BlueCare Tennessee Providers
A Message From Todd Ray (Please note updates are frequent)
Dear Valued Provider,
Now that we’ve moved into a new year, we want to reinforce how grateful we are for our relationship with you and the care you provide to our members. We realize our struggles from 2020 aren’t over yet. But we’re also encouraged by the recent availability of COVID-19 vaccines and the ongoing rollout across our state.
As governmental and operational guidelines continue to shift, we understand that you and your patients have a lot of questions. We’re doing our best to answer them in our FAQs, so please continue to visit this website for important updates. You’ll find information about our COVID-19 policies, as well as the latest information about vaccine policies and procedures.
Also, please continue to check our payer space at Availity.com for updates throughout this state of emergency.
Sincerely,
Todd Ray, Senior Vice President, Corporate Provider Network Management and Medicare Products
We’re Here To Support You
With surges of COVID-19 cases, we want to help you in continuing to provide care for our members. This isn’t a comprehensive list of BlueCare Tennessee actions we’ve taken to help (such as encouraging our members to schedule telehealth visits and the community-serving efforts of our foundation), but rather items we know are relevant to hospital operations:
- We’ve waived the authorization requirement for initial post-acute care reviews (skilled nursing facility, rehab and LTACH) to support rapid placement and discharge of currently hospitalized patients who can be safely discharged to another setting. Notification is required within one business day of admission. Concurrent reviews for medical necessity will continue after the first week of admission.
- We’re allowing flexibility to charge inpatient rates in the emergency department or other units where patients may need to be housed, based on intensity of service.
- We’ve added flu testing and COVID-19 tests to our exclusive lab exception list.
- If a hospital requests to extend appeals timeframes past 180 days, we’ll approve reasonable requests on a case-by-case basis.
- We’re suspending all medical record requests and audits for inpatient and outpatient facility claims, and postponing manual collection of medical records for HEDIS and in-office reviews for Quality and Value-based programs, through March 31, 2021. After that date, if hospitals request extension of these due to staffing shortages, overwhelmed hospital capacity, or other factors, we’ll review on a case-by-case basis and make accommodations as appropriate.
- We’re paying for COVID testing prior to inpatient admission separately, even if within the 72-hour window where it would normally be included in the DRG.
- We’re waiving readmission penalties during the PHE by paying the readmission as a separate claim. Unfortunately, CMS didn’t issue guidance to allow the same flexibility on Medicare Advantage.
Important Provider Updates and Resources From Federal and State Governments
- Tennessee Department of Health
- Division of TennCare
- Centers for Disease Control and Prevention (CDC)
- For more general information, please call the Tennessee Coronavirus Public Information Line at 1-877-857-2945.
- 30-Day Suspension of PASRR Requirements (Dec. 21, 2020)
- Telehealth Coverage Extended to March 31, 2021 (Dec. 16, 2020)
- CMS Targeted Payments to PCPs – with BlueCare FAQ attachment (Dec. 2, 2020)
- Extension of Hospital Admin Flexibilities for COVID-19 to March 31, 2020 (Nov. 30, 2020)
- HHS Provider Relief Fund Guidance Reporting Requirements (Oct. 5, 2020)
- Extension of Hospital Admin Flexibilities for COVID-19 (Sept. 30, 2020)
- Nursing Facilities COVID Test Payment for Medicare Enrollees (Sept. 30, 2020)
- CMS Guidance: COVID Test Payment Flow Chart Nursing Facilities (Sept. 30, 2020)
- Federal Relief Funds for Providers Deadline Extended to Sept. 13, 2020 (Sept. 4, 2020)
- Telehealth Coverage Extended to Dec. 31, 2020 (Aug. 26, 2020)
- Federal Relief Funds for Providers Deadline Extended to Aug. 28, 2020 (Aug. 7, 2020)
- CHOICES and CHOICES ECF Residential Special Needs Adjustment and Personal Care Rate Differential (July 28, 2020)
- Federal Relief Funds Deadline Extended to Aug. 3, 2020 (July 21, 2020)
- State of Emergency Extended and Telehealth Coverage Extended (July 2, 2020)
- COVID-19 DME Short-Term Guidance (June 12, 2020)
- HRSA Program FAQ Re: Provider and Facility Reimbursement for COVID-19 Testing and Treatment of Uninsured Patients (June 2020)
