We recognize that providers and medical professionals are making tremendous sacrifices to address the COVID-19 pandemic. Thank you for your continued commitment to our members and communities.
We are honored to be partnered with you during this time and are working internally to ensure that you have the support you need from us as a health plan. This page contains the most up-to-date information around our policies and coverage relating to COVID-19. We will update this page as information evolves.
To better serve our patients and provider partners during COVID-19 crisis, we have fulfilled our pledge to:
- Waive member cost-sharing for COVID-19 testing and treatment
- Make it easier for more members and providers to conduct telehealth appointments
- Relax prescription refill limitations and promote mail order pharmacy services
- Relax prior authorization requirements to allow for more efficient care
Health Plan Guidance on Billing, Telehealth, Prior Authorization, and More:
This FAQ is meant to serve as a living document and will be updated on an ongoing basis to include clarifications and additional guidance as needed.
What codes should I use for COVID-19 testing?
There are two new HCPCS codes for healthcare providers who need to test patients for coronavirus.
Providers using the Centers for Disease Control and Prevention (CDC) 2019 novel coronavirus Real Time RT-PCR Diagnostic Test Panel may bill for that test using the newly created HCPCS code (U0001).
A second new HCPCS code (U0002) can be used by laboratories and healthcare facilities. HCPCS code (U0002) generally describes 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19) using any technique, multiple types or subtypes (includes all targets).
For clinical diagnostic laboratory tests making use of high-throughput technologies, two new HCPCS codes, U0003 and U0004, have been created for laboratories to bill for the detection of SARS–CoV–2 or the diagnosis of the virus that causes COVID–19. HCPCS U0003 and U0004 are effective for dates of service on and after 4/14/2020 and will remain active until the end of the public health emergency. HCPCS code U0003 generally describes infectious agent detection by nucleic acid, amplified probe technique whereas HCPCS U0004 generally describes detection of the virus, non-CDC, using any technique, multiple types or subtypes (includes all targets). Effective 01/01/2021, a new add-on code, U0005, can be reimbursed if the high throughput technologies are completed within 2 calendar days from date of specimen collection with U0003 or U0004.
Additionally, effective 06/25/2020, a new code, 87426, has been created for use in accurate reporting and tracking of antigen tests using an immunofluorescent or immunochromatographic technique for the detection of biomolecules produced by the SARS-CoV-2 virus.
What are the Proprietary Lab Analyses codes that I should use for COVID-19 testing?
Code 0202U, effective 05/20/2020, describes a multiplex amplified probe test that provides qualitative identification of multiple respiratory viral and bacterial pathogens from a single specimen obtained using nasopharyngeal swabs.
Code 0223U, effective 06/25/2020, describes a novel type of fully automated molecular assay that provides simultaneous qualitative detection and identification of multiple respiratory pathogens based on viral and bacterial nucleic acids obtained via nasopharyngeal swabs.
Code 0224U, effective 06/25/2020, describes qualitative and quantitative detection of antibodies in serum and plasma. The test may aid in determining whether an individual suspected of significant exposure or prior infection with SARS-CoV-2 virus has a high titer of IgG antibodies against this virus when performed.
Code 0225U, effective 08/10/2020, describes infectious agent detection by nucleic acid (DNA and RNA) by amplified probe technique through polymerase chain reaction and electrochemical detection that generates a result of detected or not detected for each of the analytes.
Code 0226U, effective 08/10/2020, describes a high-throughput quantitative blocking ELISA assay to assess the patient’s viral neutralization capacity to SARS-CoV-2.
|PLA Code||Effective Date||Manufacturer|
|0202U||05/20/2020||BioFire® Respiratory Panel 2.1 (RP2.1), BioFire®|
|0223U||06/25/2020||QIAstat-Dx Respiratory SARS-CoV-2 Panel, QIAGEN Sciences, QIAGEN GMbH|
|0224U||06/25/2020||Antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), includes titer(s), when performed|
|0225U||08/10/2020||ePlex® Respiratory Pathogen Panel 2, GenMark Dx, GenMark Diagnostics, Inc.|
|0226U||08/10/2020||Tru-ImmuneTM, Ethos Laboratories, GenScript® USA Inc.|
My laboratory does not use the CDC test kit, what code should we use to bill?
If your laboratory uses the method specified by CPT 87635, the appropriate code to use would be CPT 87635. If your laboratory has a test that uses a method not described by CPT 87635, the appropriate code to use would be HCPCS Code U0002.
If your laboratory utilizes high-throughput technologies, the appropriate code to bill would be HCPCS U0004.
What codes should I use for COVID-19 antibody tests?
There are two new codes, effective 4/10/2020 for COVID-19 antibody tests. CPT 86328 generally describes a single step method immunoassay whereas CPT 86769 has been established for antibody tests using a multiple step method.
For SCO members only, effective 06/25/2020, CPT 0224U may also be billed for the specific Proprietary Laboratory Analyses (PLA) test.
Antibody test are covered when such tests are conducted in accordance with DPH and CDC guidance and are medically necessary. At this time, antibody testing should not be used to guide release from isolation or for return to work purposes and are not indicated for diagnostic purposes.
Will WellSense reimburse providers for specimen collection for COVID-19 clinical laboratory tests?
For MH and QHP Members:
In addition to the laboratory analysis, we will reimburse the following providers for specimen collection billing either G2023 or G2024:
- Independent Clinical Laboratories
- Acute Outpatient Hospitals
- Community Health Centers
- Family Planning Agencies
- Rapid Testing Sites (Drive-thru Testing Site)
WellSense will also reimburse eligible providers an additional payment when billing modifier “CG” along with G2023 or G2024. The CG modifier can only be applied when, in addition to collecting the specimen, the provider:
- has a qualified ordering clinician present at the specimen collection site available to order medically necessary COVID-19 tests; and
- ensures that the test results (and any initial follow-up counseling, as appropriate) are provided to the member, either directly or through the member’s ordering clinician.
For SCO Members:
- In accordance with Medicare, WellSense will reimburse the following providers:
- Independent Labs: Bill with code G2023 or G2024
- Physicians and Non-physician practitioners: Bill with code 99211 for services furnished incident to their professional services for both new and established patients.
- Outpatient hospitals: Bill with code C9803 to bill for a clinic visit dedicated to or including specimen collection
I am an Out of Network provider. Will I be reimbursed for COVID-19 Testing, Evaluation and Treatment of a WellSense member?
WellSense will cover outpatient COVID-19 testing, evaluation, and treatment services provided by out-of-network providers for the duration of the COVID-19 emergency.
WellSense will also cover follow-up care provided by out-of-network providers when such follow-up care is not available in-network. Out-of-network follow up care requires prior authorization. When such follow-up care is available in-network, the out-of-network provider should refer the member back to WellSense Health Plan's provider network.
Will WellSense reimburse ambulance providers for specimen collection for MH Members?
Ambulance providers may be reimbursed for medically necessary visits to obtain and transport COVID-19 specimens by billing code A0998 (EMS Treat no transport) with modifier SS (Seen at Scene). No mileage will be reimbursed.
For non-emergent transportation, WellSense should only be billed to facilitate out-of-state medical services that cannot be obtained within a 50 mile radius of the Commonwealth of Massachusetts. All other non-emergent transportation should be billed to MassHealth directly.
What codes should I use for COVID-19 diagnoses?
All providers must report diagnosis codes in accordance with CDC guidelines as follows. For complete guidance on COVID-19 diagnosis coding and sequencing providers should reference the ICD-10-CM Official Guidelines for Coding and Reporting.
|Confirmed COVID-19 Cases||For dates of service prior to 04/01/2020:
B97.29 – Other coronavirus as the cause of diseases classified elsewhere
For dates of service on or after 04/01/2020:
U07.1 – 2019-nCoV acute respiratory disease
|Exposure to COVID-19||
For dates of service prior to 01/01/2021:
Z03.818 – Encounter for observation for suspected exposure to other biological agents ruled out
Z20.828 – Contact with and (suspected) exposure to other viral communicable diseases
For dates of service on or after 01/01/2021:
Z20.822 – Contact with and (suspected) exposure to COVID-19
Screening for asymptomatic individuals with no known exposure
|For dates of service prior to 01/01/2021:
Z11.59 – Encounter for screening for other viral diseases
For dates of service on or after 1/1/21:
Per ICD-10 official guidelines: During the COVID-19 pandemic, a screening code is generally not appropriate. Do not assign Z11.52, encounter for screening for COVID-19. For encounters for COVID-19 testing, including preoperative testing, code as exposure to COVID-19.
|Personal History of COVID-19||For dates of service on or after 1/1/21:
Z86.16 - Personal history of COVID-19
For visits unrelated to COVID-19, please report diagnosis codes according to ICD-10 guidelines.
