All Other Providers
A Message from Todd Ray
UPDATED: We’re Here To Support You
Throughout the COVID-19 pandemic, we made changes to help our members and providers stay safe. With the National Public Health Emergency ending on May 11, 2023, we’re taking steps to return to some of our original policies and procedures. Please continue to visit this section of the bcbstupdates.com website for updates. You can also refer to the Provider Administration Manual for more information.
For Commercial, Medicare Advantage and BlueCare Plus lines of business unless stated otherwise.
COVID-19 Vaccine
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.
- Commercial members who receive the vaccine from an in-network provider. Coverage for vaccines administered by out-of-network providers will be based on OON plan benefits. Grandfathered employer self-funded health plans (those that 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.
Our in-network providers should file these 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.
Our reimbursement for vaccine administration will be consistent with the current CMS rates.
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.
All U.S. residents age 6 months or older are now eligible for the Pfizer and Moderna bivalent vaccines. Adults over 18 and adolescents between the ages of 12 and 17 are also eligible for the Novavax vaccine as an alternative to mRNA bivalent doses. However, as of April 2023, the FDA recommends a Pfizer or Moderna bivalent dose as the primary COVID-19 vaccination.
- Unvaccinated adults can receive a single dose of the vaccine.
- Children between ages 6 months and 5 years can receive two doses of the Moderna vaccine and three doses of the Pfizer vaccine.
- Those who are immunocompromised and adults ages 65-plus are authorized for a second bivalent booster dose at least four months after their initial bivalent booster.
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For more information about booster shots and patient eligibility, review the CDC guidance here.
Your patients can check 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.
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.
COVID-19 Testing and Treatment
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 bill BlueCross for administering the treatment only 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.
During the public health emergency, we covered our members' cost-share for COVID-19 testing that was recommended by a member's health care provider based on their symptoms, risk or exposure. Now that the PHE is lifted, the tests will still be covered; but they are subject to the member's normal cost share per the terms of their health care plan.
In addition, we no longer require the CS modifier for COVID-related claims. If you have questions, please contact the Provider Service line at 1-800-924-7141 for assistance.
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.
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.
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 -
NEW 86413 – Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) (COVID-19)
Effective for dates of service Sept. 8, 2020, until further notice during the COVID-19 emergency. We are still awaiting the allowable amount from CMS for this code.
COVID-19 Drive-Through Testing
COVID-19 Antibody Tests
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.
Telehealth Coverage
Yes. 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.
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.
- 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.
During the COVID-19 emergency, we waived telehealth cost-share for our Commercial and Medicare Advantage members if the service was related to COVID-19 testing and performed by network providers. Now that the PHE is lifted, telehealth services related to COVID-19 testing are still covered; but they’re subject to the member’s normal cost-share per the terms of their health care plan.
If telehealth is provided for other conditions, member cost-share will also 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.
Contracting, Credentialing and Enrollment
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.
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.
Operations
Procedural
Effective Aug. 23, 2021, we’re waiving prior authorization requirements for all levels of post-acute care (skilled nursing facilities, acute inpatient rehabilitation facilities and long-term acute care hospitals). We’ll still perform continued stay reviews once our members are in those post-acute settings. This waiver is in effect through Oct. 31, 2021, at which time we’ll reevaluate the policy.
As before, we request notification within 24 hours, or one business day, following any related facility transfers in order for our clinical staff to assist our members and their families, and to meet our contractual obligations with plan sponsors.
Effective Jan. 12, 2022, we’re waiving prior authorization requirements for all levels of post-acute care (skilled nursing facilities, acute inpatient rehabilitation facilities and long-term acute care hospitals). We’ll still perform continued stay reviews once our members are in those post-acute settings. This waiver is in effect through Feb. 28, 2022, at which time we’ll reevaluate the policy.
As before, we request notification within 24 hours, or one business day, following any related facility transfers in order for our clinical staff to assist our members and their families, and to meet our contractual obligations with plan sponsors.
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 for added convenience.
Medicare Advantage members have a benefit that allows a 100-day fill on certain generic prescriptions. Utilizing this benefit may decrease the number of needed trips to the pharmacy or frequency of mail-order deliveries.
Yes. Any prescriptions for at-home symptom treatment will have a normal copay or cost-share.
Medicare Advantage members have a new benefit that offers an over-the-counter benefit allowance each quarter. We encourage you to let your patients know they can use this allowance to purchase over-the-counter items such as cold medicines, symptom relief medications, bandages, blood pressure cuffs, etc. through CVS pharmacy. Members can call in, order online, or shop in the store or through a catalog. Please see (attach OTC benefit info here) for more information.
