BlueCare Tennessee Providers

Last Updated on July 13, 2023

Please refer to this section for helpful information about treating BlueCare Tennessee members during the COVID-19 state of emergency.

A Message From Todd Ray (Please note updates are frequent)

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.

Below, we’ve outlined some of the steps we’ve taken in response to the COVID-19 emergency. These flexibilities expired May 11, 2023:

BlueCare Tennessee allowed flexibility to charge inpatient rates in the emergency room or other units where patients may need to be housed, based on intensity of service.
If a hospital requested an extension for BlueCare appeals time frames past 180 days, we approved reasonable requests on a case-by-case basis.
Hospitals could request an extension for medical record audits and audits for inpatient and outpatient facility claims, manual collection of medical records for HEDIS, and in-office reviews for Quality and Value-based programs due to staffing shortages, overwhelmed hospital capacity or other factors. Until the national PHE ended on May 11, we reviewed requests on a case-by-case basis and made accommodations as appropriate.
We paid for COVID testing prior to inpatient admission separately, even if within the 72-hour window where it would normally be included in the DRG.

These changes will remain in effect:

We’ve permanently added flu testing and COVID-19 tests to BlueCare's exclusive lab exception list.
BlueCare is permanently waiving readmission penalties for COVID-19 hospital stays, unless there’s evidence of an unsafe discharge.

For BlueCare, TennCareSelect and CoverKids lines of business unless stated otherwise.

COVID-19 Vaccine

Yes, we cover COVID-19 vaccine administration. We’re waiving member copay for the vaccine until Sept. 30, 2024. Beginning Oct. 1, 2024, normal copays will apply for COVID-19 vaccination.

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. Our in-network providers should file these claims as follows:

	Medicare Advantage and BlueCare Plus	BlueCare, TennCareSelect and CoverKids	Commercial
Hospitals	Submit administration claims to us according to your regular hospital contract.	Submit administration claims to us according to your regular hospital contract.	Submit administration claims to us according to your regular hospital contract.
Health Departments	Submit administration claims according to your regular health department contract.	Submit administration claims according to your regular health department contract.	Submit administration claims according to your regular health department contract.
Pharmacies	If pharmacy coverage is through BlueCross, submit claims through the BlueCross PBM.	Submit claims to TennCare's Pharmacy Benefit Manager (PBM).	If pharmacy coverage is through BlueCross, submit claims through the BlueCross PBM.
Other - Mobile Units - Group Practices - Etc.	Submit administration claims according to your regular professional services contract.	Submit administration claims according to your regular professional services contract.	Submit administration claims according to your regular professional services contract.

Our reimbursement for vaccine administration will be consistent with the current CMS rates. Please use the appropriate codes when billing the vaccines and administration codes. If you have questions about these vaccines, please refer to the CDC website.

No. Member cost-share for COVID-19 vaccines and the vaccine administration should be covered by BlueCross, CMS, 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 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.

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 availability 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.com site as we receive new information.

Vaccine counseling gives providers an opportunity to educate patients about vaccines and answer any questions they have. It’s a vital part of ensuring people have the information they need to make personal decisions about vaccination.

The Division of TennCare recognizes the additional administrative responsibilities vaccine counseling places on Tennessee’s providers. So, on April 1, 2023, the TennCare managed care organizations began covering stand-alone vaccine counseling for COVID-19 and non-COVID-19 immunizations for members of all ages. Stand-alone vaccine counseling occurs when patients receive counseling about vaccinations but don’t get the vaccines on the same day. For more information, please see the REVISION – Update to Stand-alone Vaccine Counseling TennCare memo.

If your patients live in Davidson, Hamilton, Knox, Shelby or Sullivan counties, please have them call their county health department as listed below.

Davidson: 615-862-7777
Hamilton: 423-209-8383
Knox: 865-215-5555
Shelby: 901-222-SHOT (7468)
Sullivan: 423-279-2777

If your patients live in a county not listed above, please have them call 1-866-442-5301 for assistance with getting on a wait list if they meet the criteria for their county’s vaccine phase.

Online scheduling is also available in some counties. For more information, or to check the vaccine phase for your patient’s county, please visit https://covid19.tn.gov/ and use the drop-down menu.

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 federal government and are free of charge. Providers should only bill BlueCross for administering the treatment when products are supplied by the federal government. 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, related office visits and services. This includes reimbursement for multiple tests of 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. 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.

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/outpatient 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/outpatient 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.

No. We understand that as businesses reopen and adapt their health and safety practices, many require routine COVID-19 testing as part of their return-to-work or ongoing safety procedures. Employment-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 in-office and at-home 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.

No. We understand that many schools have revised their health and safety protocols to require COVID-19 testing as part of their return-to-school policy for students. However, school-mandated testing isn’t part of our members’ health plan benefits. 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. 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.

