Provider Central

Blue Cross Blue Shield of Massachusetts follows federal and state-mandated requirements for COVID-19 treatment coverage.

For our commercial products (managed care HMO and POS, PPO, and Indemnity), we will accept the following CPT codes for COVID vaccines and COVID vaccine administration. For Medicare Advantage plans, you must submit claims for COVID-19 vaccine and the administration of the vaccine to the CMS Medicare Administrative Contractor (MAC) for payment.

Please submit the vaccine administration procedure code and vaccine/toxoid code on the same claim. Since the vaccine is supplied free, we will not reimburse separately for the vaccine, regardless of the modifier.

If a vaccine administration service is provided with an evaluation and management service that:

• Is appended with modifier 25 and is unrelated to the vaccine administration service, Blue Cross will reimburse both services.
• Is not appended with modifier 25 or appended with modifier 25 and is related to vaccine administration service, Blue Cross will deny the evaluation and management service.

This applies to professional and facility claims.

Vaccine and vaccine administration codes for COVID-19

Blue Cross Blue Shield of Massachusetts covers all FDA-approved (both full FDA approval and Emergency Use Authorization (EUA)) drugs for COVID-19 with no cost share to our members throughout the duration of the public health emergency.

For our Medicare Advantage members, coverage is through original Medicare.

For our commercial products (managed care HMO and POS, PPO, and Indemnity), we will accept the following CPT codes for treatment for COVID-19 infection. For Medicare Advantage plans, you must submit claims for COVID-19 drug and the administration of the drug to the CMS Medicare Administrative Contractor (MAC) for payment.

We are following guidelines from the Blue Cross Blue Shield Association regarding coverage for Federal Employee Program members. For more details please visit fepblue.org.

When a drug is supplied free, we will not reimburse separately for the drug regardless of modifier.

Covered investigational drugs
Several drugs are under investigation as potential treatments for COVID-19 that have shown early benefit in clinical trials. Blue Cross Blue Shield of Massachusetts covers the following drugs when used outside a clinical trial for patients who are in an inpatient hospital setting and require treatment beyond respiratory support, at the discretion of their treating provider:

• Antiviral therapy (such as hydroxychloroquine; the original hydroxychloroquine policy still applies – see below)
• Immunomodulators (such as dexamethasone)

Please note that standard inpatient payment policy rules apply.

On June 5, 2020, the FDA revoked the Emergency Use Authorization (EUA) for hydroxychloroquine and chloroquine for the treatment of COVID-19 because the benefits of using them outweigh the known and potential risks for authorized use. For more information, read these FAQs: Frequently Asked Questions on the Revocation of the Emergency Use Authorization for Hydroxychloroquine Sulfate and Chloroquine Phosphate (PDF, 125 KB)

As of April 1, for the duration of the COVID-19 public health emergency, we have added a 10-day supply limit to these medications for:

• Members who are newly prescribed the medication for rheumatological and dermatological use (for example, to treat lupus, malaria, rheumatoid arthritis).

This supply limit applies to members who use our standard Blue Cross Blue Shield of Massachusetts formulary.

Quantity
You can request an authorization to cover more. To make this request, please submit the Massachusetts Standard Form for Medication Prior Authorization Requests (click the link and find the form by choosing Authorization – Pharmacy). Or, contact our Clinical Pharmacy Operations area.

Rheumatological and dermatological use
Members who filled a prescription for rheumatological and dermatological use within the previous 180 days are excluded from the quantity limit. We’re contacting them to suggest that they take advantage of our early refill policy during this public health emergency, so they can have a supply of their medication. Some members may also contact you for a prescription for up to a 90-day supply from the Express Scripts Pharmacy®' (mail order).

Why we made the change
You may be aware that on March 30, 2020, the Food and Drug Administration (FDA) issued an emergency authorization to use chloroquine and hydroxychloroquine as experimental coronavirus treatment.

The Massachusetts Division of Insurance (DOI) issued a March 26, 2020 Bulletin addressing this topic. The DOI asked insurers to continue covering these medications for rheumatologic or dermatologic conditions under their current policies. For COVID-19-related diagnoses, they asked insurers to add quantity limits.

