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Provider News & Updates – February Special Edition

Information about COVID-19 is rapidly changing. Please read through the following updates.

Provider News

Guidance on COVID-19 Vaccination & Administrative Costs

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The COVID-19 vaccine is available at NO charge. The vaccine itself has been paid for through funding authorized by the CARES Act. Providers who receive the COVID-19 vaccine free from the federal government are prohibited from seeking reimbursement from members for vaccine administration costs—including through cost sharing or balance billing. Providers should bill any cost to administer the vaccination as follows:

IHN-CCO Providers

Administration costs should be billed to IHN-CCO for reimbursement. Vaccine doses may be billed to IHN-CCO at $.01 for reporting purposes (reimbursement will not be considered).

Samaritan Advantage Health Plans Providers

Payment for the administration costs will be reimbursed by Original Medicare. Claims should be submitted through the Medicare Administrative Contractor and not include charges for the vaccine dose itself. Claims submitted to Samaritan Advantage Health Plans will be denied.

Samaritan Employer Group Plans & Samaritan Choice Plans

Administration costs should be billed to the member’s plan. Vaccine doses may be billed at $.01 for reporting purposes (reimbursement will not be considered).

Modifiers are not required when submitting claims for the COVID-19 vaccine or administration costs. All places of service (POS) on the CMS POS list for vaccine codes are acceptable.

Please go to the CMS Medicare Part B web page for COVID-19 vaccine information on coding and reimbursement rates.

IHN-CCO Now Requires Prior Authorization for Antibody Testing

Effective Jan. 1, 2021, antibody testing for COVID-19 will require a prior authorization for in- and out-of-network providers. Authorizations for antibody testing codes can be submitted through the Provider Portal.

Medicare Has Extended Fee-For-Service Claims

Medicare has announced that the 2% adjustment (sequestration) on fee-for-service (FFS) claims will be suspended through March 31, 2021. This suspension is an extension of the program that was set to expire on Dec. 31, 2020. Review the official release from CMS.

Reimbursement Guideline Updated for Assistant Surgeons

We are updating our reimbursement guidelines for all lines of business to align with Medicare methodologies as supported in our current agreement and payment policies. Effective Jan. 1, 2021, reimbursement for assistant surgeon services will follow the CMS standard reimbursement of 16% of the primary surgeons allowed amount. For additional information or questions, please contact SHP Customer Service at 541-768-5207 or 888-435-2396, Monday through Friday, 8 a.m. to 5 p.m.

New Services Added to Prior Authorization List

Below are new services introduced in 2021 that have been added to the prior authorization list. For a complete list of services that require prior authorization, please go to Prior Authorization Lists and Forms.

Bamlanivimab and Administration

Prior authorizations are required for investigational COVID-19 treatment, Bamlanivimab, 700 milligrams. injections, intravenous infusion and post-administration monitoring. This aligns with Samaritan Health Plans authorization requirement on potentially cosmetic, experimental or reconstructive surgery and services, including new and emerging technologies and infused/injected drugs and clinical trials. Authorizations for these codes can be submitted through the Provider Portal.

Applicable plans: Samaritan Advantage Health Plans, Samaritan Choice Plans, Samaritan Employer Group Plans and IHN-CCO.

Deflazacort (Emflaza)

Prior authorization must be obtained when deflazacort (Emflaza) is billed with the unlisted procedure code J8499.

NDC Codes Include:

  • 52856-501
  • 52856-502
  • 52856-503
  • 52856-504
  • 52856-505

Applicable Plans: Samaritan Advantage Health Plans, Samaritan Choice Plans, Samaritan Employer Group Plans and IHN-CCO.

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