Skip to Main Content

Coronavirus Updates

Coronavirus disease 2019 (COVID-19) is an emerging illness. Many details about this disease are still unknown, such as treatment options, how the virus works, and the total impact of the illness. New information, obtained daily, will further inform the risk assessment, treatment options and next steps. We always rely on our provider partners to ensure the health of our members, and we want you to be aware of the tools available to help you identify the virus and care for your patients during this time of heightened concern.

COVID-19 Vaccine Information and Resources

Please review all available provider guidance related to the COVID-19 vaccine listed below.

Superior HealthPlan is closely following advancements in the prevention and treatment of COVID-19, including vaccinations. As a health-care provider, you will play an integral role as COVID-19 vaccines become available. We want to update you on important new information about vaccine coverage.

To prepare for vaccine administration, the Centers for Medicare and Medicaid (CMS) have published billing guidance (PDF) for Medicaid (STAR, STAR+PLUS, STAR Health and STAR Kids), Children’s Health Insurance Program (CHIP), Marketplace (Ambetter from Superior HealthPlan) and Medicare (Allwell from Superior HealthPlan) providers. Similar to other COVID-19 services, the vaccines will be offered at no cost to your patients. However, please be aware of the following billing specifics:

Medicaid and CHIP

  • Superior will configure its systems to properly adjudicate COVID-19 vaccine-related claims, for the administration of the vaccine, in accordance with Texas’s coverage determinations for Medicaid beneficiaries. 
  • Member liability will be $0.
  • Non-participating provider pre-auth requirements will be waived.
  • Provider reimbursement rates and emergency use authorizations (EUA) are all still pending and we will update you as that information becomes available.

Ambetter

  • Ambetter from Superior HealthPlan will configure its systems to properly adjudicate COVID-19 vaccine-related claims, both for the vaccine and its administration.
  • Member liability will be $0.
  • Non-participating provider pre-auth requirements will be waived.
  • Provider reimbursement rates and emergency use authorizations (EUA) are all still pending and we will update you as that information becomes available.

Medicare

  • For Calendar Years (CYs) 2020 and 2021, Medicare payment for the COVID-19 vaccine and its administration for Medicare Advantage plan members will be made through the original fee-for-service Medicare program.
  • Allwell from Superior HealthPlan will not be able to process these claims.
  • Therefore, providers must submit claims for administering the COVID-19 vaccine to their CMS Medicare Administrative Contractor (MAC) using product-specific codes for each vaccine approved.

The American Medical Association (AMA) has published updates to the Current Procedural Terminology (CPT®) code set that includes new vaccine-specific codes to report immunizations for the novel coronavirus (SARS-CoV-2). The code set will continue to be updated as additional vaccines receive EUA approval by the U.S. Food & Drug Administration (FDA).

The following codes have been published as of November 10, 2020. However, they will not be billable until the specific vaccine receives official EUA approval.

CODE

CPT SHORT DESCRIPTOR

LABELER NAME

VACCINE/PROCEDURE NAME

91300

SARSCOV2 VAC

30MCG/0.3ML IM

Pfizer

Pfizer-Biotech Covid-19 Vaccine

0001A

ADM SARSCOV2 VAC

30MCG/0.3ML 1ST

Pfizer

Pfizer-Biotech Covid-19 Vaccine

Administration – First Dose

0002A

ADM SARSCOV2 VAC

30MCG/0.3ML 2ND

Pfizer

Pfizer-Biotech Covid-19 Vaccine

Administration – Second Dose

91301

SARSCOV2 VAC

100MCG/0.5ML IM

Moderna

Moderna Covid-19 Vaccine

0011A

ADM SARSCOV2 VAC

100MCG/0.5ML 1ST

Moderna

Moderna Covid-19 Vaccine

Administration – First Dose

0012A

ADM SARSCOV2 VAC

100MCG/0.5ML 2ND

Moderna

Moderna Covid-19 Vaccine

Administration – Second Dose

0031A

IMM ADMN SARSCOV2 AD26 5X1010 VP

0.5 ML 1 DOSE

Janssen

Janssen COVID‑19 Vaccine

91303

SARSCOV2 VACCINE AD26 5X1010 VP

0.5ML IM USE

Janssen

Janssen COVID-19 Vaccine


Additionally, CMS has also published a set of toolkits to help providers prepare to swiftly administer the vaccine once it is available. If you have any further questions about this upcoming vaccine or the COVID-19 services Superior covers, please contact Provider Services at 1-877-391-5921.