It’s important that we closely watch drug distribution, so everyone has access and lifesaving drugs don’t go to waste. So on April 2, 2020, BlueCross implemented an anti-stockpile policy with quantity limits on the following medications:
- Short-Acting Beta Agonist Inhalers (ProAir; Proventil; Ventolin; Xopenex)
- Chloroquine
- Hydroxychloroquine (Plaquenil)
- Lopinavir/Ritonavir (Kaletra)
- Azithromycin (Zithromax)
We’ve adopted this policy temporarily until we’re no longer in a state of crisis. We’ll provide an update in this Q&A document when we decide to make a change.
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. 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
To better serve our members, we’ve made the decision to waive prior authorization requirements on post-acute admission requests when the member is coming from an inpatient setting and transferring to an in-network facility. This will include admissions to skilled nursing facilities, inpatient rehabilitation facilities and long-term acute care facilities.
Here are some important details:
- Waiver of initial post-acute authorization requirements is good for dates of service effective April 10 through May 31, 2020.
- Waiver is only for members coming from an acute care facility to an in-network post-acute facility (LTACH, acute rehab hospital or SNF).
- BlueCross will still require notification on the next business day following transfers. Please use the regular authorization forms for each line of business (located on Availity).
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.
Your Health
The first step is to stay home and separate yourself from other people or animals as much as possible. That’ll help keep germs from spreading until you can get tested and advice from a doctor.
Next, see if your city or county has a free testing site set up. If so, schedule with them to get a test. You can also call your provider’s office and tell them your symptoms. If they think you need to be tested, they can give you instructions on where to go and what to do if you’re unable to get tested through your health department.
Other than for testing, please stay at home, wear a mask and isolate yourself from others in your home, if possible.
The first step is to stay home and separate yourself from other people or animals as much as possible. That’ll help keep germs from spreading until you can get advice from a doctor.
Next, see if your city or county has a free testing site set up. If so, schedule with them to get a test. You can also call your provider’s office and tell them your symptoms. If they think you need to be tested, they can give you instructions on where to go and what to do if you’re unable to get tested through your health department.
Other than for testing, please stay at home, wear a mask and isolate yourself from others in your home, if possible.
The latest guidance from the CDC says that, if you’ve had a mild case, you may leave self-isolation if it’s been 10 days since your symptoms started, you’ve been without a fever for 24 hours and haven’t used a fever reducer, and your other symptoms are improving. If you’ve had a moderate or severe case of COVID-19 or are immune-compromised, you’ll need to isolate for 20 days. In these cases, you’ll need to talk with your doctor about when it’s OK for you to leave isolation.
The CDC has also released new guidance for household family members of someone who tests positive.
If you live with others, they’ll also need to quarantine during the time you’re in isolation. They’ll also need to quarantine for an additional 14 days starting the last day they had contact with you or the day you’re no longer in isolation. This could mean quarantine at home for anyone you share a home with of up to 24 days total if symptoms can be safely managed at home.
For example, if you began self-isolation at home on Sept. 2 with a mild case, the health department would likely clear you 10 days later on Sept. 12 if you meet the standards above. Your household members’ 14 days for home quarantine would begin on Sept. 12. If you were able to fully isolate from others in the house and not share any space, such as the bathroom or kitchen, and had no contact with them, their 14 days would begin the last day they had contact with you.
Yes. Many providers are slowly reopening their practices to see our members in person. They’ll be following some safety social distancing guidelines, so be sure to call their office before your appointment to know what extra safety steps they’ll want you to follow when you get there. You also should take some personal safety measures, including wearing a cloth mask while in public and making sure you don’t have a fever or any signs of COVID-19 before going in person. If you have any symptoms or have been exposed to someone with COVID-19, you’ll need to reschedule your appointment.
If you have health issues that put you at higher risk of COVID-19 complications or simply don’t feel comfortable going out in person, many providers are still offering telehealth appointments.
Protecting Yourself and Others
Social distancing is the best way to protect yourself. That means staying home other than for necessary groceries or medicine.
Wear a face covering when going out in public. The CDC recommends everyone, except children under age 2 or people who have trouble breathing or are incapacitated and unable to remove a mask, wear a cloth face covering to help slow the spread of the virus. Your mask should cover your nose and mouth, be secured under your chin, and rest snugly against the sides of your face. Make sure you can breathe easily through it, and always wash your hands before putting on or taking off your mask. You can find expert guidance about face coverings here.
Wash your hands with soap and water frequently, especially if you’re out of your home. Hand sanitizer can help when soap and water are unavailable.
Clean all frequently touched surfaces in your home, car and workspace, if you’re still going in to work.
Cover your coughs and sneezes, and immediately throw away the used tissues.
If someone in your house is sick or has symptoms, have them self-isolate away from others in the house. Call their provider for instructions on what to do next.