Please note that the following information applies to Empire BlueCross BlueShield’s (“Empire”) Commercial health plans. Please review the Medicare and Medicaid specific sites noted below for details about these plans.

 

Commercial:  Provider News Home

Medicaid:  Medicaid Provider News - COVID-19

Medicare:  Medicare Advantage Provider News Archives

 

Information from Empire for Care Providers about COVID-19 (Updated April 6, 2021

 

Empire is closely monitoring COVID-19 developments and what it means for our customers and our healthcare provider partners. Our clinical team is actively monitoring external queries and reports from the Centers for Disease Control and Prevention (CDC) to help us determine what action is necessary on our part.

 

To help address care providers’ questions, Empire has developed the following updates and frequently asked questions.

 

Contents:

Update Summary

Frequently Asked Questions:

  • Empire’s actions
  • COVID-19 testing
  • COVID-19 vaccines
  • Virtual, telehealth and telephonic care
  • Coding, billing, and claims
  • Other

 

Update Summary

 

COVID-19 testing and visits associated with COVID-19 testing

Empire is waiving cost shares for our fully-insured employer, individual, Medicare and Medicaid plan members—inclusive of copays, coinsurance and deductibles—for COVID-19 test and visits associated with the COVID-19 test, including visits to determine if testing is needed.  Empire looks for the CS modifier to identify visits and services leading to COVID-19 testing. This modifier should be used for evaluation and testing services in any place of service including a physician’s office, urgent care, ER or even drive-thru testing.  While a test sample cannot be obtained through a telehealth visit, the telehealth provider can help you get to a provider who can do so.

 

IMPORTANT:  In-network providers are reminded that they may not collect any deductible, copayment, or coinsurance for COVID-19 testing or visits to get the test.

 

Telemedicine (live video + audio via app)

For COVID-19 treatments via telemedicine visits, Empire will cover telehealth and telephonic-only visits from in-network providers and will waive cost shares through January 31, 2021. 

 

For non-COVID-19 treatments via telemedicine including covered visits for mental health and substance use disorders, Empire will waive cost shares for in-network visits through November 9, 2020, or any longer period required by state law. This applies to fully insured employer plans, individual plans and Medicaid plans, where permissible.

 

 

For out-of-network providers, Empire waived cost shares for these services through June 14, 2020. This applied to use of our LiveHealth Online platform, as well as for care received from other providers delivering virtual care through internet video + audio services. We encourage our self-funded customers to participate, and these plans will have an opportunity to opt in.

 

Telehealth (telephonic with video capability)

For COVID-19 treatments via telehealth visits, Empire will cover telehealth and telephonic-only visits from in-network providers and will waive cost shares through January 31, 2021.

 

For telehealth services not related to the treatment of COVID-19 from Empire’s telehealth provider, LiveHealth Online, cost sharing will be waived from March 17, 2020 through May 31, 2021, for our fully-insured employer, individual, and where permissible, Medicaid plans. Medicare Advantage members pay no member cost share for LiveHealth Online, regardless of national emergency.

 

Effective March 16, 2020, through April 4, 2021, Empire will waive member cost sharing for telehealth visits (by phone with video capability) with in-network, providers acting within the scope of their license. Out of network visits are also covered if the member’s benefit plan has out of network benefits. This includes covered visits for medical services as well as mental health and substance use disorders services, where medically appropriate if all other requirements for a covered health service are met. Self-insured plan sponsors may have opted out of this program. This waiver will remain in place from March 19, 2020, through April 4, 2021, or any longer period required by state law for our insured employer plans, individual plans and Medicaid plans, where permissible and from March 19, 2020, through September 30, 2020, for our Medicare members. Phone/video delivery must be HIPAA compliant.

 

Telephonic-only care

Empire will also cover telephonic-only visits with in-network providers where medically appropriate if all other requirements for a covered health service are met. Out-of-network coverage will be provided where required and in accordance with benefit plan terms.

  • This includes visits for medical services and behavioral health, for our fully insured employer plans, individual plans, Medicare plans and Medicaid plans, where permissible and medical appropriate.
  • Cost shares will be waived for in-network providers only. We encourage our self-funded customers to participate, and these plans will have an opportunity to opt in.
  • Phone delivery must be HIPAA compliant.

