COVID Resources for Providers
COVID-19 testing and treatment
Wellmark is complying with the CMS, AMA and CDC coding guidelines for COVID-19. More information is available at AMA Resource Center for Physicians External Link.
Wellmark pays for COVID-19 tests that are clinically appropriate and medically necessary for disease diagnosis and treatment purposes, after a physician or other licensed practitioner has individually assessed the member. The COVID-19 test must be ordered by the healthcare practitioner to be payable or reimbursable by Wellmark.
There are situations in which COVID-19 tests would not be considered medically necessary for an individual member, particularly for serologic/antibody tests. Guidance has recently been issued by the Department of Labor, the Department of Health and Human Services, and the Internal Revenue Service External Link, as well as the Iowa Insurance Division External Link that outlines situations in which it would be appropriate to bill a member’s health insurance and situations in which it would not be appropriate to bill a member’s health insurance. Wellmark has compiled the following table to assist providers identify when to bill Wellmark for COVID-19 tests, which applies to both Iowa and South Dakota providers.
Covered by Wellmark
- COVID-19 tests are covered by Wellmark when the member is under the care of a physician or other licensed practitioner who recommends and orders testing based on an individualized clinical assessment, which may include, but is not limited to, COVID-19 symptoms or known/suspected exposure.
Not covered by Wellmark
- Testing of individual members when some sort of an individualized clinical assessment has not been done.
- Public health surveillance and other broad population-based serologic/antigen testing.
- For example, serologic testing to meet university requirements for returning college students, regardless of symptoms or exposure, would not be covered by Wellmark.
- Employee screening and COVID-19 testing for employment purposes, which is considered occupational health and the responsibility of the business and employee.*
- Any other purpose not primarily intended for individualized diagnosis or treatment of COVID-19. Examples include testing to return to school or to play sports.
*Employment-based testing occurs when an employer routinely or frequently tests all or a portion of its employee population for COVID-19, regardless of symptoms or exposure.
In all cases, COVID-19 tests must be approved or authorized by the FDA. Additionally, the COVID-19 test specimens must be collected in accordance with the manufacturer's guidelines and processed in an Authorized Setting as designated by the FDA.
When COVID-19 vaccine doses are provided by the government without charge providers can either
- Bill only for the administration of the vaccine
- 1500 claim form – Apply zero charge to the line and append the SL modifier
- UB claim form – Apply charge to the line and append the SL modifier
COVID vaccine administration is treated as an ACA preventative. As required by the CARES Act, there would be no member cost share for members of Non-Grandfathered plans. Grandfathered plans are not required to waive member cost-share for COVID-19 vaccine administration under the CARES Act. However, during the public health emergency declared by HHS, Wellmark has decided to waive member cost-share for its fully-Insured members of Grandfathered plans, and most self-funded Grandfathered plans have followed suit.
The CDC has provided final coding guidance on ICD-10 diagnosis coding: https://www.cdc.gov/nchs/data/icd/Announcement-New-ICD-code-for-coronavirus-19-508.pdf External Link
- Review the interim coding guidelines External Link for dates of service prior to April 1, 2020.
- Review the final code guidelines External Link effective for dates of service April 1, 2020 and after.
- Review the new ICD-10-CM diagnosis code External Link *
*Note: ICD-10 code U07.1 is available for use for dates of service April 1, 2020 and after.
See COVID-19 FAQ External Link provided by AHIMA and the AHA.
Cost-sharing does not apply for COVID-19 testing-related services which are medical visits that result in an order for, or administration of, a COVID-19 diagnostic test, but only to the extent that the items or services relate to the furnishing or administration of the test or to the evaluation of such individual for purposes of determining the need of the individual for the test as determined by the individual's attending health care provider.
Modifier CS - For services furnished on March 18, 2020 through the HHS-declared public health emergency, outpatient providers, physicians, and other providers and suppliers can use the CS modifier on applicable claim lines to identify service(s) the provider believes would be eligible for the cost-sharing waiver for COVID-19 testing-related services. Note: inclusion of the CS modifier does not guarantee the cost-sharing waiver will apply – Wellmark reviews claims with the CS modifier to determine cost-share waiver eligibility based on applicable diagnosis codes and Wellmark-identified CPT/procedure codes.
Applicable diagnosis codes for testing and related services when appropriately billed with the following diagnosis codes regardless of sequencing of diagnosis (primary, secondary, etc.) for dates of service prior to January 1, 2021 are:
- Possible exposure to COVID-19, ruled out Z03.818
- Contact with COVID-19, Suspected exposure Z20.828
- Asymptomatic, no known exposure, results unknown or negative Z11.59
Diagnosis codes effective January 1, 2021
- Encounter for screening for COVID-19, reported for people who are asymptomatic Z11.52
- Contact with and (suspected) exposure to COVID-19 Z20.822
- Pneumonia due to coronavirus disease 201), which includes the inclusion terms, “Pneumonia due to COVID-19” and “Pneumonia due to 2019 novel coronavirus (SARS-CoV-2)” J12.82
- (Multisystem inflammatory syndrome) M35.81
- Other specified systemic involvement of connective tissue M35.89
Note: Wellmark may, in its discretion, apply other diagnosis codes to trigger cost-share waiver in combination with its identified CPT/procedure codes.
