LifeWise Assurance Company Student Insurance Response to COVID-19

  • LifeWise is here to support members, employers, and healthcare providers during the coronavirus (COVID-19) outbreak.

    Updates as of December 22, 2020

    • New information about COVID-19 vaccine availability and administration is now posted in the section on COVID-19 Vaccines, which includes information on approvals and tentative phases of distribution.
    • In order to administer COVID vaccines, providers must qualify and enroll as a mass immunizer (or other Medicare provider type that allows billing for administering vaccines). In Washington, provider facilities/organizations must enroll in the federal COVID-19 Vaccination Program coordinated through Washington's immunization program. There are also specific codes assigned to each available vaccine, which are required for reimbursement for administration of the vaccine.
    • Check our section with all COVID-19 key dates for coverage and benefits.
    • LifeWise is waiving cost shares for all COVID-19 related testing and treatment. Learn more.

    • Get all the latest COVID-19 updates from the Centers for Disease Control and Prevention (CDC), including people at risk for serious illness and hygiene tips for home, school, and work.

      For general questions about COVID-19:
      Washington State Department of Health
      Centers for Disease Control and Prevention

      If you have health plan questions not covered in these resources, call our customer service team at the number on the back of the member ID card, or your provider network team.

      We'll be updating the following FAQ as additional information is available.

      COVID-19 Key Dates

      COVID-19 Coverage
      See related section for more information about health plan coverage.
      End Date
      Cost share waivers for FDA-approved COVID-19 diagnostic testing other virus/respiratory testing tied to a COVID-19 diagnosis (federal Families First Act and Washington State OIC mandate)  January 21, 2021
      Antibody tests covered only when they are for the purpose of diagnosing a COVID-19 related condition. (CDC and EEOC guidelines) Policy effective July 1, 2020
      Cost share waivers for treatment related to COVID-19 diagnosis is waived (LifeWise initiative) March 31, 2021
      Cost share waivers for telehealth/virtual care visits (LifeWise initiative) December 31, 2020
      PHP and IOP available through telehealth
      • Partial hospitalization programs (PHP) for mental health and substance use disorders
      • Intensive outpatient programs (IOP) for mental health and substance use disorders
      • Telehealth policy updated to allow ongoing coverage effective January 1, 2021.

      Policy effective January 1, 2021
      Applied behavioral analysis (ABA) available through telehealth March 31, 2021
      Waiver of prior authorization requirements for home health care or long-term facility services (Washington State OIC mandate) January 11, 2021
      Prescription "refill too soon" override (LifeWise initiative) January 31, 2021
      Allowance for certain procedures to be handled through Tele-dentistry (LifeWise initiative) March 31, 2021
      Personal Protective Equipment (PPE) separately billed PPE charges will not be allowed Policy effective November 1, 2020

      COVID-19 vaccines

      Note: We’re updating our vaccine FAQs as information becomes available. Information about vaccines and distribution will continue to evolve. We anticipate that broad scale vaccination across our populations (those not in the first few phases) will likely not be until mid-2021.

      Do providers and pharmacies need to do anything to be able to administer the COVID vaccine?

      Yes.

      For commercial plans, to receive/administer COVID-19 vaccine, constituent products, and ancillary supplies, vaccination provider facilities/organizations must enroll in the federal COVID-19 Vaccination Program coordinated through their jurisdiction's immunization program. Enrolled COVID-19 vaccination providers must be credentialed/licensed in the jurisdiction where vaccination takes place, and sign and agree to the conditions in the CDC COVID-19 Vaccination Program Provider Agreement. These conditions are detailed in the agreement itself.

      Washington state has developed a draft plan for COVID-19 Vaccine preparedness addressing a variety of topics.  That includes phases of distribution and allocation, identification of critical populations and initial plan for prioritization of administration to different groups.

      In Washington, to receive and administer the COVID-19 vaccine, providers have to enroll in a federal vaccine distribution program, coordinated through the state immunization program (unless they are part of a national chain registered directly with the CDC [e.g., major retail pharmacy chains). Washington state providers can enroll as COVID-19 vaccine providers.


      When will a vaccine be available?