 

Prescription coverage

Empire is also providing coverage for members to have an extra 30-day supply of medication on hand, and we are encouraging that when member plans allow that they switch from 30-day home delivery to 90-day home delivery. This applies to members who have Empire prescription drug coverage.

 

Frequently Asked Questions

 

Empire’s Actions

 

What is Empire doing to continue to address the COVID-19 crisis?

Empire is committed to help provide increased access to care, while eliminating certain costs and helping alleviate the added stress on individuals, families and the nation’s healthcare system.

 

These actions are intended to support the protective measures being taken across the country to help prevent further spread of COVID-19 and are central to Empire’s commitment to remove barriers for our members and support communities through this unprecedented time. 

 

Empire is committed to help our members gain timely access to care and services in a way that places the least burden on the healthcare system. Our actions should reduce barriers to seeing a physician, getting tested and maintaining adherence to medications for long-term health issues.

 

Empire is waiving:

  • cost sharing for the treatment of COVID-19 from April 1, 2020, through January 31, 2021, for members of our fully-insured employer, individual, Medicare Advantage and Medicaid plans. We encourage our self-funded customers to participate, although these plans will have an opportunity to opt out.
  • cost sharing for COVID-19 diagnostic tests as deemed medically necessary by a healthcare clinician who has made an assessment of a patient, including serology or antibody tests, for members of our employer-sponsored, individual, Medicare and Medicaid plans.
  • cost sharing for visits and services during the visits to get the COVID-19 diagnostic test, beginning March 13, 2020, for members of our employer-sponsored, individual, Medicare and Medicaid plans. Cost share waiver extends to the end of the public health emergency.
  • cost sharing for telemedicine visits, including visits for behavioral health, for our fully-insured employer, individual and where permissible, Medicaid plans from March 16, 2020, through January 31, 2021, or any longer period required by state law. We encourage our self-funded customers to participate, and these plans will have an opportunity to opt in.
  • cost sharing for telehealth services not related to the treatment of COVID-19 from Empire's telehealth provider LiveHealth Online, from March 17, 2020, through May 31, 2021, for our fully-insured employer, individual, and where permissible, Medicaid plans. Medicare Advantage members pay no member cost share for LiveHealth Online, regardless of national emergency.
  • cost sharing for S. Preventive Services Task Force (USPSTF) or CDC approved vaccines as they become available.

 

The cost sharing waiver includes copays, coinsurance and deductibles.

 

For additional services, members will pay any cost shares their plan requires, unless otherwise determined by state law or regulation. Members can call the number on the back of their identification card to confirm coverage. Providers should continue to verify eligibility and benefits for all members prior to rendering services.

 

In compliance with New York’s Circular Letter No. 17, prior authorization requirements are suspended for patient transfers from acute IP hospitals to skilled nursing, inpatient rehabilitation, and home health care facilities effective December 23, 2020, through February 21, 2021. In addition, the suspension also applies to transfers between acute IP hospitals and inpatient mental health treatment following a hospital admission. Prior authorization will still be required for non-emergency air transport. These adjustments apply for our fully-insured and self-funded employer, individual, and Medicaid plan members. We encourage our self-funded customers to participate, and these plans will have an opportunity to opt out. While prior authorization is not required, we continue to require notification of the admission via the usual channels and clinical records on day two of admission to aid in our members’ care coordination and management. Empire reserves the right to audit patient transfers. Concurrent and Retrospective reviews may be performed. Providers are encouraged to transfer to in-network providers. To locate an in-network provider, including skilled nursing and rehabilitation facilities, go to https://www.empireblue.com/find-care/.

 

How is Empire monitoring COVID-19?

Empire is monitoring COVID-19 developments and what they mean for our associates and those we serve. We are fielding questions about the outbreak from our customers, members, providers and associates. Additionally, our clinical team is actively monitoring external queries and reports from the Centers for Disease Control and Prevention to help us determine what, if any, action is necessary on our part to further support our stakeholders.

 

Empire has a business continuity plan for serious communicable disease outbreaks, inclusive of pandemics. Empire’s enterprise wide business continuity program includes recovery strategies for critical processes and supporting resources, automated 24/7 situational awareness monitoring for our footprint and critical support points, and Empire’s Virtual Command Center for Emergency Management command, control and communication.

