Billing/Coverage for COVID-19

Below is member coverage and billing information for COVID-19 treatments and testing: 

 

COVID-19 VACCINES

The Food and Drug Administration (FDA) has granted emergency authorized use (EAU) of both the Pfizer and Moderna COVID-19 vaccines. The rollout and distribution of the vaccines will be determined by each state and the CDC has helped to set those guidelines. In most states, the vaccines will be given to frontline workers (first responders, health care workers) first and then people who are deemed “high-risk.”

 

MEMBER COVERAGE AND CLAIMS SUBMISSION

During the Public Health Emergency (PHE), the federal government will pay for the cost of the COVID-19 vaccine for all individuals and throughout 2021 for Medicare Advantage members regardless of when the PHE ends. Additional costs associated with administering the vaccine (such as vaccine supplies, storage and provider costs) will be covered by either the federal government or the member’s health plan, depending on the member.

See the following table for more information regarding coverage and claims submission.

Membership Coverage Claims Submission
Medicare Advantage The federal government will pay all vaccine-related costs, with no cost to members during the public health emergency.

During the public health emergency, providers should file claims related to the vaccine and administration of the vaccine directly to Original Medicare.

If providers file vaccine-related claims with Highmark during the public health emergency, the system will deny the claim.

Commercial members, including ACA and self-funded groups

The federal government will pay for the cost of the COVID-19 vaccine.

Highmark and self-funded groups will cover vaccine administration fees during the public health emergency with no cost to members.

Providers should submit vaccine administration claims to Highmark. See the table on the next page for coding guidance.

Federal EmployeeProgram (FEP)

The federal government will pay for the cost of the COVID-19 vaccine.

All federal employee health benefit carriers are required to cover the vaccine without any member cost-sharing during the public health emergency.

Providers should submit vaccine administration claims to Highmark. See the table on the next page for coding guidance.

 

VACCINATION CODES

Vaccine Code Code Descriptor Vaccine Admin. Code(s) Vaccine Manufacturer
91300 Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19])

0001A (1st dose)

0002A (2nd dose)

Pfizer, Inc.
vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3mL dosage, diluent reconstituted, for intramuscular use

91301

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5mL dosage, for intramuscular use

0011A (1st dose)

0012A (2nd dose)

Moderna, Inc

 

OUT-OF-NETWORK PROVIDERS

Highmark will cover vaccine administration fees for out-of-network (OON) providers during the public health emergency. Current state and/or federal regulations prohibit any provider from balance billing patients for the COVID-19 vaccine.

 

INPATIENT HOSPITAL CARE 

Member Coverage

Highmark members who receive inpatient hospital care for COVID-19 from an in-network facility will not incur any deductibles, co-insurance and co-pays, effective for dates of service from February 1, 2020 through March 31, 2021. The decision applies to members with group employer coverage (self-funded groups may elect to opt into the program), as well as ACA and Medicare Advantage members.

Additional Information:

  • Waiver applies to inpatient claims with a confirmed diagnosis (after positive COVID-19 test).
  • Benefit limits/maximums (e.g., SNF days) still apply.
  • Standard prior authorizations still apply.
  • Waiver applies to covered services from in-network providers. 
  • Upon discharge, routine medical benefit coverage will apply.

 

Billing

Please remember to use the new CMS diagnosis code, U07.1, for COVID-19 on claims as appropriate. 

 

OFFICE VISITS

In alignment with the Families First Coronavirus Response Act, Highmark will waive the member cost share for office visits (including telehealth), urgent care visits and Emergency Department visits when the visit results in a COVID-19 test being ordered or administered.

This means copayments, deductibles, and coinsurance do not apply for COVID-19 testing. This applies to all Medicare Advantage, ACA, and select employer plans. (Members should contact Member Services to see if this applies to their plan using the number on the back of their card.)

If the visit does not result in the COVID-19 diagnostic test being ordered or administered, the visit will be paid based on the member’s benefit plan and standard cost sharing will apply.

