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Provider Notices

Providers’ COVID-19 Benefit and Reimbursement Policy Frequently Asked Questions (FAQs)

3/24/2020 9:47:44 AM

This document is intended to answer the most common benefit and coding questions we’ve received from our provider community in response to the COVID-19 pandemic. Statements in this document address the most urgent needs of our provider community. This FAQ will be updated as additional information is available.

Q.        Is PacificSource covering the cost of COVID-19 diagnosing and tests with no member cost share (deductible, coinsurance, copay)?

A.        Yes, PacificSource is covering the cost of COVID-19 testing performed by in network providers with no member cost share.

Tests provided by out of network providers will be paid at the same benefit as our in-network benefit.

Q.        What HCPCS/CPT codes should be billed for COVID-19 test?

A.        Please use the following codes to report COVID-19 laboratory tests




Test for SARS-CoV-2 (CDC laboratory test)


Test for SARS-CoV-2 (non-CDC laboratory test)


Infection agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), amplified probe technique


Q. Should I administer the COVID-19 test to any of my patients who request it?

A. No. As with all medically necessary services, patients should present with appropriate signs and symptoms prior to being considered for COVID-19 testing. Tests should be administered to those who meet your screening protocol.

Q.        Is PacificSource covering any other COVID-19 related services with no member cost share?

A.        PacificSource is waiving member out-of-pocket costs for COVID-19 testing and diagnosis-related office visits, urgent care visits, telemedicine visits, ER visits, testing and radiology if billed with one of the COVID DX codes. PacificSource providers are instructed to not collect copay/coinsurance or deductibles for visiting and testing services. Other services not specified above will adhere to the member’s cost share under their standard benefit.

Services provided by out of network providers will be paid at the same benefit as our in-network benefit.

Q. If a lab bills for the COVID-19 test, how will PacificSource know that the doctor’s office visit on a separate claim is related to the COVID-19 test?

A.  PacificSource is recognizing claims with a combination of any of the following diagnosis and procedure codes for full coverage with no member cost share. The complete CDC update is available for download here.


ICD-10 Diagnosis Codes

Pneumonia, confirmed as due to COVID-19

J12.89, B97.29

Acute bronchitis, confirmed as due to COVID-19

J20.8, B97.29

Bronchitis NOS, confirmed as due to COVID-19

J40, B97.29

Acute/lower respiratory infection NOS, confirmed as due to COVID-19

J22, B97.29

Respiratory infection NOS, confirmed as due to COVID-19

J98.8, B97.29

Acute respiratory distress syndrome, confirmed as due to COVID-19

J80, B97.29

Possible exposure to COVID-19, condition ruled-out


Exposure to confirmed COVID-19


Coronavirus infection, unspecified


nCoV acute respiratory disease




Q.        How long will PacificSource be extending these member benefits with no member cost share?

A.        PacificSource will be extending these member benefits with no cost share until further notice.

Q. How is PacificSource addressing the needs of your members who choose to practice social distancing by not visiting clinics, yet need to seek medical or behavioral help?

  1. PacificSource has expanded coverage to allow the following provider types to bill appropriate Evaluation and Management type services that can be performed in real time via telehealth.
    • Physicians
    • Nurse Practitioners
    • Nurse-Midwife
    • Physician Assistants
    • Clinical Nurse Specialists
    • Registered Dietitians or Nutrition Professionals
    • Clinical Psychologists
    • Clinical Social Workers and other mental health providers as outlined in member’s benefit
    • Certified Registered Nurse Anesthetists
    • FQHC and RHC Providers
    • Speech Therapists, Occupational Therapists, and Physical Therapists

Q.        How does PacificSource reimburse for telehealth services?

A.          PacificSource reimburses for telehealth services as if the service was done in the clinic setting (for services appropriate for telehealth delivery).

Q.        How do you define ‘telehealth’ services? 

A.        Telehealth or Telemedicine–refers to consultations with a qualified healthcare professional provided in real-time over an electronic mechanism. These services are rendered to patients using electronic communications such as telephone, online audio and/or video conferencing.

Q.        Given the broad range of services for which patients may need telehealth coverage and the various mediums for telehealth delivery, how can I indicate telehealth services on my claim?

A.        Professional claims for telehealth services should be submitted with a Place of Service code ‘02’ on your claim. Modifier GT is also recognized, but not required. Facility claims for telehealth services should be submitted with a Modifier GT to identify the claim as a telehealth service.

Q.        Are self-insured companies offering the same benefits through PacificSource to their members?

A.        Self-insured companies determine if they will provide the same benefit that PacificSource is providing for fully insured groups. Most of our self-insured groups have decided to provide the same benefits. Providers can contact PacificSource Customer Service for questions about specific groups.

Q.        What is PacificSource doing to ensure access to medications for your members?

  1. PacificSource is taking additional steps support our members fillingprescriptions, including:

  • PacificSource is increasing access prescription medications by waiving early medication refill limits 30-day prescription maintenance medications (consistent with a member’s benefitplan)

  • PacificSourceisencouragingmemberstoadvantageoftheirabilityobtaina 90-day prescription supply via mail order approved retail pharmacies.

Q.        How do I know if a service or medication requires a prior authorization?

A.        To determine if a service and or medication requires preauthorization, consult our Prior Authorization Grid ( If the service requires preauthorization when done in-person, then preauthorization is required when done as telehealth. Medication coverage status and prior authorization requirements by line of business can be found here:


Medicare Advantage: Medicaid:

Q.        How do I know if a service is covered under the Oregon Health Plan (OHP)?

A.        This can be identified by using LineFinder. LineFinder is an online tool to assist providers in determining what is covered by OHP. OHP generally updates the information quarterly. (

Q.        Who can I contact if I have additional questions about PacificSource’s coverage of my COVID-19 related services or other needs during this pandemic?

  1. Our Provider Service Team stands ready talk through your concerns. can contact us

  • Idaho and Montana: (541) 246-1459, toll-free (855)247-7579

  • Oregon and Washington: (541) 246-1457, toll-free (855)247-7575


Resources: CMS Fact Sheet Medicare FAQ OHA Fact Sheet CMS Provider Quality Reporting FAQ