 

In addition, Empire has established a team of experts to monitor, assess and help facilitate timely mitigation and response where we have influence as appropriate for the evolving novel coronavirus crisis.

 

How can you ensure that your contracted providers can still provide services during this crisis?

Empire is committed to working with and supporting its contracted providers. Our benefits already state that if members do not have appropriate access to network physicians that we will authorize coverage for out-of-network physicians as medically necessary.

 

In addition, Empire’s telehealth provider, LiveHealth Online, is another safe and effective way for members to see a physician to receive health guidance related to COVID-19 from home via a mobile device or computer with a webcam. 

 

COVID-19 testing

 

When member cost sharing has been waived (where permissible) by Empire as outlined in this FAQ for COVID-19 testing and visits associated with COVID-19 testing, telemedicine (video + audio) services, telehealth (telephonic with video capability) and telephonic-only services, how does that impact provider reimbursement?

Empire will process the claim for in-network services as if there is no member cost sharing, as it does, for example, with preventive health services. Out-of-network coverage will be provided where required and in accordance with benefit plan terms.

 

How is Empire reimbursing participating hospitals that perform COVID-19 diagnostic testing in an emergency room or inpatient setting?

Reimbursement for COVID-19 testing performed in a participating hospital emergency room or inpatient setting is based on existing contractual rates inclusive of member cost share amounts waived by Empire. As we announced on March 6, 2020, Empire will waive cost shares for members of our fully insured employer-sponsored, individual, Medicare, Medicaid and self-funded plan members—inclusive of copays, coinsurance and deductibles—for COVID-19 test and visits to get the COVID-19 test. 

 

How is Empire reimbursing participating hospitals that are performing COVID-19 diagnostic testing in a drive-thru testing setting?

Based on standard AMA and HCPCS coding guidelines, for participating hospitals with a lab fee schedule, Empire will recognize the codes 87635 and U0002, and will reimburse drive-thru COVID-19 tests according to the lab fee schedule inclusive of member cost share amounts waived by Empire.  Participating hospitals without lab fee schedules will follow the same lab testing reimbursement as defined in their facility agreement with Empire inclusive of member cost share amounts waived by Empire. As we announced on March 6, 2020, Empire will waive cost shares for members of our fully-insured employer-sponsored, individual, Medicare, Medicaid and self-funded plan members—inclusive of copays, coinsurance and deductibles—for COVID-19 test and visits to get the COVID-19 test.

 

Does Empire require a prior authorization on the focused test used to diagnose COVID-19?

No, prior authorization is not required for diagnostic services related to COVID-19 testing.

 

Does Empire require use of a contracted provider for the COVID-19 lab test in order for waiver of the member’s cost share to apply?

Empire will waive member cost shares for COVID-19 lab tests performed by participating and non-participating providers. This is applicable for our employer-sponsored, individual, Medicare and Medicaid plan members. Self-insured plan sponsors are required under federal law to also waive cost sharing for COVID-19 tests and visits to get the test.

 

What codes would be appropriate for COVID-19 lab testing?

Empire is encouraging providers to bill with codes U0001, U0002, U0003, U0004, 86328, 86769 or 87635 based on the test provided.

 

COVID-19 vaccines

How is Empire reimbursing U.S. Food and Drug Administration (FDA)-approved COVID-19 vaccines?
The cost of COVID-19 FDA-approved vaccines will initially be paid for by the government.

For members of our fully-insured employer and individual plans, as well as self-funded plans, Empire will reimburse for the administration of COVID-19 FDA-approved vaccines at a reasonable prevailing rate. Empire will cover the administration of COVID-19 vaccines with no cost share for in- and out-of-network providers, during the national public health emergency, and providers are not permitted under the federal mandate to balance-bill members.

For members of Medicare Advantage plans, CMS issued guidance (https://www.cms.gov/files/document/COVID-19-toolkit-issuers-MA-plans.pdf) that the COVID-19 vaccine administration should be billed by providers to the CMS Medicare Administrative Contractor (MAC) using product-specific codes for each vaccine approved. This will ensure that Medicare Advantage members will not have cost sharing for the administration of the vaccine.

For members of Medicaid plans, Medicaid state-specific rate and other state regulations may apply.