- Request to CMS for Targeted Payments to PCPs (June 9, 2020)
- Telehealth Coverage Extended to June 30, 2020 (June 4, 2020)
- Update on Administrative Change Flexibilities (May 8, 2020)
- Guidance and Information for Administrative Changes (April 21, 2020)
- Civil Rights Guidance (April 8, 2020)
- Federal PASRR Requirements (April 1, 2020)
COVID-19 Emergency Disclaimer
During the COVID-19 emergency, we’ll continue to follow the COVID-19-related policies and processes listed in this section of the BCBSTupdates website. Many of our decisions are guided by federal and state mandates, which occur frequently, so we encourage you to refer to this site daily. Should we decide to make a non-mandated change to a policy or process listed in the provider Q&As during the COVID-19 emergency, we’ll post the update 30 days in advance on this site.
For BlueCare, TennCareSelect and CoverKids 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.
CMS will cover the cost to administer the vaccines to:
- Medicare Advantage and BlueCare Plus members.
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.
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, Health Departments, Pharmacies, and Other (Mobile Units, Group Practices): Submit administration claims to the CMS Medicare Administrative Contractor’s (MAC) system.
- 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.
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.
According to the TDH, there will be restrictions based on CDC guidelines. The TDH’s expectation is that most Tennesseans will be able to get vaccinated once COVID-19 vaccines become more widely available.
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.
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.
COVID-19 Testing and 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) – NEW
- U0005 (Effective Dec. 4, 2020) – NEW
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
- G2024 – home/nursing home collection
- 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 at the time of an admission/outpatient procedure and billed on the same claim as the admission/outpatient procedure will be included in the admission or outpatient procedure reimbursement.
Please note: The test will be covered even if the member’s admission/OP procedure is canceled due to a positive COVID-19 test.
COVID-19 Drive-Through Testing
No. We’ll only reimburse for our members’ COVID-19 swabs and test results in drive-through testing.
*Codes included on preferred lab exclusion list for BlueCare, TennCareSelect and CoverKids.
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. Effective for dates of service March 16, 2020, until March 31, 2021, you may bill for telehealth in the following ways:
- CPT® codes 99441 – 99443 for telephonic provider-to-member consultations for all lines of business’s PCP or specialist benefits.
- E/M codes 99201 – 99215 for virtual and telephonic consults with your patients.
- E/M codes 99421 – 99423 for non-face-to-face digital online consultations.
- HCPCS codes G2061, G2062 and G2063 for online assessments and management.
- HCPCS code G2010 for remote evaluation of video and/or images.
- HCPCS code G2012 for virtual check-ins with your patients.
- CPT® codes 97153, 97155, 97156, 90791, 90792, 90832, 90834 and 90837 for behavioral health consultations.
- CPT® codes H0032 and H2019 (with or without a modifier HO) for Applied Behavior Analysis (ABA) therapy.
- In addition, here are some more recent behavioral health codes.
When billing for telehealth, applicable service codes, diagnostic codes, modifiers and units should be reported with Place of Service-02 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.
The Division of TennCare posts regular updates, including recommendations on providing care for Long-Term Services and Supports (LTSS) members in home settings. Visit the site for helpful advice.
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 for dates of service March 18, 2020, until March 31, 2021.
- 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 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
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.
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
Yes. The following coronavirus/COVID-19 diagnosis codes have been added to the medical emergency list for all lines of business:
- B97.29
- B97.21
- Z03.818
- Z20.828
- U07.1
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.
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.