      The FDA Vaccine Advisory Committee voted to approve the Emergency Use Authorization (EUA) for the Moderna COVID-19 vaccine for those 18 and older. The CDC’s Advisory Committee on Immunization Practices (ACIP) recommended use of the Moderna vaccine. The Scientific Safety Review Workgroup, made up of members from Washington, Oregon, Nevada, Colorado and California, met and voted to recommend the vaccine for immediate use.

      Earlier in December the Pfizer COVID-19 vaccine for those 16 and older was given an Emergency Use Authorization (EUA).


      How many vaccines are there?

      Two vaccines have made it through all the required trials and have received EUA from the FDA. Vaccines made by AstraZeneca and Johnson and Johnson are expected in the first quarter of 2021.


      How soon can the public get a vaccine?

      The CDC Director has approved additional phases of the COVID-19 vaccination program. Note that each state can vary who is included in each phase or accept the CDC recommendations. We expect Washington and Alaska to follow CDC guidelines; we’ll know more in early January. It’s expected that the next phase of vaccinations (phase 1b) will not start before the end of January. 

      Phase 1a: Healthcare personnel and residents/staff of long-term care facilities

      1. Health care personnel. Health care personnel are defined as paid and unpaid persons serving in health care settings who have the potential for direct or indirect exposure to patients or infectious materials.
      2. Residents and staff of long-term care facilities. Long-term care facility residents are defined as adults who reside in facilities that provide a variety of services, including medical and personal care, to persons who are unable to live independently.

      Phase 1b: Frontline essential workers and Persons aged 75 years or older

      Frontline essential workers include:

      • First responders (e.g., firefighters, police)
      • Education workers (teachers, support staff, daycare)
      • Food and agriculture workers
      • Correctional/prison facility staff
      • U.S. postal service workers
      • Public transit workers
      • People who work in manufacturing
      • People who work in grocery stores

      Phase 1c: Persons age 65-74 years, persons aged 15-64 with high-risk conditions, essential workers not recommended in Phase 1b

      Essential workers include people who work in the following areas:

      • Transportation and logistics
      • Food Service
      • Shelter and housing (construction)
      • Finance
      • IT and communication
      • Energy
      • Media
      • Legal
      • Public safety (engineers)
      • Water and wastewater

      The National Academies of Sciences, Engineering, and Medicine (NASEM) and the Centers for Disease Control and Prevention’s (CDC) Advisory Committee on Immunization Practices (ACIP) will provide guidance on who gets the vaccine first when one is available via EUA or FDA approval.


      Are there specific codes to use when administering the vaccine?

      After the emergency use authorization (EUA) or licensure of each COVID-19 vaccine product by FDA, CMS will identify the specific vaccine code(s), by dose if necessary, and specific vaccine administration code(s) for each dose for Medicare payment. CMS and the American Medical Association (AMA) are working collaboratively on finalizing a new approach to report use of COVID-19 vaccines.

      Codes are now available for the Pfizer, Moderna and Astra-Zenica. Use the links below to ensure the new codes are in your system to facilitate efficient claims processing.

      It's recommended that providers download the new release of PC-ACE. This release includes the coding structure, currently comprised of both a HCPCS Level I CPT code structure issued by the American Medical Association (AMA) and a HCPCS Level II code structure issued by CMS. This code structure was developed to facilitate efficient claims processing for any COVID-19 vaccines and monoclonal antibody infusions that receive FDA EUA or approval. CMS and the AMA are working collaboratively regarding which codes to submit for COVID-19 vaccines and administration. Most of these codes are not currently effective and not all codes will be used.  Specific code descriptors will be issued in the future.  Effective dates for the codes for Medicare purposes will coincide with the date of the FDA EUA or approval.

      Get the most up-to-date list of billing codes, payment allowances and effective dates.


      How are the vaccines being distributed?

      Washington received its first allotment of the Pfizer vaccine on December 14 and began administration of the vaccine to high-risk workers in health care settings, high-risk first responders, and patients and staff of long-term care facilities. It’s estimated around 500,000 people in Washington will be eligible for the vaccine in phase 1a. The Moderna vaccine shipment is currently expected in the next week and vaccinations will begin shortly after distribution.