Who should be tested for COVID-19?
Individuals who are symptomatic or have been in close contact of COVID cases should be tested using a molecular diagnostic test such as polymerase chain reaction (PCR) or other nucleic acid amplification methodology. Symptomatic individuals are those who display:
- Fever, chills or shaking chills,
- Signs of a lower respiratory illness (e.g., cough, shortness of breath, lowered oxygen saturation),
- Fatigue, sore throat, headache, body aches/myalgia, or new loss of sense of taste or smell
- Other less common symptoms can include gastrointestinal symptoms (e.g. nausea, vomiting, diarrhea, rash, and inflammatory conditions such as “COVID toes”).
- In elderly, chronically ill, or debilitated individuals such as residents of a long-term care facility, symptoms of COVID-19 may be subtle such as alterations in mental status or in blood glucose control
Close contact is defined as being less than 6 feet of a COVID-19 case for at least 10-15 minutes which can occur while caring for, living with, visiting, or sharing a healthcare waiting area or room with a COVID-19 case while the case was symptomatic or having direct contact with infectious secretions of a COVID-19 case (e.g., being coughed on) while not wearing recommended personal protective equipment or PPE (e.g., gown, gloves, facemask, eye protection).
When should individuals be tested for COVID-19?
Close contacts with any symptom associated with COVID-19 should be tested promptly and should occur at any time during the contact’s 14-day quarantine period, even if the person previously had a negative test result within that same period. Close contacts without symptoms should be tested as soon as possible after they are notified of their exposure to COVID-19. The contact is required to quarantine for the full 14 days, even following a negative test result.
What are the Coverage and Payment Policies for Managed Care Plans?
Managed care plans must cover testing, treatment, and prevention of COVID-19 in at least the same amount, duration and scope as covered by MassHealth through its fee-for-service program. Coverage must include:
- Diagnostic laboratory services performed by laboratories and health care facilities that have obtained appropriate approval to test individuals for COVID-19;
- Telehealth and certain telephonic services as means by which members may access all clinically appropriate, medically necessary covered services;
- Home visits;
- COVID-19 quarantine in a hospital as administrative or observation days; and
- Drugs, including 90-day supplies and early refills of covered drugs.
Will you relax Credentialing requirements during the COVID-19 pandemic?
We have implemented a Provisional Credentialing process to expedite the onboarding of new practitioners into its provider networks. This process will go into effect immediately and will discontinue on the date when the COVID-19 public health emergency is lifted.
Provisional credentialing will allow us to enroll new practitioners before their full credentialing process has been completed. In accordance with the National Committee for Quality Assurance (NCQA), practitioners may hold a provisional status for up to 180 calendar days. We will complete the practitioner’s full credentialing before his/her provisional status has expired.
- The Provisional Credentialing process will be available for any new practitioner who requires full credentialing (under the our credentialing policies), and is requesting to enroll under one of the following specialties:
Cardiovascular Disease Internal Medicine Otolaryngology Critical Care Medicine Nephrology Pediatrics General Surgery Neurology Pulmonary Disease Infectious Disease Obstetrics and Gynecology
- Expedited enrollment and onboarding is also available for the following practitioners: Emergency Medicine, Anesthesiology, Hospitalists or other individuals who practice exclusively within an inpatient setting, and who provide care to our members-only because the members are directed to the hospital or inpatient setting.
- Providers submitting the above provider types for credentialing should submit with the Subject noted as “Critical” to ensure these requests are identified timely.
- A group may also request provisional credentialing for any practitioner who does not practice one of the specialties listed above, and if there is a critical need for the practitioner as a result of this public health emergency. These requests should be submitted with the Subject noted as “Critical” to ensure the requests are identified timely.
- To prevent unnecessary delays, practitioners should ensure that they have a current and complete CAQH application.
Are you covering telehealth visits?
In accordance with the State response to COVID-19 management, WellSense will cover telephonic visits in addition to telehealth visits for our members until further notice. Please see codes for each telehealth visit type below.
Can I provide telehealth services to my patients?
Providers capable of offering telehealth services—either via telephone only or a combination of telephone and video— may do so.
What codes should I use for telehealth visits for MassHealth or QHP members?
Providers should code for telehealth visits in one of two ways depending on the type of visit:
- Visits that would have been rendered in the person – These must include place of service code 02 in addition to the applicable code(s) describing the services provided.
- Visits that do not constitute an in-person visit – These must be reported using the CPT code tables below. We will reimburse for clinically appropriate, medically necessary telephone evaluations.
Eligible providers may bill a facility fee if such a fee is permitted under such provider’s contract.
Audio Only Telehealth Coding for MassHealth and Qualified Health Plan members
|Physician telephone evaluation 5-10 MIN|
|99442||Physician telephone evaluation 11-20 MIN|
|99443||Physician telephone evaluation 21-30 MIN|
|98966||Qualified nonphysician health professional telephone evaluation 5-10 MIN|
|98967||Qualified nonphysician health professional telephone evaluation 11-20 MIN|
|98968||Qualified nonphysician health professional telephone evaluation 21-30 MIN|
Services may not be set up to pay at the time of claim submission. We will reprocess any impacted claims after implementation.
Will providers be paid for regular E&M visits billed with a POS 02 for MassHealth or QHP Members?
Yes, providers will be paid for regular E&Ms with a POS 02. Providers may render the telehealth service via audio-only or a combination of audio and video modalities. Rates of payment for services delivered via telehealth will be the same as rates of payment for services delivered via traditional (e.g., in-person) methods. Follow the below rules for billing the E&M’s with a POS 02.
The test for whether you can bill something to MassHealth telehealth is:
- Were you able to bill it to MassHealth and be paid before?
- Is it clinically appropriate to be delivered via telehealth?
- Are you conforming to the guidance in Appendix A of the Provider Bulletin 289?
- Is it medically necessary for the member?
If “Yes” to these four inquires of validation, then the visit can be billed and paid by MassHealth or any MassHealth managed care entity at the same rates as if rendered in person.
- All services should be billed with the same CPT codes as when a face-to-face visit is performed.
- Must add POS 02 on claim
How should facility providers submit claims for services delivered via telehealth for MassHealth or QHP members?
Providers billing under an 837I/UB-04 form must include the modifier “GT” when submitting claims for services delivered via telehealth. Rates of payment for services delivered via telehealth will be the same as rates of payment for services delivered via traditional (e.g., in-person) methods.
How should facility providers submit claims for services delivered via telehealth for MassHealth or QHP members?
Providers billing under an 837P/1500 form must include the place of service code “02” when submitting claims for services delivered via telehealth. Additionally, effective 10/16/2021, for any such professional claim, providers must include:
- Modifier 95 to indicate services rendered via audio-video telehealth;
- Modifier V3 to indicate services rendered via audio-only telehealth;
- and/or Modifier GQ to indicate services rendered via asynchronous telehealth.
Rates of payment for services delivered via telehealth will be the same as rates of payment for services delivered via traditional (e.g., in-person) methods.
When a physician or practitioner who ordinarily practices in the Hospital Outpatient Department furnishes a telehealth service to a SCO member who is located at home, can the hospital bill an originating site fee?
When a SCO member registered as an outpatient of the hospital is receiving a telehealth service, the hospital may bill the originating site facility fee to support such telehealth services furnished by a physician or practitioner who ordinarily practices there and bills for the telehealth service that is or would otherwise be furnished in the hospital outpatient department. This includes patients who are at home, when the home is made provider-based to the hospital (which means that all applicable conditions of participation, to the extent not waived, are met).
What codes should I use for telehealth visits for Senior Care Options members?
In accordance with Medicare interim regulations, WellSense will reimburse providers for services provided via telehealth that are listed in Medicare’s expanded list of telehealth services.