Keep in mind

• For Federal Employee Program and Medicare Advantage members, coverage for these drugs remains the same at this time.
• For members using the National Preferred Formulary (managed by Express Scripts, Inc.), there are new quantity limits for these medications.

Blue Cross Blue Shield of Massachusetts does not cover drugs under investigation through clinical trials that have not demonstrated improvement in patient outcomes in early studies or are not recommended for use outside of the clinical trial setting by the Centers for Disease Control and Prevention (CDC), National Institutes of Health (NIH), or Department of Public Health (DPH) guidelines.

The following drugs are not covered outside of the clinical trial setting:

• Blood-derived products (such as SARS-CoV-2 immunoglobulins, mesenchymal stem cells)
• Antiviral therapies or immunomodulators without published supporting evidence (such as lopinavir/ritonavir, other HIV protease inhibitors)
• Other therapies currently under investigation without published supporting evidence

We lifted limits on early refills of most prescription medications, allowing members to obtain one additional fill of their existing prescription. This is at the discretion of the prescriber and/or dispensing pharmacist. At the same time, Blue Cross Blue Shield of Massachusetts continues to monitor and comply with all applicable state and federal regulations, including regulation of opioid prescribing and dispensing.

Per state mandate Chapter 260 of the Acts of 2020 – Patients First Act, cognitive rehabilitation for cognitive impairment resulting from COVID-19 is covered in the outpatient setting.¹

Providers should document ALL of the following for coverage:

• Cognitive impairments resulted from COVID-19 that was either clinically diagnosed or diagnosed through PCR/Antigen testing, AND
• Patient symptoms impair daily functioning and are unlikely to resolve on their own over time, AND
• Patient symptoms are expected to improve with cognitive rehabilitation.

Inpatient cognitive rehabilitation for cognitive impairment resulting from COVID-19 is not covered unless the patient otherwise meets criteria for inpatient level of care.

For more information, see Medical Policy 660: Cognitive Rehabilitation

Effective for claims with discharge dates or dates of service on or after April 1, 2020, for all commercial products, we have updated our APR-DRG grouper with the ICD-10 diagnosis codes below. This update also includes the ICD-10 vaping-related disorder code.

When testing patients in a drive-through or other temporary setting (such as a tent), please use the following codes for claims with dates of service on or after March 1, 2020. These codes apply to all commercial, Medicare Advantage, and Federal Employee Program (FEP) members.

*Reimbursement for these codes is included in the payment for an evaluation or management (E/M) service if reported by the same provider on the same day, for the same member.

Please also use one of the following applicable place of service codes that describes the location of the drive-through or temporary testing site.

Blue Cross Blue Shield of Massachusetts follows federal and state requirements for SARS CoV-2 (COVID-19) testing coverage.

Commercial members: Managed care (HMO and POS), PPO, and Indemnity

At-home tests
As of January 15, 2022, we will cover up to eight self-administered at-home tests per commercial member per month for personal, diagnostic use, without cost-share and without any need for prior clinical assessment.

The coverage is not retroactive and will not apply to any test kit purchases made prior to January 15, 2022.

Commercial members can use any pharmacy in the Express Scripts network to buy FDA-authorized tests at the pharmacy counter for $0. In-network pharmacies include CVS, Walgreens, Wal-Mart, and many others. Members can purchase up to eight kits per month, or four 2-test kits.

Members also have the option to order up to eight tests per month from Express Scripts mail order pharmacy.

Members who buy a different test or shop at an out-of-network retailer can get reimbursed up to $12 per test, for up to eight tests a month by submitting a a reimbursement form. The coverage does not apply to test kit purchases made before January 15.

Please note that Blue Cross is also covering at-home COVID-19 tests for Medicare Advantage members. We will reimburse Medicare Advantage members for up to four FDA-authorized, self-administered at-home tests (purchased on or after January 15, 2022), without any need for prior clinical assessment.

