The federal public health emergency (PHE) ended at 11:59 p.m. on May 11, 2023. Included below are the member benefit and provider reimbursement changes that occurred for dates of service on and after May 12, 2023, for commercial and Medicare Advantage members.

The outbreak period is now extended through July 10, 2023. This allows additional time for timely claims filing and appeals submissions.

Benefits that returned to non-PHE status for dates of service May 12, 2023, or later

• Testing
  • COVID-19 testing performed in the provider’s office and treatment are covered at regular plan cost shares for in- and out-of-network services.
  • Out-of-network COVID-19 testing claims are priced at allowed amounts rather than a negotiated or cash price. Balance billing may apply for commercial members, depending on the service.
  • We no longer cover over-the-counter (OTC) tests. Some Medicare Advantage members have OTC benefits that cover purchasing test kits.
• We returned to our standard credentialing process for locum tenens and expedited credentialing.

• Washington state changes:

  • Vaccine counseling is subject to regular plan benefits.
  • We will no longer cover costs for personal protective equipment.
• For Medicare Advantage members, out-of-network services, including medical and dental, are covered as out-of-network. If a member has out-of-network dental services, they will be subject to balance billing by the provider for any amount we don’t cover.

Benefits that have been updated based on federal and Centers for Medicare & Medicaid Services (CMS) guidance

• COVID-19 vaccines are covered as preventive care with no member cost for most health plans if received from an in-network provider.
  • Note: Providers must submit claims for the vaccine using the appropriate codes.
• For commercial members, Paxlovid is covered on the non-preferred brand tier. For Medicare Advantage members, Paxlovid is covered as a Tier 3 preferred drug.
• Telehealth:
  • We will continue to cover expanded telehealth services through December 31, 2024.
  • Some of the temporary telehealth services allowed during the PHE were added to our Virtual Care (Administrative #132) commercial and Medicare Advantage reimbursement policies.

6/1/2023 (Updated)

Determination letters for pre-authorizations you submit via Availity Essentials are now available on the Authorization/Referral Dashboard, making it even easier to manage your pre-authorizations.

Availity’s Electronic Authorization application checks patient benefits and whether a service is excluded from coverage or requires pre-authorization. You can quickly submit a medical pre-authorization request and supporting clinical documentation, or check the status of requests you have submitted or have been named in.

5/21/2023

Reducing fall risk, understanding the importance of physical activity and managing incontinence are three vital topics for Medicare patients to discuss with their providers. They are also Medicare Advantage Quality Incentive Program measures that are critically important to the health of our members.

We created a flyer with QR codes that link your patients to videos to help educate them on these vital topics. Scanning the QR codes with a smartphone will instantly load videos that address fall risk reduction, the importance of physical activity and approaches to manage incontinence. The flyer joins our extensive library of helpful resources in our quality improvement toolkit.

If you’d like a laminated version of the flyer to display in your exam rooms or waiting areas, please email us.

5/10/2023

You can prepare now for upcoming pre-authorization site-of-service reviews of select joint surgeries performed in an outpatient hospital setting.

The site-of-service reviews are an extension of our Physical Medicine program with eviCore Healthcare (eviCore) and apply to groups participating in that program. Site-of-service review will not be required when the procedure will be performed in an ambulatory surgical center (ASC), a physician’s office or an emergency facility (for urgent services).

For services delivered on or after June 1, 2023, we will redirect services to ASCs when medically appropriate and geographically available. You can begin requesting review from eviCore for these services on May 26, 2023. Pre-authorization requests submitted on or before May 25, 2023, will not be reviewed for site of service and will not result in a denial because of the site of service.

Review affected codes

View the codes that will require pre-authorization in an outpatient hospital setting in the joint management site-of-service section of our commercial and Medicare Advantage pre-authorization lists.

Attend a training

eviCore has scheduled several one-hour trainings about the pre-authorization process and accessing information on the eviCore website. The trainings will include a question-and-answer period.

• Wednesday, May 24, 2023, 1 p.m. (all times PT)
• Thursday, May 25, 2023, 1 p.m.
• Friday, June 2, 2023, 2 p.m.
• Wednesday, June 7, 2023, 1 p.m.

To register, choose a Joint SOC Training from the Upcoming tab. Your registration e-mail will include the session link and call-in number.

5/3/2023