How You Can Engage and Inform Your Patients in a Meaningful Way

As COVID-19 vaccines are approved and distributed, providers will be a key part in their adoption and administration to the American public. Patients look to their health-care professionals for medical guidance and assurance, and while much is still unknown, you can start laying the groundwork now for when the vaccines are available. As your partners in healthcare, we want to share some tips for effectively setting expectations and addressing questions from your patients.

Start COVID-19 Vaccine Conversations Early

Even before you are able to offer COVID-19 vaccinations, consider including the topic in your conversations with patients. This will give you the opportunity to set expectations about vaccine availability, including if/when you might recommend vaccination for them, and learn about any concerns they have.

Engage in Effective COVID-19 Vaccine Conversations

Effective engagement can occur during an in-person office visit, through messages on your patient portal, or at a telemedicine appointment. Patients trust in their providers to help guide health-care decisions, and your strong vaccine recommendation is the most important part of the conversation.

Start with empathy and understanding.

  • Acknowledge the disruption COVID-19 has caused in all our lives.
  • Provide an opportunity to recognize common concerns that can be addressed by a vaccine.

Assume patients will want to be vaccinated but may not know when to expect it.

  • Consider providing the following general information to patients about the timeline for COVID-19 vaccines:
    • Limited COVID-19 vaccine doses may be available in 2020.
    • It is anticipated that vaccine supply will increase substantially in 2021.
    • The goal is for everyone to be able to easily get a COVID-19 vaccine as soon as large quantities are available. However, not everyone will be able to get vaccinated right away.
  • Encourage patients to continue taking steps to protect themselves from COVID-19 and let them know how you plan to share updates about vaccine availability.

Give your strong recommendation.

  • Let your patients know if you plan to recommend COVID-19 vaccination for them.
  • Share the importance of COVID-19 vaccines to protect patients’ health as well as the health of those around them.
  • Talk about your personal plans to get a COVID-19 vaccine.
  • Reassure your patients that the vaccine is safe.

Listen to and respond to questions.

  • If a patient has concerns or questions, this doesn’t mean they won’t accept a COVID-19 vaccine. Sometimes patients want your answers to their questions.
  • Your willingness to listen to their concerns will play a major role in building trust in you and your recommendation. Make it clear that you understand they have questions, and that you want to answer them, so they feel confident in choosing to get vaccinated.
  • Seek to understand patient/caregiver concerns and provide information they need in a way they can understand it (see Q&A below).

Keep the conversation open.

  • After answering their questions, let your patients know that you are open to continuing the conversation and answering any additional questions they may have.
  • Encourage patients to take at least one action like:
    • Scheduling another appointment.
    • Reading any additional information you provide them about COVID-19 vaccination.
    • Encourage others to get their COVID-19 vaccine when available.
  • Continue to remind patients about the importance of getting a COVID-19 vaccine during future routine visits.

Answering Patient Questions about the Vaccine

Your patients will likely have a lot of questions about the vaccine, and as their health-care provider, they will turn to you for answers.

Q: Can I make an appointment with you to be vaccinated? If not, why? Do I have to go to a pharmacy to receive the vaccine?

A: Pharmacies are generally the most convenient locations to individuals and they also have great expertise in administering vaccines. While many providers anticipate to have the vaccine in their office later on, for now we recommend patients visit their local pharmacy. The website www.vaccinefinder.org  can help them locate the closest location with current inventory.

Q: Why are some people getting the vaccine before others? Why can’t I get mine yet?