Effective Aug. 1, 2022 — Because of recent member inquiries, Wellmark has noticed an increase in claims billed with U07.1 as the only diagnosis code. The diagnosis code U07.1, which represents a confirmed case of COVID-19, is not listed above, and does not provide Wellmark with sufficient information to determine whether the member presented with symptoms/exposure concerns at the time of the visit.
For claims received August 1, 2022, and later, Wellmark will not waive the member cost-share when a COVID-19 testing-related claim is billed with a diagnosis of U07.1 only. All claims for a COVID-19 testing-related services claim for an asymptomatic patient should also include the applicable diagnosis codes listed in Wellmark’s billing guidelines. Member inquiries regarding the application of member cost-share on COVID-19 testing-related claims billed only with U07.1 will be referred to the provider.
We recognize this may not align with billing information you may have received from other sources. However, to meet Wellmark cost-share waiver requirements, providers must follow Wellmark’s billing guidelines and include one of the five diagnosis codes listed above for each applicable line on a COVID-19 testing-related service claim, along with the “CS” modifier. Providers may continue to use U07.1 as a diagnosis code on claims for COVID-19 testing-related services, in addition to one of the five diagnosis codes listed above. Whether U07.1 is listed as a primary or secondary diagnosis code will not impact the application of cost-share waiver. This ensures providers are being reimbursed correctly for the services rendered and that members are receiving a cost-share waiver on appropriate claims.
Wellmark to reimburse members
Services billed with a diagnosis code of U07.1 for claims received by Wellmark from Nov. 1, 2021, to July 31, 2022, will be reviewed to determine if they qualify for the member cost-share waiver associated with COVID-19 testing-related services. Wellmark will issue a cost-share reimbursement check and letter to Wellmark members whose claims would have qualified for the cost-share waiver if they had been billed with the applicable diagnosis codes identified in Wellmark’s billing guidelines. These claims will not be adjusted, and providers should not submit corrections on these claims to add an applicable diagnosis code.
We appreciate your patience as Wellmark works to identify an approach for the monoclonal antibody, bebtelovimab, after the sudden transition from a government supply to a commercial supply. Wellmark typically does not cover drugs and biological products that are not FDA-approved, and bebtelovimab is still under an Emergency Use Authorization (EUA) from the FDA.
However, because we are still in the HHS-declared public health emergency, Wellmark plans to cover bebtelovimab when administered to individuals for whom bebtelovimab has been recommended by the CDC and NIH. Currently, bebtelovimab should only be administered for the treatment of non-hospitalized patients with mild to moderate COVID-19 when:
- The patient has received positive results of direct SARS-CoV-2 viral testing,
- The patient is at high risk for progression to severe COVID-19, including hospitalization or death, and
- Alternative COVID-19 treatment options approved or authorized by FDA are not accessible or clinically appropriate for the patient (currently Paxlovid [nirmatrelvir co-packaged with ritonavir] and Veklury [remdesivir]).
- Please note: using bebtelovimab over remdesivir because bebtelovimab is a single injection instead of remdesivir’s multiple days of treatment is considered to be for the patient’s convenience, not for reasons of treatment/medication accessibility or clinical appropriateness.
Providers can review the CDC Interim Clinical Considerations for COVID-19 Treatment in Outpatients External Link or the FDA fact sheet for EUA of bebtelovimab External Link for additional information.
Medical policy and prior authorization process for bebtelovimab
Wellmark has adopted a medical policy governing criteria for the medically necessary administration for bebtelovimab. Review the bebtelovimab medical policy. PDF File This medical policy mirrors the criteria for use of bebtelovimab as recommended by the NIH and CDC.
Wellmark recognizes that time is of the essence to administer bebtelovimab following a positive COVID-19 diagnosis. To facilitate quick prior authorization, Wellmark plans to use Novologix as its prior authorization platform, and if complete information is submitted by the provider, automated approval may be available through use of the Novologix tool. Until the Novologix prior authorization process is implemented, Wellmark reserves the right to review.
Please note that the prior authorization requirement does not apply to the Emergency Department place of service.
SL modifier for government-supplied injections
Wellmark recognizes that during the supply transition, there will a mix of government-supplied injections and commercially purchased injections. When a government-supplied injection is used for a particular patient, the provider must continue to submit that claim either without the Q0222 code or with a Q0222 code that has an SL modifier.
Pricing for bebtelovimab
Pricing for bebtelovimab has been loaded in Wellmark’s drug fee schedule for current and future dates.
Contact Wellmark Customer Service with any questions.