Viral testing
Reverse transcription-polymerase chain reaction (RT-PCR) or antigen testing to detect the presence of SARS-CoV-2 for the diagnosis of COVID-19 is covered when ordered by a health care provider who is making an individualized clinical assessment of the patient in accordance with current standards of medical practice. This includes the Centers for Disease Control (CDC) and the Massachusetts Department of Public Health (DPH) guidelines.

Covered tests must be approved by the FDA or have Emergency Use Authorization, or the developer must have requested, or intends to request Emergency Use Authorization approval.

In accordance with the Centers for Disease Control (CDC) and the MA Department of Public Health guidelines, covered scenarios include (but are not limited to):

• Symptoms consistent with COVID-19, such as fever, cough, shortness of breath, chills, muscle pain, sore throat, anosmia, and gastrointestinal distress
• Asymptomatic patients with direct exposure and/or close contact to another individual with a confirmed case of COVID-19
• Close contact is defined by the CDC as someone who was within 6 feet of an infected person for a cumulative total of 15 minutes or more over a 24-hour period* starting from 2 days before illness onset (or, for asymptomatic patients, 2 days prior to test specimen collection) until the time the patient is isolated
• Asymptomatic patients who have been identified by contact tracing
• Symptomatic or asymptomatic patients who require testing prior to a medical procedure or surgery
• Admission to a facility – including but not limited to a hospital operated or licensed by the Department of Public Health or Mental Health, a long-term acute care hospital, or a skilled nursing facility

* Individual exposures added together over a 24-hour period (e.g., three 5-minute exposures for a total of 15 minutes).

Covered testing sites include (but are not limited to):

• Drive-through testing sites
• Emergency rooms
• Medical provider offices
• The patient’s home (using a testing kit—a patient self-swab)

What’s not covered
PCR or antigen testing to detect SARS-CoV-2 is not covered in the following scenarios:

• General screening purposes such as
• return-to-work
• to attend school, day care, or camp
• For public health or surveillance purposes
• For periodic or serial testing of asymptomatic high-risk individuals (examples include congregate housing and occupational safety)
• Tests that have been denied FDA approval, an Emergency Use Authorization from the FDA, or laboratories that have not submitted an Emergency Use Authorization request within a reasonable timeframe
• Member transportation to or from testing sites (unless the member meets requirements for ambulance services)

Antibody testing
Serologic testing for the presence of SARS-CoV-2 IgM/IgG antibodies is covered for FDA and Emergency Use Authorization tests (as described above) when ordered by a health care provider who is making an individualized clinical assessment of the patient in accordance with current standards of medical practice, including the Centers for Disease Control (CDC) and  Massachusetts Department of Public Health (DPH) guidelines.

According to the CDC, serologic testing:

• Should not be used to determine immune status in individuals
• Should not be used to determine if someone can return to work.
• Should not be used to group people together in settings such as schools, dormitories, and correctional facilities.
• Can be offered as a method to support a diagnosis of acute COVID-19 illness for persons who present late. For persons who present 9-14 days after the onset of illness, serologic testing can be offered in addition to recommended direct detection methods, such as polymerase chain reaction.*
• Should be offered as a method to help establish a diagnosis when patients present with late complications of COVID-19 illness, such as multisystem inflammatory syndrome in children

* Detection of specific antibody in serum, plasma, or whole blood that indicates new or recent infection provides presumptive laboratory evidence of COVID-19 illness, according to the Council of State and Territorial Epidemiologists (CSTE) interim case definition for COVID-19.

Serologic testing for the presence of antibodies is not covered

• For general screening purposes such as:
• return-to-work
• to attend school, day care or camp
•  for public health or surveillance purposes
• for periodic or serial testing of asymptomatic individuals (examples include congregate housing such as dormitories and residential facilities, and occupational safety)
• For tests that have been denied FDA approval, an Emergency Use Authorization from the FDA, or laboratories that have not submitted an Emergency Use Authorization request within a reasonable timeframe
• For member transportation to or from testing sites (unless the member meets requirements for ambulance services)
• To screen for eligibility to donate plasma

Medicare Advantage members

At-home tests
Blue Cross is also covering at-home COVID-19 tests for Medicare Advantage members. We will reimburse Medicare Advantage members for up to eight FDA-authorized, self-administered at-home tests (purchased on or after January 15, 2022), without any need for prior clinical assessment. Eligible Medicare Advantage members can complete the Medicare Advantage COVID-19 At-Home Test Reimbursement form (PDF).