A: Initially, there will be a limited number of vaccines available.  Because of the limited supply, some groups are recommended to get the vaccine first:

  • Phase 1A will include residents and employees of nursing homes and long-term care facilities.  They are recommended to get the vaccine first, as they are deemed highly vulnerable.  Long-term care facilities account for a high percentage of the deaths from COVID-19 (40%).
  • Additional phases are being developed by federal and state governments.  This will address first-responders, essential workers, older adults and people more at risk for either contracting the virus or becoming seriously ill with the virus.

Q: How do we really know if COVID-19 vaccines are safe?

A: The Food and Drug Administration (FDA) carefully reviews all safety data from clinical trials. It only authorizes emergency vaccine use when the expected vaccine benefits outweigh potential risks.

  • The Advisory Committee on Immunization Practices (ACIP) reviews all safety data before recommending any COVID-19 vaccine for use.
  • FDA and CDC will continue to monitor the safety of COVID-19 vaccines to make sure even very rare side effects are identified.

Q: Is the vaccine that helpful? I heard getting COVID-19 gives you better and longer immunity than the protection a vaccine can give. Can it actually make my illness worse if I do end up getting COVID-19?

A: Explain the potential serious risk COVID-19 infection poses to them and their loved ones if they get the illness or spread it to others.

  • Remind them of the potential for long-term health issues after recovery from COVID-19 disease, especially for those who have chronic conditions, are older, or have weakened immune systems.
  • Explain that scientists are still learning more about the virus that causes COVID-19. And it is not known whether getting COVID-19 disease will protect everyone against getting it again, or, if it does, how long that protection might last. Therefore getting a vaccine is a safer choice. 
  • Some vaccines are more effective than the natural illness; it is not clear whether natural illness or vaccination will provide more effective immunity in this case.
  • Early information indicates that COVID-19 vaccination may reduce the severity of illness, as well as the incidence of illness. As we learn more about the efficacy of the vaccine, we will also learn more about potential long-term protection it may bring.
  • Describe how the vaccine was tested in large clinical trials and what is currently known about its safety and effectiveness.
  • Be transparent that the vaccine is not a perfect fix. Patients will still need to practice other precautions like wearing a mask, social distancing, handwashing and other hygiene measures until public health officials say otherwise.

Q: I heard I need 2 vaccines. Why? I don’t want to come back for a second vaccine.

A: Two vaccines are needed to provide the best protection against COVID-19.

  • The first vaccine primes the immune system and helps recognize the virus. The second vaccine strengthens the immune response.
  • The two doses are given a few weeks apart (e.g. 21 or 28 days depending on vaccine type). Explain the dosing options available in your office and advise the patient that they can set up an appointment before they leave to come back for a second dose.
  • Provide members with a vaccination record card to ensure that they know when they received their first vaccine, what type of vaccine they received, and when they need to come back and receive their second vaccine.
  • Direct them to their insurance health plan to set up non-emergency transportation, if applicable.

Q: Will the shot hurt? Can it cause you to get sick? I don’t want to get the vaccine because it will give me COVID.

A: List the most common side effects from vaccination are and how severe they may be (e.g. fever, headache, body aches, cold symptoms). Emphasize that a fever could be a potential side effect and when to seek medical care.

  • Symptoms will typically go away on their own within a week. Let them know when they should seek medical care if their symptoms don’t go away.
  • Explain that the vaccine cannot give someone COVID-19 as the vaccine does not contain a live coronavirus.
  • Explain that side effects are a sign that the immune system is effectively working.

Q: Do I have to pay for my vaccines?

A: No! The vaccine will be at no cost to patients. They will not have to pay for either dose of the COVID-19 vaccine.

Providers and pharmacies are required to enroll with the Texas Department of State Health Services (DSHS) Immunization Program Portal to receive and administer any approved COVID-19 vaccine. For further COVID-19 enrollment information, visit the DSHS Vaccination Provider Enrollment webpage

To register, visit the DSHS Immunization Program Portal

For questions about registration, call the DSHS COVID-19 Vaccine Provider hotline at 1-877-835-7750, 8 a.m. to 5 p.m., Monday through Friday or email COVID19VacEnroll@dshs.texas.gov.