What CPT/HCPCS codes would be appropriate to consider for the administration of a COVID-19 vaccines?

CMS has provided coding guidelines related to COVID-19 vaccines: https://www.cms.gov/medicare/medicare-part-b-drug-average-sales-price/covid-19-vaccines-and-monoclonal-antibodies  

 

Virtual telemedicine, telehealth and telephonic care

 

How will Empire cover telehealth (telephonic with video capability)? 

Effective March 16, 2020, Empire began waiving cost sharing for telehealth visits (by phone with video capability) where medically appropriate if all other requirements for a covered health service are met with in-network providers. Out of network visits are also covered if the member’s benefit plan has out of network benefits. This will remain in place through March 31, 2021, or any longer period required by state law. Self-insured plan sponsors may opt out of this program.

 

What codes would be appropriate to consider for telehealth, telemedicine or a telephonic visit?

Based on standard coding guidelines from the AMA and HCPCS, office visit (99201-99215) telehealth claims will require Place of Service (POS) code 02 and either modifier “95” or “GT”. 

 

For Medicare Advantage telehealth claims, please follow original Medicare coding guidance.

Audio-only telephonic codes (99441, 99442, 99443, 98966, 98967, 98968) do not require a telehealth modifier to be appended. Place of service would be the location where the provider initiates such a call.

For Medicare Advantage audio-only telephonic claims please use codes 99441, 99442, 99443, 98966, 98967 and 98968. Note, however, Medicare Advantage coding for either telehealth or audio-only telephonic claims could change in the future based on guidance from CMS.

 

How does a provider submit a telehealth, telemedicine or a telephonic visit with an existing patient who lives in a bordering state?

For providers (for example, in bordering states) who were previously seeing members in approved locations that met state and/or CMS billing requirements, effective from March 17, 2020, through March 31, 2021, or any longer period required by state law, you may submit your telehealth claim using the primary service address where you would have normally seen the member for the face-to-face visit.

 

Is Empire’s vendor, LiveHealth Online, prepared for the number of visits that will increase to telehealth?

As there is a heightened awareness of COVID-19 and more cases are being diagnosed in the United States, LiveHealth Online is increasing physician availability LiveHealth Online stands ready to have physicians available to see the increase in patients, while maintaining reasonable wait times.

 

How can I support access to telemedicine?

Providers can apply to join the LiveHealth Online panel of providers here: https://providers.amwell.com/.

 

What codes would be appropriate to consider for a telemedicine (video +audio) health visit with a patient who wants to receive health guidance related to COVID-19?

Submit Telemedicine with the CPT code for the service rendered, place of service (POS) code 02, and append either modifier “95” or “GT”.

 

What codes would be appropriate to consider for telemedicine (live video + audio via app) and telehealth (telephonic with video capability) for physical, occupational, and speech therapies?

Telemedicine and telehealth visits for the following physical, occupational and speech therapies for visits coded with Place of Service (POS) code 02 and modifier “95” or “GT” would be appropriate for our fully-insured employer, individual, Medicare Advantage plans  and Medicaid plans, where permissible:

 

  • Physical therapy (PT) evaluation codes 97161, 97162, 97163 and 97164
  • Occupational (OT) therapy evaluation codes 97165, 97166, 97167 and 97168
  • PT/OT treatment codes 97110, 97112, 97530 and 97535
  • Speech therapy (ST) evaluation codes 92521, 92522, 92523 and 92524
  • ST treatment codes 92507, 92526, 92606 and 92609
  • PT/OT codes that require equipment and/or direct physical hands-on interaction and therefore are not appropriate via telehealth include: 97010-97028, 97032-97039, 97113-97124, 97139-97150, 97533 and 97537-97546.

 

What is the best way that providers can get information to Empire’s members on Empire’s alternative virtual care offerings?

Anthem.com and Empire’s COVID-19 site (https://www.empireblue.com/coronavirus/) are great resources for members with questions and are being updated regularly.

 

Empire members have access to telemedicine 24/7 through LiveHealth Online. Members can access LiveHealth Online at https://livehealthonline.com/ or download the LiveHealth Online app from the App Store or Google Play.