      CVS Pharmacy, which is preparing to begin vaccinations in long-term care facilities, said that December 21 would be the earliest vaccine administration can start in the facilities.

      The Pfizer COVID-19 vaccine is a two-dose vaccine given 21 days apart. The Moderna vaccine is also a two-dose vaccine given 30 days apart. The CDC will be issuing a guidance that addresses use in those with vaccine allergic reactions, are pregnant/breastfeeding, and have weak immune systems.

      We anticipate that broad scale vaccination across our populations (those not in the first few phases) will likely not be until mid-2021.


      Do we know what other states are doing with the phases?

      Each state can determine if they’ll follow the CDC guidance on each phase. States have their own Department of Health websites that will be tracking information, providing updates on available vaccine doses, who is eligible to administer the vaccine, and who is included in each phase.


      Where can I get more information about the vaccines?

      Information about vaccines and distribution will continue to evolve.

      For general questions about COVID-19 vaccines and vaccine trials, and for the CDC playbook:

      Washington state has developed a draft plan for COVID-19 Vaccine preparedness addressing a variety of topics. That includes phases of distribution and allocation, identification of critical populations and initial plan for prioritization of administration to different groups.


      How much will it cost?

      The federal government has mandated that the cost of the vaccine will be $0 for everyone in the U.S. The cost for administering the vaccine will be covered by insurance, for those with coverage, or waived for those without coverage. Providers may bill an insurance company for administrative costs.


      How will the vaccine be billed?

      The cost of the actual vaccine is being covered by the government currently. The cost of administering the vaccine will be covered by insurers, like Premera. CMS has recently released expected costs for vaccine administration. We expect the vaccines will be billed by dose, similar to how other 2-dose vaccines are billed.


      Do I need a doctor’s referral or prescription?

      Currently only those in Phase 1a category are receiving doses of the vaccine. For Phase 1b and 1c, you may need a doctor’s note or identification to prove you’re eligible when the vaccine becomes available. We expect to know more about requirements in early January.


      Are these vaccines available for children?

      Not currently for those under 16. The vaccines were only tested on adults. The Pfizer vaccine is approved for those 16 and older; Moderna is approved for those 18 and older. We’ll need additional studies to determine if these vaccines will be effective for those under age 18.


      What if I don’t get the second dose?

      You may not be fully protected from contracting the COVID-19 virus. There are many vaccines that require more than one dose to ensure adequate immune response (i.e., antibodies) and to protect you from contracting a virus.


      Why is a second dose needed?

      For some vaccines (primarily inactivated vaccines), the first dose does not provide as much immunity as possible. So, more than one dose is needed to build more complete immunity. The vaccine that protects against the bacteria Hib, which causes meningitis, and the vaccine that protects against shingles, are good examples. If you get your second shot too early or too late, you DO NOT need to repeat the dose.


      What if I get the wrong vaccine for my second shot?

      If you accidentally get the wrong vaccine for your second shot, you DO NOT need to repeat the dose. For example, if you get the Pfizer vaccine and then for your second shot you accidentally get the Moderna vaccine, you do not need another dose of either the Pfizer OR Moderna vaccine.


      How will I know when I need to go back for my second dose? Can LifeWise track and email members about their second dose?

      You should receive a vaccine card from the provider letting you know when you’ll need to get your second dose and which vaccine you received. You may also be asked to provider your email address or phone number for a reminder as well. Premera is looking into reminders as well, but because claims for vaccinations can come in up to 60 days after the fact, we may not be able to provide timely reminders.


      Am I required to get the COVID-19 vaccine?

      There are no requirements currently that you must get the vaccine. It is, however, highly recommended.


      Can I require my employees to get vaccinated?

      We can’t provide you with employment law advice on this topic. You’ll want to check in with your own legal counsel to determine if there are any restrictions or considerations to that requirement. The vaccine will be covered under your health plan benefits.


      Does this mean I can return to my normal activities?

      Not quite yet. According to studies, we need more than 65% of the population to get the COVID-19 vaccine in order to begin to see protection among the general population. Once you receive both doses of a vaccine, you may be able to resume normal activities. In the meantime, continue to exercise caution, wash your hands frequently, and wear a mask.


      COVID-19 and waivers

      Is COVID-19 testing covered?