Important Coronavirus Information and Resources

Please review all available provider guidance, actions and resources listed below.

  • Be alert for patients who meet the criteria for persons under investigation and know how to coordinate laboratory testing.
  • Review your infection prevention and control policies and CDC's recommendations for healthcare facilities for COVID-19.
  • Know how to report a potential COVID-19 case or exposure to facility infection control leads and public health officials. Contact your local and/or state health department to notify necessary health officials in the event of a person under investigation for COVID-19.
  • Refer to the Centers for Disease Control and Prevention (CDC) and the World Health Organization for the most up-to-date recommendations about COVID-19, including signs and symptoms, diagnostic testing, and treatment information.
  • Be familiar with the intended scope of available testing and recommendations from the FDA.    

This guidance is in response to the current COVID-19 pandemic and may be retired at a future date.

  • Know the warning signs of COVID-19. Patients with COVID-19 have reported mild to severe respiratory symptoms. Symptoms include fever, cough, and shortness of breath. Other symptoms include fatigue, sputum production, and muscle aches. Some individuals have also experienced gastrointestinal symptoms, such as diarrhea and nausea, prior to developing respiratory symptoms.  
  • However, be aware that infected individuals can be contagious before symptoms arise. Symptoms may appear 2-14 days after exposure.
  • Instruct symptomatic patients to wear a surgical or isolation mask and promptly place the patient in a private room with the door closed.
  • Health care personnel encountering symptomatic patients should follow contact precautions, airborne with N95 precautions, and wear eye protection and other personal protective equipment.
  • Refer to the CDC’s criteria for a patient under investigation for COVID-19. Notify local and/or state health departments in the event of a patient under investigation for COVID-19. Maintain a log of all health care personnel who provide care to a patient under investigation.
  • Monitor and manage ill and exposed healthcare personnel.
  • Safely triage and manage patients with respiratory illness, including COVID-19. Explore alternatives to face-to-face triage and visits as possible, and manage mildly ill COVID-19 cases at home, if possible. 

This guidance is in response to the current COVID-19 pandemic and may be retired at a future date.

New Telehealth Policies Expand Coverage for Healthcare Services

Superior HealthPlan has developed a Telemedicine Quick Reference Chart (PDF) (updated March 25, 2021) to help providers navigate telemedicine and telehealth reimbursement.

For more information, please refer to the guidelines below.

Superior is closely monitoring and following all guidance from the State and the Centers for Medicare and Medicaid as it is released, to ensure we can quickly address and support the prevention, screening and treatment of COVID-19. The following guidance can be used to bill for services related to COVID-19 testing, screening and treatment services. This guidance is in response to the current COVID-19 pandemic and may be retired at a future date. For additional information and guidance on COVID-19 billing and coding, please visit the resource centers of the Centers for Medicare and Medicaid (CMS) and the American Medical Association (AMA).

COVID-19 Testing Services

  • Providers performing the COVID-19 test can bill us for testing services that occurred after February 4, 2020, using the following newly created HCPCS codes:
    • HCPCS U0001 - For CDC developed tests only - 2019-nCoV Real-Time RT-PCR Diagnostic Panel.
    • HCPCS U0002 - For all other commercially available tests - 2019-nCoV Real-Time RT-PCR Diagnostic Panel.
    • CPT 87635 – For Medicaid, Medicare and Marketplace. Effective March 13, 2020 and issued as “the industry standard for reporting of novel coronavirus tests across the nation’s health care system.”
    • PLA 0202U – For Medicare and Marketplace. Effective May 20, 2020. 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.

Please note: It is not yet clear if CMS will rescind the more general HCPCS Code U0002 for non-CDC laboratory tests that the Medicare claims processing system is scheduled to begin accepting starting April 1, 2020.

