CurrentPremera BluecrossPolicy N/A

Coverage for medical provider consultations regarding COVID-19 vaccination

Emergency order requiring Washington State-regulated health carriers to cover consultations about receiving COVID-19 vaccination as preventive services without cost-sharing in most plans; applies to participating medical providers and eligible consultations in Washington State.

Policy Summary

PayerPremera Bluecross

PolicyCoverage for medical provider consultations regarding COVID-19 vaccination

Policy CodePolicy N/A

Change TypeEmergency orderadded coverage and billing requirements

Effective DateJun 24, 2021

Next Review DateN/A

Key ActionBill eligible COVID-19 vaccine consultations with diagnosis code Z71.89 and one of CPT/CPT-like codes 99401, 99441, or 98966, ensuring patient is not fully vaccinated and an established relationship exists.

SourceLink

POLICY UPDATE CHANGES

Carriers shall cover consultations related to receiving vaccination against COVID-19 as preventive services while the Order is in effect.

Consultations covered must meet specific conditions including provider participation, verification of vaccination status, established patient relationship, contemporaneous conversation, limits on audio-only billing rules, and billing limits.

Carriers may not require copayments, deductibles, or other cost sharing for these consultations unless the plan is an HSA-qualifying high deductible plan.

2maximum consultations reimbursable per patient

3 yrsminimum recent in-person relationship

Z71.89required diagnosis code

99401,99441,98966allowed billing codes

thru 2021-08-20order duration

Coverage Criteria for COVID-19 Vaccination Consultations

Covered Consultations

Covered consultations must meet ALL of the following conditions:

Eligibility criteria: 1) Consultation conducted by a participating medical provider (medical provider does not include providers of pharmacy services).

See RCW definition referenced in Order.

Verification of vaccination status: 2) The participating medical provider has checked the patient’s vaccination status in the provider's medical records and the Washington State Immunization Information System (WAIIS) and has queried the patient at initiation of the consultation to confirm the patient is not fully vaccinated.

Documentation and primary diagnosis code Z71.89 required on claim.

Established patient relationship: 3) The participating medical provider has an established relationship with the patient that includes at least one in-person appointment within the past three years with the provider or another provider employed at the same clinic.

Policy Summary

PayerPremera Bluecross

PolicyCoverage for medical provider consultations regarding COVID-19 vaccination

Policy CodePolicy N/A

Change TypeEmergency orderadded coverage and billing requirements

Effective DateJun 24, 2021

Next Review DateN/A

SourceLink

On This Page

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At least one in-person visit within past 3 years is required.

Interaction type required: 4) A contemporaneous conversation between the provider and patient actually occurred, either in-person or by live electronic voice communication (e.g., phone call or teleconference). Written correspondence, voicemail, text message, facsimile, e-mail, or internet chat are not eligible for coverage.

Asynchronous communications are excluded.

Audio-only telemedicine rules: 5) For audio-only telemedicine consultations, the provisions of ESHB 1196 (amending RCW 48.43.735) apply upon its effective date (July 25, 2021), including obtaining patient consent for billing in advance of the service when required.

Follow ESHB 1196 consent/billing requirements for audio-only services effective July 25, 2021.

Billing and per-patient limits: 6) The participating medical provider has billed no more than two consultations for the patient; the claim includes diagnosis code Z71.89 in the primary position and is billed using one of the allowed CPT/CPT-like codes (99401, 99441, or 98966).<= 2 consultations per patient

Claims must use Z71.89 primary and one of the listed CPT/CPT-like codes.

Providers of pharmacy services are explicitly excluded from eligibility as participating medical providers for the purposes of this Order. Claims for COVID-19 vaccine consultations must be submitted by eligible participating medical providers as defined in the Order; pharmacy service providers do not meet that participating provider definition and are therefore not eligible to bill under this policy.

The Order specifies that the following communication formats are not eligible for coverage: written correspondence, voice message (voicemail), text message, facsimile (fax), e-mail, and internet chat. Coverage is limited to contemporaneous conversations (in-person or live electronic voice communication) and excludes asynchronous or written modalities.

Consultations that fail to satisfy all conditions set out in paragraph D of the Order are not eligible for coverage. Examples include situations where the provider lacks an established relationship with the patient (no in-person visit within the past 3 years with the provider or another provider employed at the same clinic), or where the interaction was asynchronous only (e.g., written correspondence, voicemail, text, fax, e-mail, or internet chat). Other failures—such as not verifying vaccination status, incorrect billing/coding, or exceeding the maximum of 2 consultations billed for the patient—also render the consultation non-covered.

Billing Codes, Diagnosis, and Limits

Covered CPT/CPT-like CodesCPTCovered

99401	in-person consultation and available for audio and visual telehealth visits.
99441	audio-only (telephone) counseling for physicians
98966	audio-only (telephone) counseling for non-physicians (Medical Assistants, Nurses, etc.).

Required Diagnosis Code (primary)ICD-10Covered

Z71.89

Other specified counseling

inv-07: Maximum consultations per patient

Maximum reimbursable consultations per patientNo more than 2 consultations billed for a patient under this Order.