All of the services listed may be rendered via telehealth with a combination of audio and video technology. Additionally, Medicare has identified certain telehealth services that meet the Audio-only interaction requirements and can be rendered via audio-only only through the end of the PHE. Providers may not be reimbursed for audio-only telehealth visits at the same rate as if the visit were in person. Providers should bill for the same service delivered via telehealth as would have been delivered via in-person methods.
Providers should code for telehealth visits in one of two ways depending on the type of visit:
- Visits that would have been rendered in person –These codes must include modifier 95 and the POS where the service would have been rendered if not for the PHE or;
- Visits that would have been rendered via traditional Medicare telehealth – Bill in accordance with standard Medicare billing guidelines.
FQHC/RHC Telehealth Coding for Senior Care Options members (Medicare)
FQHC/RHC providers should bill for telehealth visits in accordance with Medicare guidelines effective with dates of service on or after 01/27/2020. These visits may be performed via audio-only or a combination of audio and video telehealth modalities using the following code:
|G2025||Distant Site Telehealth Services FQHC/RHC|
FQHC/RHC providers must report all online digital evaluation and management or virtual communication services, video and audio, in accordance with Medicare guidelines using the following code:
|G0071||Payment for communication technology-based services for 5 minutes or more of a virtual (non face-to-face) communication between a rural health clinic or federally qualified health center practitioner and RHC or FQHC patient.|
FQHC/RHC providers should note that on an interim basis the rate of payment for this code has been increased with the expansion of Virtual Communication services that can be performed at the FQHC/RHC.
All above services may not be set up to pay at the time of claim submission. We will reprocess any impacted claims after implementation.
Will providers be paid for regular E&M visits billed with a modifier 95 for Senior Care Options (SCO) members?
Yes, per Medicare guidelines, providers will be reimbursed at the same rate for services delivered via telehealth as the rates of payment for services delivered via in-person methods.
Can Non-physician practitioners (i.e. PT/OT/SLP) be reimbursed for visits performed via telehealth for Senior Care Options (SCO) members?
In accordance with expanded Medicare telehealth regulations, health care professionals who were previously ineligible to furnish and bill for Medicare telehealth services, including physical therapists, occupational therapists, speech language pathologists, and others, may receive payment for Medicare telehealth services.
Can Adult Day Health Services be delivered remotely (via Telehealth and In Home Settings) during the PHE?
Remote ADH services, as well as any in-person services provided in an in-home setting, will be reimbursed by WellSense if the following requirements are met:
- Remote ADH services are provided to members only if the provider’s congregate site is open and in operation no later than September 25, 2020;
- Services align with the member’s individualized plan of care and promote the prevention of decompensation in mental and physical status due to isolation in the home;
- Care management and follow-up from telehealth interaction with the member or caregiver provides necessary interventions to maintain safety in the home;
- Remote ADH services are provided only on days in which a member does not attend programming in a congregate setting; and
ADH providers should only bill with code S5101 for Basic Level of Care and S5101TG for Complex Level of Care along with Place of Service “02” for the services delivered via telehealth/remote/in-home settings. Codes other than S5101 may not be used to bill remote services.
Services delivered via telehealth/remote/in-home may be billed only for the day in which the service was delivered. Remote ADH services can be delivered and billed for up to three times per week at the partial per diem rate only (up to three hours of services).
Should providers perform Behavioral Health Screening to pediatric and perinatal members during the PHE?
It is crucial during the pandemic that perinatal and primary care providers (PCPs) offer behavioral health screenings to pediatric members and depression screening in perinatal women and caregivers (perinatal members) to ensure early detection and access to treatment. PCPs play an essential role during the COVID-19 pandemic in identifying behavioral health needs and supporting children and youth from communities affected by longstanding health inequities. Also, several studies have found that low-income women and women of color are more likely to experience perinatal depression than middle- and upper-income peers and white women. The combination of increased stressors and decreased utilization of preventative and well-check visits during the COVID-19 pandemic heightens the need to reinforce the recommendations for both perinatal behavioral health screening and timely follow-up care.
The Plan encourages providers to perform these important behavioral health screenings during their well-child or as needed other non-routine visits with pediatric and perinatal members, whether those visits occur in person or via telehealth.
What if my office can’t provide COVID-19 testing or treatment?
We recommend that providers reach out to their local hospitals for specific COVID-19 testing availability and protocols.
If you are unable to provide COVID-19 testing or treatment and there are no viable in-network facilities to provide care for your patient, or if your patient has urgent testing or treatment needs, we will cover visits to out-of-network providers.
Which providers are authorized to receive reimbursement for the COVID-19 vaccine and administration?
The following providers are eligible to administer and be reimbursed separately for the COVID-19 vaccine and administration:
- Acute outpatient hospitals (AOHs)
- Community health centers (CHCs)
- Local boards of health
- Family planning agencies
- Hospital licensed health centers (HLHCs)
- Limited service clinics (Urgent Care)
- Physicians and Physician assistants
- Certified nurse practitioners, Certified nurse midwives, and Certified registered nurse anesthetists
- Clinical nurse specialist and Psychiatric clinical nurse specialists
- Ambulance providers (rendered by a paramedic, advanced emergency medical technician (EMT), or EMT-basic)
- Home Health Agencies
Also, Mass Immunizers may bill and receive payment from the Plan for the administration of the COVID-19 vaccines provided that they are authorized by MassHealth and meet the requirements set forth by the Massachusetts Department of Public Health and are enrolled in the Massachusetts COVID-19 Vaccination Program.
Reimbursement for COVID-19 vaccine and administration will be included in the existing payment methodology for Acute Inpatient Hospitals and Indian Health Service facilities and Tribal clinics.
What codes should providers use for the COVID-19 vaccines and their administration?
The vaccine codes and their administration codes are listed in the below tables by manufacturer:
|Code||Vaccine Descriptions||Effective Date|
|91300||SARSCOV2 VAC 30MCG/0.3ML Pfizer-Biontech COVID-19 Vaccine||12/11/2020|
|91301||SARSCOV2 VAC 100MCG/0.5ML IM Moderna COVID-19 Vaccine||12/18/2020|
|91303||SARSCOV2 VAC AD26 .5ML IM Jansen (Johnson & Johnson) Covid-19 Vaccine||02/27/2021|
|91306||SARSCOV2 VAC 50MCG/0.25ML IM Moderna Covid-19 Vaccine Low Dose||10/20/2021|
|91307||SARSCOV2 VAC 10 MCG TRS-SUCR Pfizer-BioNTech Covid-19 Pediatric Vaccine||10/29/2021|
|Code||Vaccine Administration Description||Effective Date|
|0001A||ADM SARSCOV2 30MCG/0.3ML 1ST Pfizer-Biontech Covid-19 Vaccine Administration – First Dose of 91300||12/11/2020|
|0002A||ADM SARSCOV2 30MCG/0.3ML 2ND Pfizer-Biontech Covid-19 Vaccine Administration – Second Dose of 91300||12/11/2020|
|0003A||ADM SARSCOV2 30MCG/0.3ML 3RD Pfizer-Biontech Covid-19 Vaccine Administration – Third Dose of 91300||08/12/2021|
|0004A||ADM SARSCOV2 30MCG/0.3ML BST Pfizer-Biontech Covid-19 Vaccine Administration – Booster of 91300||09/22/2021|
|0011A||ADM SARSCOV2 100MCG/0.5ML1ST Moderna Covid-19 Vaccine Administration – First Dose of 91301||12/18/2020|
|0012A||ADM SARSCOV2 100MCG/0.5ML2ND Moderna Covid-19 Vaccine Administration – Second Dose of 91301||12/18/2020|
|0013A||ADM SARSCOV2 100MCG/0.5ML3RD Moderna Covid-19 Vaccine Administration – Third Dose of 91301||08/12/2021|
|0031A||ADM SARSCOV2 VAC AD26 .5ML Janssen (Johnson & Johnson) Covid-19 Vaccine Administration - First Dose of 913003||02/27/2021|
|0034A||ADM SARSCOV2 VAC AD26 .5ML B Janssen (Johnson & Johnson) Covid-19 Vaccine Administration Booster Dose of 91303||10/20/2021|
|0064A||ADM SARSCOV2 50MCG/0.25MLBST Moderna Covid-19 Vaccine (Low Dose) Administration – Booster Dose of 91306||10/20/2021|
|0071A||ADM SARSCV2 10MCG TRS-SUCR 1 Pfizer-BioNTech Covid-19 Pediatric Vaccine - Administration - First dose||10/29/2021|
|0072A||ADM SARSCV2 10MCG TRS-SUCR 2 Pfizer-BioNTech Covid-19 Pediatric Vaccine - Administration - Second dose||10/29/2021|
|M0201||Covid-19 vaccine home admin||06/08/2021|
What codes should I report for administering monoclonal antibody therapy to treat COVID-19?
