatment when products are supplied by the federal government.

Effective Oct. 1, 2021, we began reimbursing our in-network providers for administering this treatment to our Commercial members, per their BlueCross provider agreements. Effective Jan. 1, 2022, we also began reimbursing our in-network Medicare Advantage and BlueCare Plus providers for administering this treatment, per their BlueCross agreements. To find the most current listing of monoclonal antibody treatments, please visit CMS.gov. 

Yes. Effective Dec. 28, 2021, and until the end of the public health emergency, we’ll cover the administration of COVID-19 convalescent plasma with high titers of anti-SARS-CoV-2 antibodies for treatment of COVID-19 in patients with immunosuppressive disease or getting immunosuppressive treatment, in the outpatient or inpatient setting. Providers should bill HCPCS code C9507 to be reimbursed for this treatment.

Since Feb. 4, 2020, we’ve covered our members’ cost-share for COVID-19 testing that’s been recommended by a member’s health care provider based on their symptoms, risk or exposure. We also covered related office visits and services, including reimbursing for multiple tests for the same patient.

Please help us identify your COVID-related claims by using the CS modifier for these types of services provided after March 18, 2020, and through the COVID-19 emergency or until further notice. When billing with the CS modifier, please be sure to use the appropriate modifiers, per guidelines from the AMA, CMS, etc. This policy applies to FDA-approved tests and those currently pending FDA approval. It also applies to testing performed by providers outside of our network.

If you have claims that have been processed any differently, please contact the Provider Service line at 1-800-924-7141 for assistance.

Prior authorization isn’t required for the testing of coronavirus; however, other prior authorizations or notification requirements continue to be in effect during the Public Health Emergency. We have prior authorizations in place for several reasons, but mainly to make sure treatments are covered and our members don’t pay more than they should.

From Feb. 4, 2020, until further notice during the COVID-19 emergency, our reimbursement will be consistent with the current CMS rates for COVID-19 lab testing. This applies to FDA-approved COVID-19 tests and those currently pending FDA approval. Please use the following codes for all contracted and non-contracted labs and providers across all BlueCross BlueShield of Tennessee product lines:

• U0001 – CDC
• U0002 – Commercial Labs
• CPT^® code 87635 to be priced at the U0002 payment or the lesser of billed charges once physicians can do their own testing
• U0003 and U0004 – High-Throughput Testing (Effective April 14, 2020)
• 87426 – (Effective June 25, 2020)
• 87636 – (Effective Oct. 6, 2020)
• 87637 – (Effective Oct. 6, 2020)
• 87811 – (Effective Oct. 6, 2020)
• 0240U – (Effective Oct. 6, 2020)
• 0241U – (Effective Oct. 6, 2020)
• 87428 – (Effective Nov. 10, 2020)
• U0005 – (Effective Dec. 4, 2020)

From March 1, 2020, until further notice during the COVID-19 emergency, our reimbursement will be consistent with the current CMS rates for COVID-19 lab testing. This applies to FDA-approved COVID-19 tests and those currently pending FDA approval. Please use the following codes to ensure timely payment:

• G2023 – home/nursing home collection from an independent lab (POS-81)
• G2024 – home/nursing home collection from an independent lab (POS-81)
• C9803 – hospital outpatient

Yes. Testing guidelines for these circumstances are outlined below:

• COVID-19 testing done 72 hours before an admission/OP procedure will pay “in addition” to the procedural reimbursement.
• COVID-19 testing done less than 72 hours (i.e., 48 hours), but prior to the day of the admission/OP procedure, will pay “in addition” to the procedural reimbursement.
• COVID-19 testing done the day of the OP procedure and billed on the same claim as the OP procedure will pay “in addition” to any OP procedure. Inpatient admission will be included in the DRG charge.

Please note: The test will be covered even if the member’s admission/OP procedure is canceled due to a positive COVID-19 test.

Yes. COVID-19 testing performed as part of an ER visit will be reimbursed separately from the ER visit reimbursement. Please help us identify your COVID-related claims by using the CS modifier for these types of services provided after March 18, 2020, and through the COVID-19 emergency or until further notice.

When billing with the CS modifier, please be sure to use the appropriate modifiers, per guidelines from the AMA, CMS, etc. This policy applies to FDA-approved tests and those currently pending FDA approval. It also applies to testing performed by providers outside of our network.

No. While some dental practices may choose to test their patients for COVID-19 as part of their safety procedures, we’re only covering medically necessary COVID-19 tests that have been recommended by a member’s medical care provider based on symptoms, risk or exposure.