Billing requirementClaims must include diagnosis code Z71.89 in the primary position and one of the approved CPT/CPT-like codes.

Effective period for claims acceptanceCarriers must begin accepting claims submitted under this Order by July 1, 2021 for dates of service on or after the Order effective date.

Provider Billing, Documentation, and Operational Requirements

Denial Risk

Denial Protection

A Carrier may not deny a claim for a consultation that meets the conditions described in paragraph D of the Washington Insurance Commissioner's order based upon the Carrier's knowledge of an enrollee's COVID-19 vaccination status. This protects claims where the provider has met the documentation, relationship, and interaction requirements specified below.

Do not deny claims solely because carrier believes member is vaccinated
Applies when all paragraph D conditions are met

Billing Rule

Billing Codes Required

Claims must use one of the listed CPT/CPT-like codes and include diagnosis code Z71.89 in the primary position. Audio-only services are addressed separately and require patient consent per ESHB 1196 when effective (July 25, 2021).

Required diagnosis: Z71.89 in primary position
Allowed procedure codes: CPT 99401 (in-person or audio-visual telehealth), CPT 99441 (physician audio-only telephone counseling), CPT 98966 (non-physician audio-only telephone counseling)
Audio-only note: Provider must obtain patient consent for billing in advance of the service when ESHB 1196 is effective

Step Therapy

No Step Therapy

No step therapy or prior authorization requirements are specified in the Order for these consultations.

Carriers must not impose step therapy for COVID-19 vaccine consultations described in the Order

Documentation Required

Required Documentation and Claim Coding

Providers must check immunization records (practice medical records and the Washington State Immunization Information System), confirm the patient is not fully vaccinated at the time of the consultation, document the contemporaneous conversation, document an established relationship (at least one in-person visit within the past three years with the provider or another provider at the same clinic), and limit billing to no more than two consultations per patient. Claims must include Z71.89 as the primary diagnosis and one of the permitted CPT codes (99401, 99441, 98966). For audio‑only services, document that patient consent for billing was obtained in advance as required under ESHB 1196.

Verify vaccination status in provider records and Washington State IIS; query patient during consultation to confirm not fully vaccinated
Document an established relationship: ≥1 in-person appointment within past 3 years with provider or another provider at same clinic
Document contemporaneous conversation: in-person or live electronic voice (phone/teleconference). Asynchronous modes (voicemail, text, email, chat, fax) are not eligible
Limit: bill no more than two consultations per patient
Claim coding: primary diagnosis Z71.89 and procedure code one of {99401, 99441, 98966}
Audio-only: obtain and document patient consent for billing in advance per ESHB 1196 (effective July 25, 2021)

Note

Established Patient Relationship

An established patient relationship is required: the participating medical provider must have had at least one in-person appointment with the patient within the past three years, either with the provider billing for the consultation or another provider employed at the same clinic.

At least one in-person visit within the past 3 years with the provider or another provider at same clinic

Note

Interaction Type Required

The interaction must be a contemporaneous conversation between provider and patient conducted either in-person or by live electronic voice (telephone or teleconference). Asynchronous communications (written correspondence, voicemail, text message, facsimile, e-mail, or internet chat) do not meet the Order's coverage conditions.

Eligible interaction modes: in-person or live electronic voice (phone, teleconference)
Ineligible modes: voicemail, text, email, chat, fax, other asynchronous communication

Definitions

inv-15: Participating medical provider

Definition (Participating medical provider)A medical provider as defined in RCW 48.43.005 and consistent with the procedure codes listed in the Order.

Exclusion — pharmacy servicesFor purposes of this Order, 'medical provider' does not include providers of pharmacy services; pharmacy providers are not eligible participating medical providers.

Relation to billed codesProvider eligibility must align with the procedure codes specified in paragraph D (e.g., CPT codes 99401, 99441, 98966).

inv-16: Contemporaneous conversation

DefinitionA contemporaneous conversation is a live discussion between the participating medical provider and the patient either in-person or by live electronic voice communication (e.g., phone call or teleconference).

Excluded interaction typesWritten correspondence, voicemail/voice message, text message, facsimile, e-mail, or internet chat are not eligible for coverage under this Order.

Audio-only telemedicineAudio-only consultations are allowed only if ESHB 1196 provisions (including advance patient consent for billing) are followed upon its effective date (July 25, 2021).

Background

Washington State identified vaccine hesitancy as an obstacle to achieving target vaccination coverage during the COVID-19 emergency and issued this Order to promote outreach. The State reasoned that outreach by trusted sources, such as a patient’s personal physician or other participating medical providers, may encourage unvaccinated individuals to initiate or complete vaccination and thereby improve public health outcomes while the emergency order remains in effect.

Revision History

2021-06-24Emergency Order activated

Insurance Commissioner activated Emergency Order 21-02 requiring Washington State-regulated carriers to cover consultations related to COVID-19 vaccination; order entered at Olympia and effective immediately.

2021-06-24 to 2021-08-20Order effective periodLatest

Order 21-02 remains in effect immediately upon entry on June 24, 2021 through August 20, 2021 unless extended by further order of the Insurance Commissioner.