 

Empire members also can call the Empire 24/7 NurseLine at the number listed on their Empire ID card to speak with a registered nurse about health questions.

 

Coding, billing, and claims

 

Does Empire have recommendations for reporting, testing and specimen collection?

The Centers for Disease Control and Prevention (CDC) updates these recommendations frequently as the situation and testing capabilities evolve. See the latest information from the CDC: https://www.cdc.gov/coronavirus/2019-nCoV/hcp/clinical-criteria.html.

 

What diagnosis codes would be appropriate to consider for a patient with known or suspected COVID-19 for services where a member’s cost shares are waived?

The CDC has provided coding guidelines related to COVID-19:  https://www.cdc.gov/nchs/data/icd/COVID-19-guidelines-final.pdf.

 

What modifier is appropriate to waive member cost sharing for COVID-19 testing and

visits related to testing?

CMS has provided the Medicare guideline to use the CS modifier: https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2020-04-10-mlnc-se. Empire also looks for the CS modifier to identify claims related to evaluation for COVID-19 testing. This modifier should be used for COVID-19 evaluation and testing services in any place of service. 

 

Does Empire expect any slowdown with claim adjudication because of COVID-19? 

We are not seeing impacts to claims payment processing at this time. 

 

Should providers who are establishing temporary locations to provide healthcare services during the COVID-19 emergency notify Empire of the new temporary address(es)?

Providers do not need to notify Empire of temporary addresses for providing healthcare services during the COVID-19 emergency. Providers should continue to submit claims specifying the services provided using the provider’s primary service address along with your current tax ID number.

 

How is Empire reimbursing pharmacists who are performing COVID-19 diagnostic testing?

Empire would expect pharmacists to bill COVID-19 diagnostic testing to the member’s medical benefits, not pharmacy benefits. This may be different from how pharmacists bill other services currently provided. Pharmacists with questions should call the “Provider Services” number on the back of the member’s insurance card. 

 

Will Empire allow Roster Billing for the COVID-19 vaccine?

Providers who currently submit electronic claims are encouraged to do so. The electronic process is the quickest way to get the claims to Empire.

 

Yes, Empire will accept Roster Billing from providers and state agencies that are offering mass vaccinations for their local communities. Providers may submit the COVID-19 Vaccination Roster Billing Form to Availity at https://www.availity.com/ by signing in and submitting the form electronically to the Empire health plan.

 

How can a provider submit Empire’s Roster Billing claim form?

In addition to Availity.com, providers and state agencies who wish to submit Roster Billing claims can submit paper forms:

Or

Anthem Blue Cross and Blue Shield

PO Box 27401

Richmond VA 23261

 

Is there a specific diagnosis code Empire would look for on the COVID-19 Vaccination Roster Billing Form?

No.  However, to assist providers our COVID-19 Vaccination Roster Billing Form provides a default Z23 diagnosis code. 

 

Other

 

Do these guidelines apply to members enrolled in the Blue Cross and Blue Shield Service Benefit Plan commonly referred to as the Federal Employee Program (FEP®)?

Where permissible, these guidelines apply to FEP members. For the most up-to-date information about the changes FEP is making, go to https://www.fepblue.org/coronavirus.

 

What financial assistance is available for care providers during the COVID-19 crisis?

The CARES Act provides financial relief to lessen the impact of the COVID-19 crisis. Included in the law are new resources to address the economic impact of COVID-19 on employers of all sizes. The Act expands existing federal loan programs, creates new tax credits, postpones employment tax payments, and includes additional tax relief. To help care providers navigate the resources available to them, Empire has complied information on programs we have learned about that could provide additional financial relief during this crisis. This information can be found in the Federal Resources Available for Care Providers and Employers in the Federal CARES Act article in Empire Provider News.

 

Are you aware of any limitations in coverage for treatment of an illness/virus/disease that is part of a pandemic?

Our standard health plan contracts do not have exclusions or limitations on coverage for services for the treatment of illnesses that result from a pandemic.

 

Please note that the above information applies to Empire’s Commercial health plans. Please review the Medicare and Medicaid specific sites noted below for details about these plans.

  

Commercial:  Provider News Home

Medicaid:  Medicaid Provider News - COVID-19

Medicare:  Medicare Advantage Provider News Archives

 

287-0421-WP-NY



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