Providers should report both codes for the COVID-19 monoclonal antibody product and the COVID-19 monoclonal antibody administration in their bill to the Plan. Providers should report $0.00 charges for the monoclonal antibody product and append the SL modifier if the monoclonal antibody product is federally supplied at no-cost. The Plan will not reimburse for the no-cost federally supplied monoclonal antibody product but will reimburse for its administration. The monoclonal antibody codes and their administration are listed in the below tables:
|Code||Monoclonal Antibody Description||Effective Date|
|Q0220||AstraZeneca, Injection, tixagevimab and cilgavimab, 300 mg||12/08/2021|
|Q0239||Eli Lilly injection, Injection, bamlanivimab, 700 mg||11/09/2020 through 4/16/2021|
|Q0240||Regeneron, Injection, casirivimab and imdevimab, 600 mg||07/30/2021|
|Q0243||Regeneron, injection, casirivimab and imdevimab, 2400 mg||11/21/2020|
|Q0244||Regeneron, injection, casirivimab and imdevimab, 1200 mg||06/03/2021|
|Q0245||Eli Lilly injection, bamlanivimab and etesevimab, 2100 mg||02/09/2021|
|Q0247||GSK, Injection, sotrovimab, 500 mg||05/26/2021|
|Q0249||Genentech, Injection, tocilizumab, for hospitalized adults and pediatric patients (2 years of age and older) with covid-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO) only, 1 mg||06/24/2021|
|Code||Monoclonal Antibody Administration Description||Effective Date|
|M0220||AstraZeneca, Injection, tixagevimab and cilgavimab, includes injection and post administration monitoring||12/08/2021|
|M0221||AstraZeneca, Injection, tixagevimab and cilgavimab, includes injection and post administration monitoring, includes injection and post administration monitoring in the home or residence; this includes a member’s home that has been made provider-based to the hospital during the covid-19 public health emergency||12/08/2021|
|M0239||Eli Lilly intravenous infusion, bamlanivimab-xxxx, includes infusion and post administration monitoring||11/9/2020 through 4/16/2021|
|M0240||Regeneron, Intravenous infusion or subcutaneous injection, casirivimab and imdevimab includes infusion or injection, and post administration monitoring, subsequent repeat doses||07/30/2021|
|M0241||Intravenous infusion or subcutaneous injection, casirivimab and imdevimab includes infusion or injection, and post administration monitoring in the home or residence, this includes a beneficiary's home that has been made provider-based to the hospital during the covid-19 public health emergency, subsequent repeat doses||07/30/2021|
|M0243||Regeneron, intravenous infusion, casirivimab and imdevimab includes infusion and post administration monitoring||11/21/2020|
|M0244||Regeneron, intravenous infusion, casirivimab and imdevimab includes infusion and post administration monitoring in the home or residence||05/06/2021|
|M0245||Intravenous infusion, bamlanivimab and etesevimab, includes infusion and post administration monitoring||02/09/2021|
|M0246||Eli Lilly, intravenous infusion, bamlanivimab and etesevimab, includes infusion and post administration monitoring in the home or residence||05/06/2021|
|M0247||Sotrovimab, infusion, Intravenous infusion, sotrovimab, includes infusion and post administration monitoring||05/26/2021|
|M0248||Sotrovimab inf, home admin, Intravenous infusion, sotrovimab, includes infusion and post administration monitoring in the home or residence; this includes a beneficiary’s home that has been made provider-based to the hospital during the covid-19 public health emergency||05/26/2021|
|M0249||Genentech, Intravenous infusion, tocilizumab, for hospitalized adults and pediatric patients (2 years of age and older) with covid-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO) only, includes infusion and post administration monitoring, first dose||06/24/2021|
|M0250||Genentech, Intravenous infusion, tocilizumab, for hospitalized adults and pediatric patients (2 years of age and older) with covid-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO) only, includes infusion and post administration monitoring, second dose||06/24/2021|
For a SCO dual member, should I bill WellSense for a COVID-19 Vaccine and its administration?
No, for any SCO Dual-Eligible member, providers should bill Original Medicare through their Medicare Administrative Contractor for the vaccine and its administration. Providers should only bill the Plan for vaccines and their administration provided to SCO Medicaid-only members.
Providers should prepare members for their vaccination appointment by asking the member to bring their Original Medicare card, or at least their Medicare number to their vaccination appointment. Providers will then have the appropriate insurance information to bill Original Medicare for the vaccine administration.
How do Institutional Providers bill for COVID-19 vaccine products and their administration?
For all members, institutional providers shall bill the COVID-19 vaccination product codes with revenue code 0636 and the administration codes with revenue code 0771.
When billing inpatient or outpatient claims on or after February 1, 2021, providers should include condition code 91 when billing for COVID-19 vaccine and its administration. Condition code 91 allows providers to report when the service is provided as part of an Emergency Use Authorization (EUA).
How do Institutional Providers bill for COVID-19 monoclonal antibody products and their infusion?
For all members, institutional providers shall bill the product codes with revenue code 0636 and infusion codes with revenue code 0771. Institutional Providers shall report COVID-19 monoclonal antibody products and their infusion using the date of discharge and/or the “A6” condition code, and diagnosis code Z23 as required by system editing for vaccines.
When billing inpatient or outpatient claims on or after February 1, 2021, providers should include condition code 91 when billing for COVID-19 monoclonal antibody products and their infusion. Condition code 91 allows providers to report when the service is provided as part of an Expanded Access approval.
How do physicians and other clinicians bill for COVID-19 monoclonal antibody products and their infusion?
Physicians and non-physician practitioners shall bill the infusion codes with HCPCS codes listed above. Physicians and other clinicians shall report COVID-19 monoclonal antibody products and their infusion with diagnosis code Z23.
How do Institutional Providers bill for COVID-19 monoclonal antibody or COVID-19 immunization vaccine products obtained for free and dispensed to its SCO members?
When COVID-19 monoclonal antibody or COVID-19 immunization vaccine doses are provided by the government without charge, providers should only bill for the administration. Providers should not include the COVID-19 monoclonal antibody codes or COVID-19 immunization vaccine codes on the claim when the product is provided for free. However, the Plan recognizes that many provider billing systems require a charge to be submitted, even when a product is provided for free or without charge. In this instance, Institutional Providers should follow the direction provider in the IOM 100-04, Chapter 32, Section 67.2 – Institutional Billing for No Cost Items. For drugs provided at no cost, institutional providers must report the applicable drug HCPCS code and appropriate units with a token charge of $0.00 or $0.01 for the item in the covered charge field and mirror this $0.00 or $0.01 amount reported in the non-covered charge field. Institutional Providers must report the “No Cost” item as non-covered.
How do physicians and non-physician practitioners bill for COVID-19 monoclonal antibody or COVID-19 immunization vaccine products obtained for free for SCO members?
When COVID-19 monoclonal antibody or COVID-19 vaccine doses are provided by the government or any other entity without charge, physicians and non-physician practitioners should only bill for the administration of the product. Providers should not include the COVID-19 monoclonal antibody codes or COVID-19 immunization vaccine codes on the claim when the product is provided for free. However, CMS recognizes that many provider billing systems require a charge to be submitted, even when a product is provided for free or without charge. In this instance, physicians and non-physician practitioners bill the monoclonal antibody or COVID-19 immunization vaccine with a token charge of $0.01 (one penny).
How do Professional Providers bill for COVID-19 monoclonal antibody or COVID-19 immunization vaccine products obtained for free that have been disbursed to MassHealth or QHP members?