      The new Families First Coronavirus Response Act requires all group health plans, including self-funded plans, to provide coverage for diagnostic testing, including U.S. Food and Drug Administration (FDA)-approved COVID-19 diagnostic testing products and items and services related to testing furnished during an office, telehealth, urgent care center or emergency room visit. We have removed the group waivers that were previously in place to comply with this mandate.

      LifeWise follows state and federal mandates related to end dates for these services. See the COVID-19 Key Dates section in this document for current dates.

      For commercial members: We're waiving in-network copays and deductibles for FDA-authorized COVID-19 diagnostic testing. Per Washington state Office of the Insurance Commissioner (OIC) requirements, we're also waiving in-network copays and deductibles for other virus/respiratory testing tied to a COVID-19 diagnosis. The waivers apply for diagnostic testing and the related provider visit at in- and out-of-network facilities and laboratories. All other treatments and services including hospitalization not related to COVID-19 diagnosis will be subject to the usual benefits and cost shares.

      Pre-authorization isn't required for medically necessary and FDA-authorized COVID-19 testing. If a member requires testing and treatment for COVID-19 and there isn't an in-network provider within a reasonable distance to perform those services, the claims will be paid as in-network.


      Are serology tests covered?

      LifeWise's Benefit Coverage Guideline is effective for serology tests for dates of service July 1, 2020 and forward. LifeWise will reimburse for serology tests that are for the purpose of supporting a COVID-19 diagnosis as part of the treatment or management of a patient's medical condition.

      Serology tests provided on an inpatient basis are presumed to be for diagnostic purposes.  Tests performed on an outpatient basis require records confirming that the test is for the diagnosis of the disease or condition of a patient. 

      The Benefit Coverage Guideline follows CDC guidance on scenarios in which serology testing can be used for diagnostic purposes:

      • Serologic testing can be offered as a method to support diagnosis of acute COVID-19 illness for persons who present late. For persons who present 9-14 days after illness onset, serologic testing can be offered in addition to recommended direct detection methods such as polymerase chain reaction.
      • Serologic testing should be offered as a method to help establish a diagnosis when patients present with late complications of COVID-19 illness, such as multisystem inflammatory syndrome in children.

      Serological tests will not be covered when provided as the sole basis of diagnosis for current infection with COVID-19.

      We will be covering claims with dates of service June 30, 2020 or earlier.


      Is treatment covered? Are there any limitations for COVID-19 care?

      LifeWise is waiving member cost shares including copays, deductible, and coinsurance for treatment of COVID-19 or health complications associated with COVID-19, including hospitalizations and medical transportation when needed, FDA-approved medications administered inpatient for both in- and out-of-network providers. All other treatments and services including hospitalization not related to a COVID-19 diagnosis will be subject to the usual benefits and cost shares.

      See the COVID-19 Key Dates section in this document for current dates.

      This benefit applies to members of insured group, individual, grandfathered, non-grandfathered, and associations. Self-funded group plans have the option to participate. This includes qualified high deductible plan participants.

      This will not apply to Shared Admin, FEP, and Self-funded plans that opt-out. Normal plan benefits apply in this situation for our members. You can check eligibility and benefits on our website.


      Is return to work testing covered? How do I bill for a return to work test?

      LifeWise will not include testing coverage (molecular/antigen or antibody tests) for return to work strategies for our insured book of business just as we don't cover drug testing for employment purposes, as an example. The CDC said in its Interim Guidelines that antibody test results "should not be used to make decisions about returning persons to the workplace." The EEOC has stated that because of this, "requiring antibody testing before allowing employees to re-enter the workplace is not allowed under the ADA". Current versions of the antibody test can't reliably tell a person that they're immune, can't be re-infected or can't transmit the virus to someone else.

      Return to work COVID test aren't covered by the plan.  The member may want to check with their employer on whether they will reimburse the member for this expense or bill directly to the employer. 


      Are home test kits, including the ones I get at the pharmacy, covered?

      FDA-authorized COVID-19 home test kits are only covered when ordered by a licensed physician or pharmacist. Home test kits will not be covered if used for non-diagnostic purposes (e.g. travel, return to work, etc.). Members may submit claims for reimbursement for in-home tests only when they are ordered by a physician or pharmacist. There may also be tax implications for using HSA funds to purchase in-home tests that are used for purposes other than diagnostic.