  • These codes should not be used for serologic tests that detect COVID-19 antibodies.
  • All member cost share (copayment, coinsurance and/or deductible amounts) will be waived across all products for claims billed for testing services using the new COVID-19 testing codes and diagnosis codes. (TX CHIP does not waive the copayment for any claim billed with these codes, we do not apply a copay for the testing codes and we waive the copay for all office visits. A copay may still apply to a hospital or non emergent ER claim billed with one of those lab codes.)
  • We have configured our systems to apply $0 member cost share liability for those claims submitted utilizing these new COVID-19 testing codes. Medicaid does not apply a cost share for these services specifically but depending on the location and diagnosis on the claim, a cost share may be applied to other services on the claim.
  • In addition to cost share, authorization requirements will be waived for claims billed for testing services that are received with these specified codes. Medicaid does not require authorization for these services specifically but depending on the location and diagnosis on the claim, an authorization may be required for other services on the claim.
  • Providers billing with these codes will not be limited by provider type and can be both participating and non-participating.
  • We will temporarily waive requirements that out-of-state Medicare and Medicaid providers be licensed in the state where they are providing services when they are licensed in another state. 

COVID-19 Antigen Testing Services

  • Providers performing COVID-19 antigen tests can bill us for testing services that occurred after June 25, 2020, using the following HCPCS codes:
    • 87426 - Infectious agent antigen detection by immunoassay technique, qualitative or semiquantitative, multiple-step method; severe acute respiratory syndrome coronavirus (eg SARS-CoV, SARA-CoV-2 (COVID-19).
    • 0223U - For Medicare and Marketplace. 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
    • 0224U - For Medicare and Marketplace. Antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease (COVID-19) includes titer(s), when performed (Do not report 0224U in conjunction with 86769).
  • All member cost share (copayment, coinsurance and/or deductible amounts) will be waived across all products for claims billed for testing services using the above COVID-19 antibody testing codes.
  • In addition to cost share, authorization requirements will be waived for claims billed for testing services that are received with these specified codes. This includes non-participating providers.
  • Providers billing with these codes will not be limited by provider type and can be both participating and non-participating.
  • Reimbursement rates are still pending from CMS and this communication will be updated when available.

High-Throughput Technology Testing Services: Medicaid, Marketplace and Medicare 

  • Providers performing high production COVID-19 diagnostic testing via high-throughput technology can bill us for testing services that occurred after February 4, 2020, using the following newly created HCPCS codes:
    • HCPCS U0003 - 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, making use of high throughput technologies as described by CMS-2020-01-R.
    • Please note: U0003 should identify tests that would otherwise be identified by CPT code 87635 but for being performed with these high throughput technologies.
    • HCPCS 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.
    • Please note: U0004 should identify tests that would otherwise be identified by U0002 but for being performed with these high throughput technologies.
  • Neither U0003 nor U0004 should be used for tests that detect COVID-19 antibodies.
  • We have configured our systems to apply $0 member cost share liability for claims billed for testing services that are submitted utilizing these codes to indicate high production testing.
  • Providers billing with these codes will not be limited by provider type and can be both participating and non-participating.

COVID-19 Specimen Transfers Medicare and Marketplace 

  • For specimen transfer related claims, the following codes can be used:
    • G2023 - Spec Clct for SARS-COV-2 COVID 19 ANY SPEC SRC
    • G2024 - SP CLCT SARS-COV2 COVID19 FRM SNF/LAB ANY SPEC
    • C9803 - (Medicaid/Medicare/Marketplace only) Hospital outpatient clinic visit specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), any specimen source. This is effective for services provided on or after March 1, 2020.
  • Providers billing with these codes will not be limited by provider type and can be both participating and non-participating.

COVID-19 Screening Services

  • All member cost share (copayment, coinsurance and/or deductible amounts) will be waived for COVID-19 screening visits and if billed alongside a claim for testing services that uses a COVID-19 testing code.
  • If no testing is performed, providers may still bill for COVID-19 screening visits for suspected contact using the following Z codes:
    • Z20.828 – Contact with a (suspected) exposure to other viral communicable diseases
    • Z03.818 – Exposure to COVID-19 and the virus is ruled out after evaluation
  • This applies to services that occurred as of February 4, 2020.
  • Providers billing with these codes will not be limited by provider type.

