COVID Resources for Providers

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.

Effective May 12, 2023 , standard benefits will apply and may vary by group. Please make sure to check member benefits for specifics.

Self-funded groups have the option to continue waiving cost share on some services; therefore claims will process according to member benefits.

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 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

OR

• 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*

*Government-supplied vaccine doses will continue to diminish, so it will become increasingly important for providers to append the SL modifier as appropriate to differentiate between government-supplied and provider-acquired vaccine.

COVID vaccines and administration are treated as ACA preventative services. As such, there will continue to be no member cost share for members of Non-Grandfathered plans with the expiration of the PHE. Grandfathered plan coverage and cost shares may vary and providers should make sure to check member benefits.

Effective beginning with a May 12, 2023 date of service, standard benefits will apply and may vary by group. Please make sure to check member benefits for specifics.

Self-funded groups will have the option to continue waiving cost share on some services; therefore claims will process according to member benefits.

Due to self-funded group options, providers should continue to apply CS modifiers as appropriate.

CS Modifier - 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 will review claims with the CS modifier to determine cost-share waiver eligibility based on member benefits, 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 beginning January 1, 2021 are:

• 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.

Wellmark will not waive the member cost-share when a COVID-19 testing-related claim is billed with a diagnosis of U07.1 only. 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.

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.

On Nov. 30, 2022, the Food and Drug Administration (FDA) announced that these treatments are no longer authorized for emergency use in the United States. As of that same date, Wellmark is no longer covering these treatments and the prior authorization process has been termed. 

For more information, you may read the FDA's statement in its entirety here External Link.