      Are physician oversight fees from labs covered as part of the testing? 

      Some lab companies are charging members a $10 non-refundable service fee for "physician oversight services" when a member orders testing directly through a lab. The $10 fee is for an independent physician who orders test for the member. The member also has the option to consult with this physician to discuss their results. This fee is not submitted to insurance for reimbursement by the lab service or the physician. This type of service fee and claim are not covered by the medical plan. To avoid this type of service fee, members should use their own provider or clinic when requesting COVID-19 testing.  


      Can I bill for the added cost of PPE?

      As of November 1, 2020, Personal protective equipment (PPE) will no longer be separately reimbursable effective.

      When PPE is worn as part of a dental, medical or pharmacist healthcare visit, it's considered part of the practice expenses included in the main dental medical or pharmacy related procedure rendered to a patient. PPE will not be separately reimbursable.

      Review additional details in the Personal Protective Equipment payment policy.


      Can I offer and bill for drive-through testing? Is that covered?

      Yes. Drive-through testing for COVID-19 is covered and cost shares will be waived as they are for in-clinic testing.


      Are there specific codes I should be using for COVID-19?

      The following summary of coding instruction is provided by the CDC, WHO, and CMS related to the Coronavirus/COVID-19. We urge you to use this COVID-19 coding for patients so cost shares may be waived appropriately.

      There are two new HCPCS codes for lab tests to detect COVID-19: code for U0001 for the Centers for Disease Control (CDC) test panel and code U0002 for other tests.

      The American Medical Association added a new CPT code for reporting the novel coronavirus tests: 87635: 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.

      Per the CDC, a new ICD-10 emergency code, U07.1, 2019-nCoV acute respiratory disease, has been established by the WHO for reporting the virus, effective with the next update, October 1, 2020. LifeWise is accepting this code and encourages you to use it.

      To identify patients in the interim who have tested positive for COVID-19, current CDC guidance instructs to code first for the presenting illness followed by B97.29 - Other coronavirus, as the cause of diseases classified elsewhere.

      For the new serology tests, the AMA created new CPT lab test codes: 86328 and 86769. Use these codes when submitting a claim for the antibody test.

      The AMA is offering additional guidance for COVID-19 coding scenarios to help healthcare professionals apply best coding practices. The scenarios include virtual care services for all patients.

      Examples specifically related to COVID-19 testing include coding for when a patient:

      • Comes to the office for an E/M office visit and is tested for COVID-19
      • Receives a virtual care visit regarding COVID-19
      • Is directed to come to a physician's office or physician's group practice site for testing
      • Receives a virtual check-in/online visit regarding COVID-19 (not related to an E/M visit)
      • Is directed to come to a physician's office for testing

      There is also a quick-reference flowchart that outlines current procedural terminology (CPT®) reporting for COVID-19 testing. AMA also outlines CMS payment policies and regulatory flexibilities related to COVID-19. Check the AMA COVID-19 resource center for additional resources.


      Virtual care

      Are you waiving cost shares for virtual care?

      Yes. LifeWise is expanding the virtual care network to address the increased demand related to COVID-19.


      Cost shares are waived for virtual care services as follows:

      Virtual care cost shares are waived for all in-network providers. If a virtual care provider charges you a copay, deductible, or coinsurance for virtual care services LifeWise will reimburse when the claim is processed.


      Who is eligible for this in-network expansion?

      This will not apply Shared Admin, FEP, BlueCard, Providence, HCA, Medicare Supplement, Medicare Advantage, and Self-funded plans that opt-out.


      Can virtual care providers diagnose COVID-19?

      • Virtual care providers can't diagnose COVID-19 or order any COVID-19 testing. An in-person test is required for COVID-19 diagnosis.
      • Virtual care providers can:
        • Diagnose and treat acute and chronic illnesses that do not include COVID-19 symptoms
        • Fulfill necessary prescriptions or order lab tests at local facilities


      Are you expanding virtual care behavioral health and substance use disorder access during the COVID-19 health crisis?