Medicare HMO Blue^SM and Medicare PPO Blue^SM Members

In keeping with CMS guidance issued September 2, 2020 and for the duration of the COVID-19 public health emergency, Blue Cross will cover, without a healthcare professional’s order, the cost of one diagnostic test for COVID-19 and one diagnostic test each for influenza virus or similar respiratory condition for Medicare members when performed in conjunction with a COVID-19 test and needed to obtain a final COVID-19 diagnosis. Subsequent tests will require the order of an authorized health care professional.

Viral testing
The use of reverse transcription-polymerase chain reaction (RT-PCR) or antigen testing to detect the presence of SARS-CoV-2 for a diagnosis of COVID-19 infection is covered for FDA-approved tests when ordered by any healthcare professional authorized under state law.

Antibody testing
Serologic testing for the presence of antibodies for known or suspected current or prior COVID-19 infection is covered for FDA-approved tests when ordered by any healthcare professional authorized under state law.

Federal Employee Program
The Federal Employee Program (FEP) covers COVID-19 testing and antibody testing with no member cost share, regardless of provider status, including testing for:

• travel purposes
• asymptomatic members
• pre-surgical testing for elective and non-elective procedures
• return-to-work

Note: There are no limits on frequency of testing.

At-home tests
For information regarding coverage for our FEP members, please visit www.fepblue.org/coronavirus-updates/over-the-counter-tests.

Below are the codes for providers and laboratories to test patients for COVID-19. They apply to commercial, Federal Employee Program, and Medicare Advantage members.

We have added these codes to our COVID-19 Temporary payment policy.

Use the diagnosis codes below for patients presenting for evaluation of suspected COVID-19.

We expect providers to code for COVID-19 testing and treatment using guidelines provided by the CDC. Blue Cross will identify patients presenting for evaluation of possible COVID-19 using the below codes*:

If your patient has previously confirmed COVID-19 illness or tests positive for COVID-19, use the code below.

*The CDC has created an interim set of ICD-10 CM official coding guidelines, effective February 20, 2020.

Expiration of extended authorizations for deferred services on 12/31/20

In 2020, we extended time-limited authorizations through the end of the year for specific outpatient procedures that our members may not have been able to receive due to the COVID-19 emergency. New authorizations will be required for services deferred into 2021, and all other administrative requirements related to these services continue to apply.

Assisted reproductive technology services
For assisted reproductive technology services listed in our medical policy that require prior authorization:

• We extended existing authorizations issued for the first six months of 2020 to December 31, 2020. If you plan to provide a previously approved service to a patient in 2021, please call our Clinical Intake Department at the appropriate number and we will create a new authorization or update the existing one.

• We now give 180 days for services to be completed on new authorizations. After that time, an authorization extension is required.

Durable medical equipment
We extended existing authorizations through December 31, 2020. If you plan to provide a previously approved service to a patient in 2021, please call our Clinical Intake Department at the appropriate number and we will create a new authorization or update the existing one.

High-technology radiology and obstructive sleep apnea testing and treatment
For the high-technology radiology and sleep testing and treatment services that require prior authorization with AIM Specialty Health, during the public health emergency, we authorized new requests for 180 days to allow time to have services performed. Effective January 1, 2021, AIM will return to standard processes and authorize services for 60 days.

Neuropsychological testing services
For neuropsychological testing services listed in our medical policy that require prior authorization, we typically give the member 365 days to complete the authorized services. However, we’ve extended existing authorizations for the period of March 1, 2019 – December 31, 2019 to December 31, 2020. If you plan to provide a previously approved service under an authorization that expired on December 31, 2020 to a patient in 2021, please call our Clinical Intake Department at the appropriate number and we will create a new authorization or update the existing one.

We have waived pre-authorization requirements for ground ambulance transport by a contracted provider. In addition, ground ambulance transport to and from the locations listed below is covered to help our healthcare delivery system optimize inpatient capacity.