For our Commercial and Medicare Advantage lines of business, we waived member cost-share for in-network COVID-19 treatment, including hospitalization, for dates of service through May 30, 2021. Now that COVID-19 vaccines are available for everyone over the age of 12, we’re no longer waiving cost-share.  

Please note that the original waiver did not apply to air ambulance or non-emergency ground ambulance services. Also, our self-funded employer groups had the ability to opt out of this benefit. Out-of-network treatment continues to be subject to out-of-network benefits and our out-of-network allowed amounts.

No. We understand that many businesses and schools have revised their health and safety practices to require COVID-19 testing as part of their return-to-work or -school safety procedures. However, employment- or school-based COVID testing is not part of our members’ health plan benefits, similar to pre-employment and periodic drug testing, and coverage for it isn’t included under the CARES Act. We’ll continue to cover the full cost of COVID-19 testing that’s recommended by a member’s health care provider based on their symptoms, risk or exposure. And until further notice during the COVID-19 emergency, our reimbursement will be consistent with the current CMS rates for COVID-19 lab testing. This applies to FDA-approved COVID-19 tests and those currently pending FDA approval.

Yes. We’ll cover our members’ swabs and test results in a drive-through setting as part of the lab payment. However, we’ll only reimburse for our members’ COVID-19 swabs and test results in drive-through testing.

The CDC has linked to each state’s department of health contact information for testing. Here’s a link to the CDC site: cdc.gov/publichealthgateway/healthdirectories/healthdepartments.html.

We’ll pay for FDA-approved versions of these tests when they’re ordered by an in-network physician during in-person or telehealth appointments.

Many of the antibody tests marketed have proved to be ineffective, so we’ll only cover the ones that the FDA has cleared, approved or given emergency use authorization for. Like you, we’re deeply invested in making sure our members get safe, effective and conclusive tests, while minimizing false or misleading diagnoses.

If the above conditions are met, our reimbursement will be consistent with the current CMS rates for COVID-19 lab testing. This applies to FDA-approved COVID-19 tests and those currently pending FDA approval. Please use the following codes to ensure timely payment:

• 86328 and 86769 – Antibody Testing During Appointment
  Effective for dates of service April 10, 2020, until further notice during the COVID-19 emergency.
• 0224U – Antibody Testing During Appointment Effective for dates of service June 25, 2020, until further notice during the COVID-19 emergency.

Yes. During the COVID-19 emergency and beyond, you may bill for telehealth for these lines of business. This applies to services that previously required an in-person visit in settings like outpatient clinics, hospitals, emergency departments and therapist offices. Pricing will be consistent with your BlueCross fee schedule. All of the following are required:

• Effective for dates of service beginning March 16, 2020.
• The services provided are covered under the member’s benefits, and are eligible for separate payment when performed in person.
• The services take place in real time, and the provider and patient are connected via interactive audio/telephonic consultations or an interactive audio and video telecommunications system (virtual consultations).
• All services provided are medically appropriate and necessary.
• All relevant online communications about the member’s medical care and follow-up are included in their medical record.
• Any evaluation and management services (E/M) provided via telehealth include a problem-focused history and straightforward medical decision-making, per the Current Procedural Terminology (CPT^®) manual.

When billing for telehealth, applicable service codes, diagnostic codes, modifiers and units should be reported with Place of Service-02, -10 or your normal Place of Service code with a 95 modifier appended to the CPT/HCPCS code. This will let us know you’ve treated our member using telehealth.

Click here for a full guide on Medicare Advantage telehealth services.

Click here for a full guide on commercial telehealth services.

Yes, in accordance with CMS guidelines, we’ll cover these visits with in-network providers during the COVID-19 emergency or until further notice. Once the state of emergency is lifted, we’ll reevaluate our policy and provide an update on this site.

Please bill them with the appropriate Revenue code and the DR (Disaster Recovery) condition code.

No. Please continue to include your normal service codes, diagnostic codes, modifiers and units. Just be sure to include Place of Service-02, -10 or your normal Place of Service code with a 95 modifier appended to the CPT/HCPCS code. Pricing will be consistent with your BlueCross fee schedule. All of the following are required:

• Effective for dates of service beginning March 16, 2020, until further notice during the COVID-19 emergency.
• Providers supported by this exception are licensed physical therapists, occupational therapists, speech-language pathologists and ABA therapists.
• All services provided are medically appropriate and necessary.
• The services must take place in real time, and the patient and provider are connected via an interactive audio and video telecommunications system.
• All relevant online communications about the member’s medical care and follow-up are included in their medical record.
• Any existing visit limitations and/or prior authorization requirements continue to apply.