COVID-19 Antibody Tests

We’ll pay for FDA-approved versions of these tests when they’re ordered and performed 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 cover only 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.

We’ll pay for at-home tests that diagnose current disease when they’re ordered by a licensed physician. Many of the at-home tests marketed have been proved ineffective, so we’ll cover just those 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.

Telehealth Coverage

Yes, we’ll cover telehealth in certain situations. Please review the BlueCare Tennessee Telehealth Guide for information about our telehealth policies.

When billing for telehealth, applicable service codes, diagnostic codes, modifiers and units should be reported with Place of Service-02, -10, or the appropriate Place of Service code with a 95, 93, SQ, FR, GO, GQ, or GT modifier appended to the CPT^®/HCPCS code. This will let us know you’ve treated our member using telehealth.

Specific outpatient PT/OT/ST CPT^®codes are included as part of the temporary expansion of telehealth services as a result of the COVID-19 emergency.

Effective beginning March 18, 2020, until further notice
Providers supported by this exception are licensed physical therapists, occupational therapists and speech-language pathologists.
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.

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.

Category	CPT^® Code	Description
Physical Therapy	97161	Physical therapy evaluation – low complexity
Physical Therapy	97162	Physical therapy evaluation – moderate complexity
Physical Therapy	97163	Physical therapy evaluation – high complexity
Physical Therapy	97164	Physical therapy re-evaluation
Physical Therapy	97110	Therapeutic procedure, one or more areas, each 15 minutes
Physical Therapy	97116	Gait training
Physical Therapy	97530	Therapeutic activities, one-to-one patient contact, each 15 minutes
Physical Therapy	97112	Therapeutic procedure, one or more areas, each 15 minutes
Physical Therapy	97535	Self-care/home management training, each 15 minutes
Occupational Therapy	97165	Occupational therapy evaluation – low complexity
Occupational Therapy	97166	Occupational therapy evaluation – moderate complexity
Occupational Therapy	97167	Occupational therapy evaluation – high complexity
Occupational Therapy	97168	Occupational therapy re-evaluation
Occupational Therapy	97110	Therapeutic procedure, one or more areas, each 15 minutes
Occupational Therapy	97530	Therapeutic activities, one-to-one patient contact, each 15 minutes
Occupational Therapy	97112	Therapeutic procedure, one or more areas, each 15 minutes
Occupational Therapy	97535	Self-care/home management training, each 15 minutes
Speech Therapy	92507	Treatment of speech, language, voice, communication and/or auditory processing disorder
Speech Therapy	92521	Evaluation of speech fluency
Speech Therapy	92522	Evaluation of speech sound production
Speech Therapy	92523	Evaluation of speech sound production
Speech Therapy	92526	Treatment of swallowing dysfunction and/or oral function for feeding
Speech Therapy	96105	Assessment of Aphasia and Cognitive Performance Testing
Speech Therapy	97129	Therapeutic interventions that focus on cognitive function
Speech Therapy	97130	Each additional 15 minutes (use in conjunction with 97129)

Excluded from this temporary expansion of telehealth services:
Any 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.

Contracting, Credentialing and Enrollment

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.

We’re adhering to the emergency directives set forth in the State of Tennessee Executive Order by the governor, available here.

BlueCare 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

We allowed early refills through much of 2020, but this benefit ended on Jan. 1, 2021.

Patients taking certain chronic medications may receive 90-day refills. The 90-day supply benefit established at the beginning of the COVID-19 emergency for certain prescriptions became permanent on Sept. 1, 2021, and you can view the list of eligible medications here. Controlled substances, such as opioids, and specialty drugs are excluded from this benefit.

Additionally, your patients with BlueCare Tennessee coverage may use delivery services offered through local pharmacies.

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 currently in place:

We’re working with providers to change the dates of service to the date they call in.
There’s currently no limit on how far in the advance we’ll change the date.

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

Your Health

The CDC has a coronavirus self-checker on its website that helps you quickly understand which symptoms to watch out for and how to get help. The virus has a wide range of symptoms that include fever, cough, shortness of breath or trouble breathing, chills, repeated shaking with chills, fatigue, muscle pain, headache, sore throat, diarrhea, congestion or runny nose, and new loss of taste or smell.

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.

BlueCross Working for You

No. We’re considered essential, so we’ll remain open. However, we have taken steps to help keep our employees well while ensuring our members see no lapse in service. In early 2020, we transitioned many of our customer service, care management, claims and billing employees to work from home. Since March 16, 2020, the majority of our workforce has been working full time from their homes to allow them to practice social distancing. We’ve not experienced any reduction in service to you, nor do we expect any.