Providers should report both codes for the COVID-19 vaccine and the COVID-19 vaccine administration or for the COVID-19 monoclonal antibody product and the COVID-19 monoclonal antibody administration in their bill to the Plan. Providers should report $0.00 charges for the vaccine and monoclonal antibodies products and append the SL modifier if the vaccine or monoclonal antibody product is federally supplied at no-cost. The Plan will not reimburse for the no-cost federally supplied vaccine or monoclonal antibody product but will reimburse for their administration.
What rates will the Plan reimburse providers for COVID-19 testing and vaccine administration for MassHealth and QHP members?
The Plan will reimburse providers for COVID-19 testing and COVID-19 vaccine administration with the following rates on or after the effective date listed per code:
|86328||Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative, single step method (e.g., reagent strip); severe acute respiratory syndrome oronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID-19])||2/5/2021||$45.24|
|86408||Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]); screen||2/5/2021||$42.14|
|86409||Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]); titer||2/5/2021||$105.34|
|86413||Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID-19]) antibody, quantitative||2/5/2021||$51.44|
|86769||Antibody; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19])||2/5/2021||$42.14|
|87426||Infectious agent antigen detection by immunoassay technique, qualitative or semiquantitative, multiple-step method; severe acute respiratory syndrome coronavirus (e.g., SARS-CoV, SARS-CoV-2 [COVID-19])||2/5/2021||$35.34|
|87428||Infectious agent antigen detection by immunoassay technique, qualitative or semiquantitative; severe acute respiratory syndrome coronavirus (eg, SARS-CoV, SARS-CoV-2 [COVID-19]) and influenza virus types A and B||2/5/2021||$63.60|
|87635||Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID-19]), amplified probe technique||2/5/2021||$51.32|
|87636||Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) and influenza virus types A and B, multiplex amplified probe technique||2/5/2021||$142.64|
|87637||Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), influenza virus types A and B, and respiratory syncytial virus, multiplex amplified probe technique||2/5/2021||$142.64|
|87811||Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19])||2/5/2021||$41.39|
|0202U||Infectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected||2/5/2021||$298.61|
|0223U||Infectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected||2/5/2021||$298.61|
|0224U||Antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), includes titer(s), when performed||2/5/2021||$42.14|
|0225U||Infectious disease (bacterial or viral respiratory tract infection) pathogen-specific DNA and RNA, 21 targets, including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), amplified probe technique, including multiplex reverse transcription for RNA targets, each analyte reported as detected or not detected||2/5/2021||$416.79|
|0226U||Surrogate viral neutralization test (sVNT), severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), ELISA, plasma, serum||2/5/2021||$42.29|
|0240U||Infectious disease (viral respiratory tract infection), pathogen-specific RNA, 3 targets (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2], influenza A, influenza B), upper respiratory specimen, each pathogen reported as detected or not detected||2/5/2021||$142.64|
Infectious disease (viral respiratory tract infection), pathogen-specific RNA, 4 targets (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2], influenza A, influenza B, respiratory syncytial virus [RSV]), upper respiratory specimen, each pathogen reported as detected or not detected
|G2023||Specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), any specimen source||2/5/2021||$23.47|
|G2023CG||Specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), any specimen source. [Used when provider 1) has a qualified ordering clinician present at the specimen collection site available to order medically necessary COVID-19 diagnostic tests; and 2) ensures the test results are provided to the patient (along with any initial follow-up counseling, as appropriate), either directly or through the patient’s ordering clinician]||2/5/2021||$44.28|
|G2024||Specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), from an individual in a skilled nursing facility or by a laboratory on behalf of a home health agency, any specimen source||2/5/2021||$25.47|
|G2024CG||Specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), from an individual in a skilled nursing facility or by a laboratory on behalf of a home health agency, any specimen source. [Used when provider 1) has a qualified ordering clinician present at the specimen collection site available to order medically necessary COVID-19 diagnostic tests; and 2) ensures the test results are provided to the patient (along with any initial follow-up counseling, as appropriate), either directly or through the patient’s ordering clinician]||2/5/2021||$46.28|
|U0001||CDC 2019 Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel||2/5/2021||$35.92|
|2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC||2/5/2021||$51.32|
|U0003||Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARSCoV- 2) (Coronavirus disease [COVID-19]), amplified probe technique, making use of high throughput technologies as described by CMS-2020-01-R||2/5/2021||$75.01|
|U0004||2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC, making use of high throughput technologies as described by CMS-2020-01-R||2/5/2021||$75.01|
|U0005||Infectious agent detection by nucleic acid (DNA or RNA); Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique, CDC or non-CDC, making use of high throughput technologies, completed within 2 calendar days from date of specimen collection (list separately in addition to either HCPCS code U0003 or U0004) as described by CMS-2020-01-R2||2/5/2021||$25.01|
COVID-19 Vaccine Administration:
|Code||Description||Effective Date||Rate through 03/31/21||Rate as of 04/01/21|
|0001A||Pfizer-Biontech Covid-19 Vaccine Administration – First Dose (ADM SARSCOV2 30MCG/0.3ML 1ST)||12/11/2020||$33.89||$45.88|
|0002A||Pfizer-Biontech Covid-19 Vaccine Administration – Second Dose (ADM SARSCOV2 30MCG/0.3ML 2ND)||12/11/2020||$56.79||$45.88|
|0011A||Moderna Covid-19 Vaccine Administration – First Dose (ADM SARSCOV2 100MCG/0.5ML 1ST)||12/18/2020||$33.89||$45.88|
|0012A||Moderna Covid-19 Vaccine Administration – Second Dose (ADM SARSCOV2 100MCG/0.5ML 2ND)||12/18/2020||$56.79||$45.88|
|0031A||Janssen Covid-19 Vaccine Administration (ADM SARSCOV2 VAC AD26 .5ML)||02/27/2021||$56.79||$45.88|
What rates will the Plan reimburse providers for COVID-19 testing for SCO members?
The Plan will reimburse providers for COVID-19 testing with the Medicare published rates.
What rates will the Plan reimburse providers for COVID-19 vaccine administration for SCO members?
The Plan will reimburse providers for COVID-19 vaccine administration with the Plan rates listed above for Medicaid-Only members.
Will WellSense reimburse providers for transporting members to COVID-19 vaccination sites for the member’s vaccine administration?
For MassHealth members, transportation to COVID-19 vaccination sites is managed by MassHealth. Providers should follow MassHealth All Provider Bulletin 310 for instructions and billing guidance related to providing this service to any MassHealth Member. WellSense will not reimburse providers for transporting a MassHealth member to a COVID-19 vaccine administration site.
For QHP members, WellSense will not reimburse providers for this transportation service as there is no non-emergent benefit for QHP members.
For SCO members, transportation to COVID-19 vaccination sites is covered. Providers should contact WellSense Health Plan's transportation vendor, One Call, LLC.
Additional Billing section added 4/15/20
How do I bill for a COVID-19 patient quarantined in the hospital?
For MassHealth or QHP members
Acute inpatient hospitals may bill for members no longer requiring an inpatient level of care but who must be quarantined in the hospital or otherwise cannot be safely discharged due to COVID-19 by either: (1) keeping the member as an inpatient, switching the member to administrative day status, and billing accordingly, or (2) discharging the member from inpatient care, commencing observation services, and billing accordingly.
Chronic disease and rehabilitation inpatient hospitals may bill for members no longer requiring an inpatient level of care but who must be quarantined in the hospital or otherwise cannot be safely discharged due to COVID-19 by keeping the member as an inpatient, switching the member to administrative day status, and billing accordingly.
For SCO members
If a SCO member is a hospital inpatient for medically necessary care, WellSense will pay hospitals the diagnosis-related group (DRG) rate and any cost outliers for the entire stay, including any the quarantine time when the patient does not meet the need for acute inpatient care, until the SCO member is discharged. The DRG rate (and cost outliers as applicable) includes the payments for when a patient needs to be isolated or quarantined in a private room. We will also reimburse providers and additional 20% to the DRG weight for COVID-19 related discharges.
Is there additional guidance for CHC Billing for MassHealth and QHP members?
For all CHCs services rendered via telehealth visit, the CHC would continue to bill T1015 along with the appropriate E/M code but with Place of Service (POS) ‘02’. WellSense will also reimburse CHCs for encounters billed with T1015 for clinically appropriate, medically necessary telephone-only evaluations along with one of the following CPT codes for physicians: 99441, 99442, 99443; and for qualified non-physicians: 98966, 98967, 98968.