We won’t cover telehealth for educational or administrative services. We also won’t cover patient communications incidental to evaluation and management services (E/M), counseling or medical services covered by this policy. This includes, but is not limited to, providing educational materials. We also won’t cover treatment that requires specialized hands-on care or specialized equipment, such as whirlpools, etc. This includes Athletic Trainings (97169 – 97172), Modalities (97010 – 97039) and Group Therapies. Any member currently receiving group therapy should be considered for individual therapy via telehealth.

Yes. You can use E/M codes to bill for telehealth with both new and established patients.

No. Only contracted and credentialed physicians, specialists, Nurse Practitioners and Physician Assistants can bill for telehealth services. Additionally, Nurse Practitioners and Physician Assistants who provide telehealth services must be supervised by a contracted physician. Claims should be billed per Provider Administration Manual guidelines.

No. Our priority is to support our members, which may include exploring ways to temporarily relax or suspend clinical and administrative policies. Right now, our current policies remain in place. During the COVID-19 emergency, however, we’re closely monitoring the changes to federal and CMS guidelines and will align with any updates they release.

Yes. We’re relaxing the originating site and geographic requirements for all Medicare Advantage plans during the COVID-19 emergency or until further notice.

Yes. BlueCare aligns with recent CMS regulations, which allow for telehealth visits via platforms like Apple FaceTime, Facebook Messenger video chat, Skype, Google Hangouts video and Zoom.

We’re waiving telehealth cost-share for our Commercial and Medicare Advantage members if the service is related to COVID-19 testing and performed by network providers during the COVID-19 emergency or until further notice. If telehealth is being provided for other conditions, member cost-share will apply. Our self-funded employer groups have the ability to opt out of this benefit. Out-of-network treatment will be subject to out-of-network benefits and our out-of-network allowed amounts.

No. We don’t cover chiropractic services for telehealth.

Yes. We encourage our patients to use their Teladoc^TM Health benefits, if they have them. We also encourage patients to avoid using the emergency room, except in a true medical emergency, to prevent the spread of illness.

Yes. Telehealth has made it easier for members to access health care, so we’ve decided to continue to support telehealth services for our Commercial line of business for in-network providers who offer them. Until further notice, Medicare Advantage and BlueCare Plus will continue covering telehealth during the COVID-19 emergency, as we have since March 16, 2020.

We strive to deliver important updates to you quickly through this Provider FAQ, so some details may conflict with what’s already been published in our Provider Administration Manuals (PAMs). If you find information in this Provider FAQ conflicts with a provision in a PAM, the Provider FAQ information will temporarily take precedence over previously published information in the PAM during this pandemic. If you have questions or need clarification, please contact your Network Manager.

You should continue using the same credentialing and enrollment processes; but let us know of any constraints or delays that you have with third-party requirements, such as CMS or accreditation. We can process your application with this additional information, and make it part of your file for our Credentialing Committee to assess. The Committee may decide to approve the application for a shortened period of time and require you to re-credential earlier to ensure that pending requirements have been satisfied.

BlueCross is adhering to the emergency directives set forth in the State of Tennessee Executive Order by the governor, available here.

BlueCross is prepared to quickly credential and enroll all initial applicants during the COVID-19 emergency. Providers should submit a PEF and declare the need for an expedited enrollment due to the current COVID-19 emergency.

You can do this by checking the COVID-19 Emergency Declaration check box, which will tell us you believe the request is related to the location and/or enrollment waivers. It will also route your enrollment to the appropriate area for review.

When you submit your form, we recommend emailing your Network Manager with the subject line “COVID-19 Request” and include the PEF number so they are aware of the request as well as the dates the practitioners need to begin providing services.

You don’t need to notify us if the billing Group NPI, Tax ID and Individual NPI on the claim will be the same for the practitioner at either location. Reimbursement won’t change, and claims will process under the practitioner’s existing setup for that network.

Please email your Network Manager using the subject line “COVID-19 Request” so they can help you with any changes needed to your existing contract.

If your office or one of your practice locations will be closed for an indefinite period, we suggest you submit that information to us in a Change Form. In the Office Hours section of the Change Form, please indicate all days that each specific location will be closed. We’ll update our member-facing, online provider directory to reflect this closure until we receive an update from you.

Your practitioners, office locations and networks will continue to display in the directory as usual, with the exception of the Location & Hours section. When the office reopens, please submit a new Change Form with the correct office hours for the location.