      In addition to our existing LifeWise contracted behavioral health providers (Teladoc*, Talkspace, brick-and-mortar providers and Employer Assistance Programs), we're introducing new virtual access for behavioral health and substance use disorder treatment (opioid and alcohol):

      • Doctor on Demand – Doctor on Demand was added to our virtual care network for our March 25 COVID-19 virtual care expansion. These services are available to member adults and children in all states.
      • Boulder Care - Boulder Care is a digital care provider, offering long-term support and medication-based treatment for opioid use disorder (OUD) and common co-occurring conditions for members 18 years and older. Their digital platform allows patients to connect with providers 24/7 through secure video and messaging with clinicians, care advocates, and peer coaches. Boulder Care is working towards 50 states licensure. If they aren't licensed in a certain state they will transition the member to an in-network provider for the appropriate services.
      • Workit Health – Workit is a digital care provider offering support for alcohol use disorder (AUD). Via Workit web and phone apps, members age 18 and older have a "recovery in their pocket" harm reduction and sobriety solution that provides 24/7 access to interactive therapeutic courses, online support groups supervised by licensed care teams. Workit is working towards 50 states licensure. If they aren't licensed in a certain state, they will transition the member to an in-network provider for the appropriate services.

      Additional covered  services virtual care include:

      • Applied behavioral analysis (ABA)
      • Partial hospitalization programs (PHP) for mental health and substance use disorders
      • Intensive outpatient programs (IOP) for mental health and substance use disorders

      * Currently: Teladoc behavioral health is currently available only for self-funded groups who previously opted-in to Teladoc behavioral health in addition to their general Teladoc election. 

      Effective May 1, 2020, as self-funded groups renew, Teladoc behavioral health will automatically be added for groups that already have general Teladoc services elected. Cost shares would then apply for Teladoc behavioral health through December 31, depending on whether the group elected to temporarily waive cost shares for virtual care. Teladoc behavioral health will not be added for self-funded groups who do not already have Teladoc services.


      Are there resources for people that are dealing with a mental health issue?

      Yes. LifeWise offers Talkspace for all our members. This is an online, virtual behavioral health provider resource. Many local mental health providers are also offering virtual services. Your patient should check with their provider first or visit Talkspace.com.


      Can I offer virtual care services to my patients?

      Yes. Virtual care is covered under the scope of your current contract with LifeWise, if the care provided is appropriate within the scope of the provider's licensure. This change applies to LifeWise individual and commercial members. However, some self-funded employer groups do not cover virtual care, so you'll need to check benefits for your patient before providing care.

      Note: virtual care services aren't coded like in-office visits due to different modifiers and Place of Service codes needed to identify avirtual care service. There are additional codes that can be used for online video encounters as well as telephone visits in conjunction with the office visit codes.

      For LifeWise-contracted providers, your current contract covers virtual care services if the care provided is appropriate within the scope of the provider's licensure. Note: Virtual care services aren't coded like in-office visits. Refer to your LifeWise contract for allowable information for virtual care codes. For specific coding information for LifeWise patients, see our virtual care payment policy for Washington.

      LifeWise wants to emphasize that this is a temporary relaxation of the rules during this nationwide public health emergency. Correct coding and notification to the patient that the provider is using non-HIPAA compliant communication tools is required.


      Are there specific virtual care codes?

      LifeWise will be extending the payment of telehealth visits at the in person allowed amount, during the national public health emergency, beyond September 1, 2020 as previously communicated. For providers that are delivering services via telehealth, LifeWise will require providers to continue use the correct telehealth place of service (POS) 02 with the procedure code appended with either modifier 95 or GT. Claims with modifiers indicating they were telehealth, if billed with POS 11, will be rejected up front and will require the correct POS to match the service billed. We will no longer accept POS 11 for telehealth services. We recognize that action needs to be taken to resolve claims submitted between September 1 and October 1 and are exploring options that take into consideration provider administrative burden. You do not need to submit corrected bills for this change. LifeWise wants to emphasize that this is a temporary relaxation of the rules during this nationwide public health emergency. As additional information becomes available from CMS or other state regulators, we'll adjust our policies and notify you of the change. Only claims for telehealth visits from providers who members normally see in-person, in-office will be processed in this manner, and claim costs will be no more than what would have been paid had the member been able to see their providers in person.