Can the After-Hours code 99050 be billed on the telehealth claims (for MassHealth and QHP members)?
Yes. If services are rendered by telehealth after-hours, providers may bill the after-hours code 99050 where permitted under MassHealth rules. Providers should bill with place of service ‘02’.
Will WellSense reimburse claims for well-child care via telemedicine (audio and/or video) during the PHE for MH and QHP members?
Yes, as clinically appropriate, services that would have previously been rendered and covered as face-to-face may now be rendered via telehealth. Providers should bill with place of service ‘02’ for the preventive visit, any additional applicable service provided. For any vaccines administered on the same date as the telehealth visit, providers should bill the place of service where the vaccine was administered and not place of service ‘02’.
Will WellSense reimburse claims for an additional child wellness visit to collect medically necessary components of the wellness visit that cannot be completed via telehealth?
For an in-person follow-up visit to complete medically necessary components of the preventive visit not performed on the same day as the preventive visit that was provided via telehealth, providers may be reimbursed by billing the following:
- A single E&M visit at level 1, 2, or 3 (appropriate to complexity of visit) not on the same day as the preventive telehealth visit; and
- Any additional codes applicable to the service provided (e.g., laboratory, hearing/vision screening)
WellSense encourages providers to screen children for lead exposure during the COVID-19 pandemic. Because children and families are spending an increased amount of time in their homes and additionally, many families and property owners are initiating home improvement projects or renovations, lead exposure in children has increased. Please screen children as soon as possible to ensure their health and safety.
Will WellSense reimburse claims for COVID-19 remote patient monitoring for MH members?
Yes, WellSense will reimburse the following provider types for remote patient monitoring bundled services:
- Community Health Centers
- Acute Outpatient Hospitals
- Hospital Licensed Health Centers
- Group Practices
Providers should bill code 99423 with modifier U9 on the first day the provider renders COVID-19 RPM bundled services.
Providers may not bill this code again during the next seven days (including the date on which the provider billed 99423-U9).Providers may be reimbursed for a facility fee for the COVID-19 RPM bundle. The facility fee should only be billed once during the seven-day monitoring period by billing the following:
- Procedure code 99423 with modifier U9
- Principal diagnosis code U07.1
- Observation code 762
Can an Acute Outpatient Hospital be reibursed for rendering behavioral health crisis services?
Yes. For dates of service on or after March 20, 2020, WellSense will reimburse acute outpatient hospitals for Emergency Services Program (ESP) and Mobile Crisis Intervention (MCI) services. Acute outpatient hospitals should bill for the service with HCPCS code S9485.
Can providers be reimbursed for rendering home visits?
Yes. For dates of service beginning March 12, 2020, physicians and acute outpatient hospitals may be reimbursed for providing home visits by billing any of the pertinent HCPCS codes 99500 – 99507, 99509, or 99511-99512.
Can Adult Day Health providers be reimbursed for retainer payments for SCO members?
Yes, in accordance with MH regulations, ADH eligible providers may be reimbursed on a per-member, per-day basis at 100% of the plan’s current per diem rate for ADH services. WellSense will not make retainer claims for ADH claims for transportation services. ADH providers should bill for retainer payments as follows:
|S5102 *||TG U6||Complex level of care (per diem)|
|S5102||U6||Basic level of care (per diem)|
*ADH providers billing for the Complex level of care must submit with the TG modifier in the first position in order to be reimbursed appropriately.
Will WellSense reimburse Adult Day Health providers enhanced payment rates for services provided?
Yes, WellSense will reimburse providers for the following services when billed with the appropriate codes below. The enhanced payment also includes ADH services delivered remotely, regardless of the duration of the remote engagement.
|Service Department||Code||Unit||Rate Increase 8/1 - 9/30/20||Rate Increase 10/1 - 11/30/20|
|Adult Day Health – Basic Level of Care||S5102||Per Diem||40%||25%|
|Adult Day Health – Complex Level of Care||S5102 TG||Per Diem||40%||25%|
|Adult Day Health – Basic Level of Care||S5100||Per 15 Minutes||40%||25%|
|Adult Day Health – Basic Level of Care||S5101||Per 3 hours||40%||25%|
|Adult Day Health – Complex Level of Care||S5100TG||Per 15 Minutes||40%||25%|
|Adult Day Health – Complex Level of Care||S5101 TG||Per 3 hours||40%||25%|
|Adult Day Health - Transportation||T2003||Per Trip||40%||25%|
|Service Description||Code||Unit||Rate 12/1-2/28||Rate 3/1-11/30/20|
|Adult Day Health – Basic Level of Care||S5102||Per Diem||$87.74||$78.34|
|Adult Day Health – Complex Level of Care||S5102 TG||Per Diem||$111.10||$99.20|
|Adult Day Health – Basic Level of Care||S5100||Per 15 Minutes||$3.65||$3.26|
|Adult Day Health – Basic Level of Care||S5101||Per 3 hours||$43.85||$39.15|
|Adult Day Health – Complex Level of Care||S5100TG||Per 15 Minutes||$4.62||$4.13|
|Adult Day Health – Complex Level of Care||S5101 TG||Per 3 hours||$55.44||$49.50|
For dates of service on or after June 1, 2021, the Plan will reimburse providers for ADH services at the rates established under MassHealth Regulation 101 CMR 404.000.
Will WellSense be implementing the Medicare Payment Methodology changes for Facilities and Practitioners?
We will implement all Medicare interim changes that have been published in the Medicare COVID-19 interim final regulations. Please see Medicare Interim Final Rules with comment period CMS-1744-IFC, CMS-5531-IFC, CMS-3401-IFC, and CMS-9912-IFC.
These include but are not limited to, Medicare IPPS, LTCPPS, IRFPPS, SNFPPS, ASC, ESRDPPS, FQHCPPS, HOPPS, HHPPS, Physician, and DMEPOS.
Will WellSense suspend Medicare sequestration for Senior Care Options (SCO) members?
In compliance with the Coronavirus Aid, Relief, and Economic Security Act, for dates of service on or after May 1, 2020 through and including dates of service December 31, 2020, we will temporarily suspend the application of Medicare 2% sequestration for Senior Care Options members.
Where can I find more detail of the Medicare Interim changes?
Eligibility for Alternative Interim Payments
In light of the state of emergency declared in the Commonwealth due to the 2019 novel Coronavirus (COVID-19) outbreak, MassHealth is implementing measures to address funding shortfalls that providers enrolled in the MassHealth Physician Program are experiencing due to COVID-19. Specifically, MassHealth is implementing a new alternative interim payment option, in accordance with the eligibility criteria set forth in this bulletin and the methodology set forth in Administrative Bulletin 20-62. Note that all alternative interim payments are subject to the reconciliation process set forth in Administrative Bulletin 20-62. MassHealth urges providers to review both this bulletin and Administrative Bulletin 20-62 carefully before submitting a request for an alternative interim payment.
Providers meeting the eligibility criteria set forth below may request an alternative interim payment pursuant to this bulletin and Administrative Bulletin 20-62 by completing and submitting the Alternative Interim Payment Application and Attestation Form, attached to this bulletin as Appendix A, in accordance with the instructions that follow.
In order to receive and to be considered for these payments providers need to attest the Appendix A attached one Physician Bulletin 101 by June 25th.
MassHealth would like to call your attention to the following federal opportunity for provider relief: Provider Relief Fund - Medicaid and CHIP Provider Distribution.
Please note the deadline to apply is 7/20/20
Where can I find the details of the Coronavirus Aid, Relief, and Economic Security Act (CARES Act)?
Update from HHS regarding the new deadline for application submission for funding:
The U.S. Department of Health and Human Services (HHS), through the Health Resources and Services Administration (HRSA), announced that it will begin distributing $10 billion in a second round of high impact COVID-19 area funding to hospitals starting next week. Additionally, HHS announced that it is extending the Medicaid and CHIP Provider Relief Fund distribution provider application deadline to apply to August 3, 2020.
In June, HHS announced the opening of the application period and plans to distribute approximately $15 billion to eligible providers that participate in state Medicaid and CHIP programs who had not yet received a payment from the $50 billion General Distribution. Since the announcement on June 9, HHS has hosted a number of webinars targeted at providers and provider organizations to answer questions and assist those eligible through the application process. A fact sheet - PDF explaining the application process has also been created to address frequently asked questions.