• Applies to in-network, ground ambulance providers for HMO, PPO, Indemnity, Medicare Advantage, and Federal Employee Program* members
• Excludes air ambulance transport
• Notification is not required
• Cost share is waived for members with a COVID-19 diagnosis
• Cost share will apply to members without a COVID-19 diagnosis

Bill for ambulance transport
Be sure to bill using CPT A0426, A0428, A0433, or A0434 (non-emergent transports) and the appropriate modifier shown below to represent the direction of the transfer.

*These modifiers do not apply to Federal Employee Program members.

Referrals and prior authorizations are not required for medically necessary testing and treatment for COVID-19.

Blue Cross also removes all referral and authorization requirements for outpatient care if a member is being evaluated or treated for suspected or confirmed COVID-19. This applies to in- and out-of-network providers and to in-person and telehealth/virtual/visits by phone.

In alignment with guidance from the Division of Insurance, we have resumed the normal authorization processes for all services for our commercial and Federal Employee Program members, and will start requiring authorization for Medicare Advantage members on July 1, 2021.  

We will continue to waive the authorization requirement for commercial and Medicare Advantage initial requests for the following services with a COVID diagnosis:

• Emergent inpatient services
• Skilled nursing, rehab, and long-term acute care
• Home health care

If you aren’t already, please submit clinical information for all authorization requests with the exceptions noted above. The authorization process will officially resume for all products effective July 1, 2021.

On or after July 1, 2021, the ordering clinician NPI will be a required field on your claim to indicate that the lab test is medically necessary. This change is described in our April 30, 2021 News Alert, "Lab claims must include ordering clinician NPI starting July 1."

The Protecting Medicare and American Farmers from Sequester Cuts Act will reinstate the Medicare payment adjustment known as “sequestration” effective April 1, 2022. From April 1, 2022 to June 30, 2022, the Centers for Medicare & Medicaid Services (CMS) will apply a 1% payment adjustment. Beginning July 1, 2022, CMS will apply a 2% payment adjustment.

We extended the filing limit for initial claim submissions.

For dates of service between March 1, 2020 and May 31, 2020, you had 150 days from the date of service or the date of discharge (for inpatient stays) to submit your claims for HMO/POS, Medicare Advantage, and PPO members.

We resumed our usual 90-day timely filing limit for dates of service or dates of discharge on and after June 1, 2020.

There is no change to the timely filing guidelines for Indemnity claims.

This policy update applies to all medical providers.

Effective July 1, 2021, we reinstated member copayments, co-insurance, and deductibles for non-COVID telehealth visits, including all mental and behavioral health services. Member cost share continues to be waived for COVID-19 related telehealth visits provided by in-network providers.

Note: These changes do not apply to our Medicare Advantage members. We are following guidelines from the Blue Cross Blue Shield Association regarding coverage for Federal Employee Program members. For more details, please see fepblue.org.

Please bill members for their cost share once the claim has processed
When you are checking eligibility, Online Services will show the standard telehealth cost share. The system will not distinguish between a COVID visit and a non-COVID visit; therefore, we recommend that you bill the member for the applicable cost share once the claim has processed to ensure you do not have to reimburse the member.

Federal Employee Program
For Federal Employee Program members, we've removed the member cost for all telehealth services (COVID-19 and non-COVID-19-related) received through the Teladoc network. Members can register for Teladoc by visiting fepblue.org/coronavirus. For providers not in the Teladoc network, the applicable cost share will apply (unless COVID-19 related).

Medicare Advantage members
Effective January 1, 2021 Medicare Advantage members will have coverage for telehealth services for PCP, specialist, urgent care, and outpatient mental health services. Member cost will be the same as an in-person office visit, and cost will not be waived for a COVID-19 diagnosis.

We removed all member cost for in-person doctor, urgent care, and emergency room visits related to the testing, counseling, vaccination, and treatment of COVID-19.

For Federal Employee Program (FEP) members, member cost is removed for inpatient acute care hospitals, inpatient rehab facilities, long-term acute care hospitals, and skilled nursing facilities for services related to COVID-19.

FEP will determine coverage for the vaccine once it becomes available.