Thank you for continuing to keep your phone lines and websites up to date with the latest information about your practice’s policies and hours or if you’re redirecting patients to other providers. We’re reminding members to check with you before any office visit.

We understand this is a confusing time. We want to keep you updated so we can work together to care for your patients and our members. We’ve received your questions and we’re regularly posting answers here in our provider FAQs and in Availity. You can also help us communicate with you better by telling us how you prefer to be contacted. Just submit that information in Availity.

Yes. We continue to be committed to serving our members and providers during the COVID-19 emergency. We acted quickly to make sure our employees could work effectively from home while practicing social distancing. At the same time, we’ve prioritized our claims, customer service and clinical operations. We’re monitoring the situation and our service metrics, and will revisit as needed.

We allowed early refills on many medications throughout most of the COVID-19 emergency. On Sept. 1, 2021, we reverted to our standard refill timeline. We still encourage our members to ask their providers about 90-day fills for chronic medications. Controlled substances, such as opioids, and some specialty drugs are excluded from this 90-day-supply benefit. Members with a mail-order benefit can use that to avoid going to the pharmacy.

Yes. Any prescriptions or over-the-counter drugs you recommend for at-home symptom treatment will have a normal copay or cost-share.

We’ll cover home births with a certified nurse midwife for our members who have that benefit. We recommend home births only for low-risk pregnancies, and the member must have a detailed birthing plan that includes a hospital and doctor, in case of complications. For more information, please refer to your Provider Administration Manual.

To help our providers during this trying time, we announced we would temporarily delay recoupments until further notice. Effective May 15, 2020, we resumed recoupment for funds we’ve overpaid. If you have questions, please contact your Network Manager.

No. We don’t reimburse for these additional supplies under our health plans.

Prior authorization isn’t required for the testing of coronavirus; however, all other prior authorizations or notification requirements continue to be in effect during the public health emergency. We have prior authorizations in place for several reasons, but mainly to make sure treatments are covered and our members don’t pay more than they should.

If you want to extend an existing prior authorization that’s already been approved for an elective procedure, please contact us directly and we’ll work with you to change the date of service. Otherwise, please see below for prior authorization validity periods for the following lines of business:

Commercial:

• Elective outpatient procedures — 90 days
• Select office procedures — 30 days

Medicare Advantage and BlueCare Plus:

• Outpatient elective procedures — 180 days
• Inpatient requests — 5 days from date of service
• MSK spine injections — 30 days

No. Our priority is to support our members, which may include exploring ways to temporarily relax or suspend clinical and administrative policies. Right now, our current policies remain in place. During the COVID-19 emergency, however, we’re closely monitoring the changes to federal and CMS guidelines and will align with any updates they release.

No. We aren’t waiving the requirement for chronic conditions, as this is a CMS requirement. During the COVID-19 emergency, we’re closely monitoring the changes to federal and CMS guidelines and will align with any updates they release.

No. In light of COVID-19, we are prioritizing the processing of all requests. During the COVID-19 emergency, we want to support our provider partners so they can focus on dealing with this health crisis. Currently our requirements for timely filing for all lines of business are:

• Commercial — 180 days
• Medicare Advantage and BlueCare Plus — 365 days

No. Our priority right now is to support our members by exploring ways to temporarily relax or suspend clinical and administrative policies, and offering premium extensions.

Acting upon guidance from CMS and Congress, we suspended the 2% sequestration reduction for claims with dates of service April 1, 2021, through Dec. 31, 2021. As of Jan. 1, 2022, we once again began implementing the 2% payment reduction for covered services provided to BlueAdvantage (PPO)^SM, BlueCare Plus (HMO D-SNP)^SM and BlueCare Plus Choice (HMO D-SNP)^SM plan members. This is the same day that CMS is reinstating its 2% sequestration payment reduction to our Medicare Advantage plan capitation payments, as well as Original Medicare Part A and Part B payments. The 2% reduction is detailed in the terms of your provider participation agreement(s) and our Provider Administration Manuals.

When we updated our systems to reinstate the 2% reduction, we also adjusted our claims payment process to better align with the CMS sequestration reduction. Any changes should be nominal (we’re talking pennies). However, if you have concerns about a claim, we’ll be happy to review the information.

Yes. We temporarily pended impacted claims to make sure payment amounts were correct. Those claims have now been processed.

The CMS website provides updates about the 2% sequestration here.

Our reimbursement systems are up to date with all add-on payment provisions as outlined in the CARES Act. Pertinent claims will receive the proper rates as provided by CMS.

CPT^® is a registered trademark of the American Medical Association.