The full announcement is here.
Will Prior Authorization be required for COVID-19 treatment?
In an effort to ensure that members get timely and medically necessary treatment, we are waiving prior authorization requirements for testing and treatment of suspected COVID-19 cases. These requirements will be waived until further notice.
Is Prior Authorization required for Home Health Agencies when rendering hours for SCO members in place of PCA?
Prior Authorization is not required for Home Health Aide services rendered by a Home Health Agency during the COVID-19 pandemic, when providing coverage for members in lieu of currently authorized PCA services.
Per MassHealth Home Health Provider Bulletin 56, MassHealth is adding flexibilities for home health aide services to members in place of PCA services, when the member experiences a disruption in the receipt of PCA services due to COVID-19. In an effort to maintain consistency with MassHealth, the Plan will pay home health agencies to render PCA services for SCO members. These services must be billed as follows to ensure accurate payment. Medicare-certified home health agencies must also report condition code 21.
|G0299||U9||Nursing care visit for temporary emergency PCA services|
|G0300||U9||Nursing care visit for temporary emergency PCA services|
|99509||Home health aide visit for temporary emergency PCA services|
Pursuant to MassHealth Home Health Provider Bulletin 56, the home health agency must obtain the following documentation for each member it provides home health aide services pursuant to the bulletin:
- A copy of the member’s prior authorization approval for personal care attendant services
- A copy of the member’s PCA evaluation as completed by the member’s Plan care manager
For ACO/MCO members, home health agencies should follow instructions as outlined in Bulletin 56 to request these documents from the MassHealth LTSS Provider Service Center.
For Senior Care Options (SCO) members, home health agencies may request a copy of these documents by emailing LTSSPCA@bmchp.org.
Plan Guidelines for Extended Relaxation of Prior Authorization in Response to Health Facility Capacity Constraints in accordance to the issuance of MH Bulletin 2022-03
This mandate removes PA requirements, however concurrent review continues to apply.
Plan Guidelines for Suspension of Prior Authorization for Surgery and Non-behavioral Health Care in accordance to the issuance of MH Bulletin 2021-15
This mandate does not cover services not normally payable under the member benefit plan, for example, cosmetic surgeries.
Services that Plan will review or Plan will auto-approve per MassHealth and DOI Directives:
December 2, 2021
|Type of Service||MassHealth, ACO and SCO||QHP||New Hampshire|
|Elective Surgeries Performed at Hospitals (Inpatient or Outpatient)||Plan will auto approve||Plan will auto approve||Follow standard process|
|Outpatient Surgery at Free Standing Surgery Center||Plan will review||Plan will review||Follow standard process|
|Emergent Admissions||Plan will review||Plan will review||Follow standard process|
|Skilled Nursing Admissions, Rehab, LTAC||Plan will auto approve||Plan will auto approve||Follow standard process|
|Exceptions: Transplants and CAR-T||Plan will review||Plan will review||Follow standard process|
|Review OON Elective Inpatient Requests for OON Approval Only, Not Medical Necessity||Plan will review||Plan will review||Follow standard process|
|All Other Services||Follow standard process||Follow standard process||Follow standard process|
Is the Plan suspending Prior Authorization review for scheduled surgeries or admissions at Hospitals for cases unrelated to COVID-19?
For Mass Health ACO/MCO/SCO members: WellSense has resumed all prior authorization activities for scheduled surgeries and/or elective admissions at hospitals.
WellSense will conduct concurrent review for all non-Covid-19 hospital inpatientadmissions. Notification of admission is required within 48 hours of admission. WellSense retains the ability to conduct retrospective reviews.
For QHP members: WellSense will suspend prior authorization review for scheduled surgeries and/or elective admissions at acute care hospitals until March 31, 2021 unless otherwise updated by DOI. For those services that would ordinarily require a PA, we require notification within 48 hours of the date of services. For elective admissions, notification of admission is required within 48 hours of the admission. We retain the ability to conduct retrospective reviews for all non-COVID-19 cases. WellSense has suspended concurrent review for hospital inpatient services until March 31, 2021. Notification of admission is required within 48 hours of admission. WellSense retains the ability to conduct retrospective reviews for non-COVID-19 admissions and for COVID-19 claims for instances of fraud, when the claim is the subject of legal action, if the claim payment is incorrect because the provider was paid or the insured has already paid for the services identified on the claim, or if the services identified in the claim were not delivered by the provider.
Will Prior Authorization be waived for Post-Acute Care admissions?
For Post-Acute Care following an inpatient hospital admission:
Prior authorization is required for all post-acute admissions. Please send the screen and applicable clinical documentation to WellSense for a pre-admission review.
For Home Care following an inpatient hospital admission, we will follow our current process as noted here:
Providers will submit the request for authorization within 5 days from start of care and include the following information:
- Completed Universal Authorization form
- Documentation from (verbal) ordering provider to accompany referral – self referrals need to have an order from a provider before making a visit
- From an inpatient setting – hospital discharge paperwork
- From the provider office – order or recent provider notes/history of present illness
- If the agency has their own form that providers may sign to request services, include a signed version of the form
- Documentation from the initial visit (completed OASIS is ideal)
- Unsigned 485 for Plan to review (if available but not required)
Will Prior Authorization be waived for Hospice or other Ancillary services?
In response to the need for expedited access to services for hospice or other ancillary services who need to use contracted staff for services, WellSense will waive the 30 day prior notification requirement for those contracted/sub-contracted services. Please note that it is incumbent upon the provider to ensure that contracted staff meet licensure and regulatory requirements.
Nursing Facility Guidance section added 5/20/20
Has any guidance been provided for Nursing Facilities?
MassHealth published Nursing Facility Bulletin 146 May 2020 implementing measures to protect against the spread of COVID-19. MassHealth is requiring nursing facilities complete baseline testing of staff and residents for COVID-19 between April 8, 2020 and May 25, 2020. To demonstrate completion of testing, the facility must submit the attestation in Appendix A (attached to MH Bulletin 146) by May 25, 2020. EOHHS is requiring that all MassHealth nursing facility providers test a minimum of 90 percent of their total residents and a minimum of 90 percent of total staff for COVID-19 between these dates with such total staff and total residents determined as of May 7, 2020 in accordance with the requirements set in the Bulletin.
Please review the Nursing Facility Bulletin from Mass Health for more information on this requirement.
MassHealth has also provided guidance for Nursing Facilities on COVID 19 Accountability and Support which can be found in the FAQ via the link below:
What guidance has been provided for home health and hospice agencies?
The following guidance should be followed throughout the duration of the State of Emergency:
- WellSense will allow the postponement of the 12-hour annual in-service training requirement. The postponed training must be completed within three months after the State of Emergency has been lifted.
- The plan will expand the providers who may order home health services and establish a member’s initial plan of care and any recertification to the plan to include nurse practitioners, clinical nurse specialists, and physician assistants.
- WellSense permit both home health and hospice agencies to perform supervisory visits conducted by a nurse or therapist via telehealth.
- WellSense will permit both home health and hospice agencies to conduct supervisory visits in no less than every 30 days, rather than the previous 14 day requirement.
How should DME orders be placed during the COVID-19 State of Emergency?
WellSense has been closely monitoring the developments of COVID-19 and working on directives to reduce provider workload and help members receive timely equipment and supplies. Below are instructions for members requiring DME:
- We are waiving prior authorization requirements for Oxygen and Respiratory related equipment, scales, blood pressure cuffs and glucose monitoring equipment.
- Prior authorizations will be required for Mobility devices (including but not limited to, manual wheelchairs, power wheelchairs and accessories), Chest Wall Oscillation/Vest and Alternative Augmentative Communication devices.
- Prior authorizations are not required prior to dispensing all DME to patients but they are required after dispensing DME and must be completed prior to claims submission.
- We will allow early supply refills within 30 days of the member’s next DOS.
- Upon member request, we will allow 90-day supply orders rather than 30-day supply orders.
- We are waiving cost-share for members with a COVID-19 diagnosis.
- Electronic signatures are acceptable for all prescriptions and orders.
- Telemedicine or virtual appointments and evaluations are acceptable in place of in-person patient evaluations.