      This guidance is in effect for WA group plans, FEP and Individual plans. Shared Admin are excluded from this guidance.

      Refer to your LifeWise contract for allowable information for virtual care codes. For specific coding information for LifeWise patients, see our telehealth payment policy.


      How do I capture a physical exam if I'm not physically present with the patient?

      With the increasing use of telemedicine to interact and treat patients, it can be difficult to capture information and do a physical exam. Fortunately, synchronous audio and video platforms make it possible for providers to capture almost all areas of a physical exam. We suggest using best practices and information from  Telemedicine: Conducting an Effective Physical Exam to help you conduct an effective physical exam during a virtual care visit.


      What about HIPAA rules?

      Per Health & Human Services and the Office of Civil Rights (OCR), a covered physician or health care provider who wants to use audio or video communication technology to provide virtual care to patients during the COVID-19 nationwide public health emergency can use any non-public facing remote communication product that is available to communicate with patients. OCR is exercising its enforcement discretion to not impose penalties for noncompliance with the HIPAA rules in connection with the good faith provision of virtual care using such non-public facing audio or video communication products during the COVID-19 nationwide public health emergency. This exercise of discretion applies to virtual care provided for any reason, regardless of whether the virtual care service is related to the diagnosis and treatment of health conditions related to COVID-19. Additionally, the criteria that virtual care may only be used with established patients is being relaxed and new patient encounters can be billed with these codes.


      Can I see new patients using virtual care?

      Providers can care for new patients via a virtual care encounter and bill those services using the appropriate CPT code for the services rendered, in addition to the virtual care modifier and place of service. Virtual care for an established patient should also be billed with an appropriate CPT code, many of which are found in our payment policy. Note that these services must also be billed using the appropriate virtual care modifier and place of service.


      Can ABA services be provided virtually?

      Yes, ABA services can be provided virtually for dates of service on or after March 20, 2020. This is temporary and is in effect until government agencies indicate that we no longer need to practice social distancing.

      Claims for services provided virtually must be submitted with appropriate virtual care modifiers using the codes currently on the ABA fee schedule. Reimbursement for virtual care will be at the same amount as if the service were provided in-person. This change applies to our individual and commercial members.


      Prior Authorizations

      Is LifeWise extending prior authorization timeframes?

      Effective March 25, 2020, the OIC's second emergency order required we waive or expedite prior authorization requirements for home health care or long-term care facility services. See the COVID-19 Key Dates section in this FAQ for current dates.


      Pharmacy and Prescriptions

      Can patients refill prescriptions early if needed?

      Yes. We've adjusted our refill too soon policy for medications. This allows pharmacies to override refill too soon edits during a declared emergency at the pharmacy counter. Members also have access to mail order prescriptions. See the COVID-19 Key Dates section in this FAQ for current dates.

      Some virtual care providers have also temporarily waived their refill policies prohibiting the refill of chronic medications beyond twice in a calendar year. Providers will consider clinical appropriateness, patient safety and professional judgement.


      How is LifeWise covering the drugs used to treat COVID-19?

      Drugs that have received Emergency Use Authorization (EUA) or full FDA approval for the treatment of COVID will be covered under current policies and according to your health plan benefits.


      How is LifeWise responding to FDA warnings of potential drug shortages?

      We frequently see drug shortages in the U.S. based on manufacturer issues, raw product issues, etc. We may see new reported shortages based on the COVID-19 impact to Chinese manufacturers.

      LifeWise will respond to these shortages the same way we do today, by ensuring the following:

      • The pharmacy team will check public and industry resources to identify new shortages that may impact our members.
      • We'll review medical policies to determine if adjustments are needed to ensure access to alternative medications (should we change our preferred drugs or update prior authorization criteria to account for shortages both short and long term).
      • Our review processes already account for drug shortages. If a drug we require as first-line therapy is in short supply, we'll waive this requirement based on market realities and approve coverage when preferred formulary alternatives are in short supply.

      We're also reviewing rejected claims to see if members are getting the medications they need. If we see any drug shortages, we'll seek other options to meet member needs. We'll continue to monitor the situation with our pharmacy partners, so members won't run out of needed medications.