Retroactive to March 6, 2020, we waive member cost (copayments, deductible, co-insurance) for medically necessary inpatient acute care hospital services when the claim includes a diagnosis of COVID-19. This will apply to in- and out-of-network services received at an acute care hospital.

It does not include care received at chronic care and long-term acute care hospitals, psychiatric facilities, rehabilitation hospitals, skilled nursing facilities, and substance use disorder facilities.

This policy applies to Blue Cross Blue Shield of Massachusetts members* in the following plans:

• Commercial HMO/POS and PPO (fully insured accounts)
• Federal Employee Program
• Indemnity
• Medex
• Medicare Advantage

Note: Employers who are self-insured may choose not to offer waived cost share for their employees. When the claim processes and you receive your Provider Detail Advisory, you’ll know whether the member has a cost to collect.

*Blue Plan members receiving care in Massachusetts are covered according to their Home plan’s benefits and coverage.

• Coronavirus Resource Center at bluecrossma.com/coronavirus.
• FEP members: fepblue.org/coronavirus

Members can call our dedicated coronavirus help line at 1-888-372-1970.

We have removed member cost (copayments, co-insurance, and deductibles) for medically necessary telehealth (virtual video/audio) services or visits by phone for behavioral health services. The COVID-19 Temporary payment policy applies.

We will reimburse medically necessary telehealth and visits by phone at the same rate as an in-person visit, for all providers, including behavioral health providers.

Member cost still applies for an in-person, outpatient visits and for inpatient and residential services.

You can bill all services for which you are contracted using the telehealth codes with the telehealth modifier.

Blue Cross covers mental health visits by telehealth (video/virtual) or by telephone (“telephonic visits”) throughout the Massachusetts public health state of emergency. Please follow the billing instructions outlined in our COVID-19 Temporary payment policy.

To bill for telehealth/video services during the state of emergency

• Bill the same as you would for in-person visits, and include the following modifiers with the applicable place of service code*: modifier GT, 95, G0, or GQ via synchronous/asynchronous telehealth audio and/or video telecommunications systems to differentiate a telehealth (telemedicine) encounter from an in-person encounter with the patient.
• When reporting modifier GT, 95, G0, or GQ, you are attesting that services were rendered to a patient via synchronous/asynchronous telehealth audio and/or video telecommunications systems.

When reporting the telehealth modifier, if applicable, please place the telehealth modifier after the license modifier.

*UB-04 billers do not need to submit a place of service code.

To bill for services by phone
How you will bill for services by phone depends upon your specialty. See below for details.

If you were not reimbursed correctly, or your advisory shows that a member is responsible for a copayment, you can either:

• Wait for our systems to identify the claim and correct it
• Call Provider Service and ask us to reprocess the claim at one of the following toll-free numbers
  • 1-800-882-2060 (Physicians)
  • 1-800-451-8123 (Hospitals)
  • 1-800-451-8124 (Ancillary providers)

At this time, there are no changes to our licensure requirements.

UB-04 billers do not need to enter place of service codes when billing for telephonic services.

This applies to all accounts except the Federal Employee Program (FEP).

Effective March 10, 2020, we expanded the telehealth benefit and removed the member cost (copayments, co-insurance, and deductibles) for all COVID-19 related telehealth services, member cost will apply when billed with the appropriate modifiers.

Find additional coding information on Provider Central.

Member costs are being waived for all Teladoc visits (COVID-19 and non-COVID-19) during this emergency period.

To learn more about Teladoc, visit https://www.teladoc.com/providers/

We do not have any restrictions on the video or voice platform the dentist can use.

You can use Dental Connect for Providers to verify member eligibility and benefits. If you haven’t used Dental Connect before, you’ll need to register for Dental Connect using partner code BCMA01DPS (this is an important step for registration; Blue Cross Blue Shield of Massachusetts sponsors monthly fees for this service. Or, you can call Dental Provider Services at 1-800-882-1178.

Members who already have coverage for problem-focused exams (D0140) will have no cost share (deductible, copayment, or co-insurance).*

*For the Federal Employee Program, benefits and cost share are applicable according to the member’s plan.