- Out of Network providers may place orders for DME equipment. Rendering providers will need to be licensed or temporarily licensed (per COVID-19 allowance) in the state where they are operating.
For continuity of care, Northwood (following MassHealth guidance) is allowing continued delivery of equipment and supplies to members with prescriptions that expire during the COVID-19 emergency. Specifically, DME and Oxygen and Respiratory Equipment providers may continue delivery of rental equipment and supplies for 90 days from the expiration of the prescription or until the end of the COVID-19 emergency, whichever is later. For items and supplies delivered under otherwise expired prescriptions, providers must clearly document COVID-19 extensions of prescriptions in the member’s record and when submitting claims; and must obtain and document a new oral prescription.
The above changes apply to all WellSense product lines until further notice.
Will prior authorizations be needed for COVID-19 Chest CT Scans?
WellSense has lifted the requirement for prior authorization for any testing or services related to COVID-19, so an authorization for a Chest CT Scan will not be necessary. If a provider requests an authorization from eviCore, it will be approved for all COVID-19 related CT Scans and tests.
Will eviCore High Tech Radiology authorizations need to be requested again when the ban on non-essential and non-urgent services is lifted?
eviCore will give newly requested authorizations a 180 calendar day timespan. If a provider needs an authorization extended that was requested prior to the update, they will need to call eviCore to request the extension.
Will Out-of-Network Providers be allowed to service members?
eviCore and Northwood (DME) will allow out-of-network providers to be used when requesting authorizations to help relieve any possible urgent barriers to care that may arise as resources and staff are re-directed to address COVID-19 surges.
What transportation changes are being put in place to keep patients safe?
One Call, our new transportation broker for SCO members, in accordance with guidelines published by the Centers’ for Disease Control (CDC) and regulatory directives, has established guidelines in order to protect members, members’ attendants, drivers, and the community from exposure to COVID-19.
- Members are asked to check with their providers to confirm if their appointment will still be conducted in person or via telehealth before requesting transportation. Rides to appointment conducted in-person will continue to be scheduled by One Call.
- New ventilation protocols are in place when transporting members. Windows will be open when possible during the trip and all windows and doors will be opened between trips while disinfecting the vehicle.
- New cleaning and sanitation protocols are in place to disinfect inside and outside surfaces in between trips.
- Drivers are required to wear a face covering when possible.
- Drivers will no longer have physical contact with members, such as signing logs or assisting with seat belts or wheelchairs. Drivers will no longer be able to provide door-to-door assistance or enter facilities to look for patients during pick-up.
Can a member receive Early Intervention services after they turn 3 years old during the PHE?
WellSense will approve temporary age extensions for children receiving Early Intervention services until they can transition to appropriate school-based services. The temporary extension applies to children, currently undergoing Early Intervention services, who turn age 3 between March 15, 2020 and August 15, 2020. Services for these children may be covered through October 15, 2020 as long as specific criteria are met.
Will patients have to pay for testing and treatment of COVID-19?
No, members can receive COVID-19 testing and medically-necessary treatment at no cost. Members who typically have cost-sharing responsibility will have their cost-sharing (including copayments, deductible and coinsurance) waived for COVID-19 testing, consultation, vaccination, and treatment. Please note: this applies to testing and treatment from in-network providers. If testing and treatment is not available at in-network providers, services from out-of-network providers will be covered at no cost to the member.
Can members get their prescriptions by mail?
Yes, certain medications may be delivered by mail so that members do not have to pick them up at a local pharmacy. This option is available for maintenance medications that are filled regularly and used to treat conditions such as diabetes, asthma, high cholesterol and high blood pressure. Members can receive a 90-day supply of medication delivered to their home. Our mail order pharmacy can assist with transferring prescriptions and will also work with our providers for a new prescription if necessary.
With the Mail Order Pharmacy program, MassHealth members can get a 90-day supply of medications for the same cost as a 30-day supply.
Are there changes to patient eligibility or access to health insurance?
MassHealth and the Health Connector are taking steps to protect member eligibility and ensure that patients can maintain health insurance and access to medical care throughout the COVID-19 crisis.
For Current MassHealth Members
MassHealth is temporarily suspending the recertification process to ensure that MassHealth members do not lose coverage. This applies to members due for recertification after March 18, 2020 and is available until the national emergency ends. The only scenarios where members will lose coverage is if they request to terminate coverage or move out of state.
For New MassHealth Applicants
MassHealth walk-in centers are currently closed. Members are encouraged to use alternate application methods.
Individuals under 65 years old or caretakers of children can apply:
- Online at www.mahealthconnector.org
- Over the telephone at (800) 841-2900; or
- Using a paper application available here or by calling (800) 841-2900 TTY: (800) 497-4648.
Individuals that are 65 years or older, or are in need of Long-Term Care services can apply:
- Using a paper application available here, or
- By calling (800) 841-2900 TTY: (800) 497-4648.
MassHealth Eligibility Updates
MassHealth has expanded its Hospital-Determined Presumptive Eligibility (HPE) to allow individuals to receive multiple HPE benefits until the end of the month when the national emergency ends. See Eligibility Operations Memo 20-06 published in March 2020 for more detail.
If members applying to MassHealth are unable to verify certain eligibility factors, MassHealth will accept self-attestation for the eligibility factors listed below. This will last throughout the COVID-19 national emergency, and through the end of the month in which such national emergency period ends.
- Access to health insurance
- Breast and cervical cancer diagnosis and/or treatment
- HIV status
For New Health Connector Applicants
An extended enrollment period is now available for uninsured Massachusetts residents that need to buy health care coverage on the state exchange. Learn more from the MA Health Connector.
Are there any community resources for our providers?
We have gathered a list of resources to help our members obtain food, household supplies, and other health resources to keep them safe and at home. Please see a comprehensive list of COVID-19 resources.
The COVID-19 pandemic has left many individuals and families with food insecurity. MassHealth has put together a food assistance guide to help feed Massachusetts families. These resources can provide members with immediate access to food, as well as financial assistance for the purchase of food. This food security guide will help your member-facing staff better understand how to identify members who need food assistance and how to help them.
Food security guide - Spanish
LTSS and Integrated Care Guidance Added 6/26/20
Information and Guidance for LTSS, Integrated Care Plan and HCBS Waiver providers on re-opening, and DPH Attestation guidance
MassHealth expects all providers, including LTSS Fee-For-Service, Integrated Care Plan, and HCBS Waiver providers, to follow the guidance and standards outlined in the Reopening Advisory Board’s report, and any additional guidance issued by the Baker-Polito administration. Additionally, providers are required to follow the DPH Attestation guidance. Below is the link to the DPH guidelines, including the attestation guidance, applicable to all providers that are not acute care hospitals updated as of May 25th. https://www.mass.gov/lists/reopening-health-and-human-services-in-massachusetts#dph-orders-
Where can I get the most up-to-date information on the COVID-19 virus?
Since information on COVID-19 is rapidly evolving, we recommend visiting the Center for Disease Control (CDC) website for additional resources.
How can I contact WellSense if needed?
You can contact your Provider Relations Consultant if you have any further questions. Our staff is working remotely for the time being. Business and claims processing will continue as usual and our Provider Services line remains available during normal business hours. Our staff will not be making provider office visits at this time.
- CDC Clinical Guidance
- State of Massachusetts Guidance
- Request PPE for your healthcare facility
- Resource for working with deaf and hard of hearing patients
Personal Support for Providers
During this pandemic, self-care for health care workers is essential. Many organizations and businesses are offering free or discounted services for hospital and health care workers across the state. We recommend searching online for local opportunities geared towards health care professionals in your area as many acts of good will are being shared statewide. Below are a few examples that you and your team members may benefit from:
- Emergency childcare programs for health care workers
- Health care workers self-care during COVID-19
- Headspace: Currently free for healthcare providers with NPI#
- Ten Percent Happier App: Currently free for healthcare professionals
- To claim your complimentary subscription you will redeem the gift code (HEALTHCARE) on our website. Then log into the mobile app on your Apple or Android device using the same account and all the subscription contents of the app will be unlocked. Alternatively, just go to their Coronavirus Sanity Guide to access relevant free content/resources without creating an account
- Free or discounted meals from area restaurants
Please contact your dedicated Provider Relations Consultant if you would like to receive updates by email. Otherwise, check back regularly for updates.