COVID-19 Treatment Services

  • We will waive prior authorization requirements and member cost sharing for COVID-19 treatment for all members.
  •  For dates of service from February 4, 2020 through March 31, 2020 providers should use the ICD-10 diagnosis code:
    •  B97.29 – Confirmed Cases – other coronavirus as the cause of diseases classified elsewhere
  •  For dates of service of April 1, 2020 and later, providers should use the ICD-10 diagnosis code:
    •  U07.1 – 2019-nCov Confirmed by Lab Testing
  • As a reminder, only those services associated with screening and/or treatment for COVID-19 will be eligible for prior authorization and member liability waivers. For screening or treatment not related to COVID-19 normal copayment, coinsurance, and deductibles will apply, where applicable.

COVID-19 Infection Control Supplies

  • Procedure code S8301 for infection control supplies above and beyond normal protocol may be reimbursed, at invoice cost or 38% of billed if no invoice is submitted, effective for dates of service on or after April 1, 2020.
  • This code is a benefit for Texas Medicaid (STAR, STAR Health, STAR Kids and STAR+PLUS) and Superior HealthPlan Medicare-Medicaid Plan (MMP).
  • S8301 can be reimbursed for the following place of service and provider type:
    • Office – County Indigent Health Care Program, Physician, Physician Assistant, Nurse Practitioner, Clinical Nurse Specialist, Certified Nurse Midwife, Registered Nurse, Licensed Midwife, Dentistry Group
    • Home – Home Health DME and Medical Supplier (DME) Providers, Home Health Agency
    • Outpatient Hospital – Hospital Providers
    • Independent Laboratory – Independent Laboratory/Privately Owned Laboratory Providers
    • Birthing Center – Physician Providers, Certified Nurse Midwife, Registered Nurse, Licensed Midwife
    • Other Locations – Physician Providers

COVID-19 Specimen Collection Services

  • Procedure code 99001 for specimen collection services provided at drive-through testing sites during the public health emergency may be reimbursed, effective for dates of service on or after April 1, 2020.
  • This code is a benefit for Texas Medicaid (STAR, STAR Health, STAR Kids and STAR+PLUS) and Superior HealthPlan Medicare-Medicaid Plan (MMP).
  • 99001 can be reimbursed for the following place of service and provider type:
    • Office – County Indigent Health Care Program, Physician, Physician Assistant, Nurse Practitioner, Clinical Nurse Specialist, Certified Nurse Midwife, Registered Nurse, Licensed Midwife Providers
    • Home – Home Health DME and Medical Supplier (DME) Providers
    • Outpatient Hospital – Radiation Therapy Center, Hospital, Family Planning Clinic, Nephrology (Hemodialysis, Renal Dialysis), and Renal Dialysis Facility Providers
    • Independent Laboratory – Independent Laboratory/Privately Owned Laboratory and Radiation Therapy Center Providers

Reimbursement Rates for COVID-19 Services for All Provider Types (where services are covered)

  • We are complying with the rates published by CMS for the following codes
    • U0001 = $35.91
    • U0002 = $51.31
    • U0003 = $100.00 
    • U0004 = $100.00 
    • G2023 = $23.46 
    • G2024 = $25.46
  • Commercial products will reimburse COVID-19 services in accordance with our negotiated commercial contract rates.
  • We will follow these CMS published rates except where state-specific Medicaid rate guidance should supersede.
  • Any additional rates will be determined by further CMS and/or state-specific guidance and communicated when available.
  • Effective for dates of services on or after April 10, 2020:
    • COVID-19 HCPCS procedure codes 86318,86328, 86769, related to antibody testing.
    • Affected claims with dates of service from April 10, 2020, through June 4, 2020, if any are identified, must be reprocessed. 

Please note: For all codes that require manual pricing, Superior HealthPlan will pay at 38% of billed charges.

 

For member information, please reference the Coronavirus Updates for Members webpage.

Latest News

 

For any questions, please contact your Account Manager or call Provider Services at 1-877-391-5921.