 

ASSOCIATED SERVICES

Additionally, Highmark will waive member cost share for any items or services provided during the visit in which the COVID-19 test is ordered or administered. Items or services unrelated to the evaluation of whether a patient should be tested for COVID-19 will be paid based on the member’s benefit plan.

A service will be considered related to COVID-19 diagnosis or treatment if:

  • The COVID-19 test is attached to the claim OR the COVID-19 diagnosis code is on the claim when the provider is not also performing the test (e.g., when the Health department performs the test for the patient)
  • The service falls into one of the following categories:
    • Evaluation and Management (Office Visit, Urgent Care, Emergency Department)
    • Consultation
    • Chest X-ray
    • Chest CT
    • Respiratory Panel
    • Influenza Test
    • Breathing Treatment, including drugs administered in the office as part of the treatment
    • Nebulizer Treatment, including drugs administered in the office as part of the treatment

 

The following service categories are examples of those considered non-related to COVID-19 diagnosis or treatment in the outpatient setting*, where applicable member cost share liability remains in effect. This list may be revised as new information becomes available.

  • Allergy Testing
  • Ambulance
  • Anesthesia
  • Behavioral Health
  • Chemotherapy
  • DME
  • Self-administered Prescription and Non-Prescription Drugs
  • Occupational Therapy
  • Physical Therapy
  • Surgery

 

*Cost sharing for inpatient services will be waived based on Highmark’s decision to pay in-network, inpatient claims for COVID-19 treatment, except for self-funded groups that elected out of the program.

 

TESTING

Specimen-Only Collection

The following codes may be used when collecting specimens for the diagnostic purposes of COVID-19. Reimbursement for specimen collection will, in general, only be separately reimbursed if it is the ONLY code billed on the claim. If billed with another code, such as an E&M code, no separate reimbursement will be allowed.

HCPC/CPT Code

Description

Who Can Use

99000 Handling and/or conveyance of specimen for transfer from the physician's office to a laboratory Sample collected at a Mobile collection unit or Physician office billed on a 1500 form as appropriate
99001 Handling and/or conveyance of specimen for transfer from the patient in other than a physician's office to a laboratory (distance may be indicated) Sample collected at a Mobile collection unit or Physician office billed on a 1500 form as appropriate

 99211

(per CMS guidelines published on 4/30/20)

CMS has approved for specimen collection for new and established patients (normal use is Level 1 established patient office/outpatient E/M visit) Physician office ONLY when no other physician services are billed for the collection encounter
C9803 Specimen collection for severe acute respiratory syndrome coronavirus 2 (sars-cov-2) Facility Only including mobile unit UB claim billers
G2023 Specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) Independent Clinical Labs ONLY
G2024 Specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) from an individual in a SNF or by a laboratory on behalf of an HHA Independent Clinical Labs ONLY

  

 

COVID-19 Molecular Testing

The following codes have been created for providers and laboratories to allow billing for COVID-19 patient diagnostic tests. Highmark will reimburse each code at the contracted rate or Highmark established Fee Schedule for that service.

HCPC/CPT Code

Description

Who Can Use

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

Laboratories and physician offices

U0001

CDC 2019 novel coronavirus (2019-nCoV) real-time RT-PCR diagnostic panel

CDC testing laboratories

U0002

2019-nCoV coronavirus, SARS-CoV-2 (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC

Non-CDC testing laboratories
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 Labs using high through-put technology ONLY
U0004 2019-nCoV coronavirus, SARS-CoV-2 (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC, making use of high throughput technologies as described in CMS-2020-01-R Labs using high through-put technology ONLY

When filing the COVID-19 testing and office visits claims, only use one code for COVID-19 testing. Other services provided during the visit may be billed on the same claim but as a separate claim line with the appropriate CPT/HCPC codes. Testing collection code may bundle and not be separately reimbursed when billed with some other services as per standard edit procedure.

For additional coding guidance, CPT Assistant has provided a fact sheet for the SARS-CoV-2 (COVID-19) test in relation to the use of the new CPT code.

 

Antibody Testing

While serological tests are becoming more available, these tests have only received emergency use authorization. Serological tests are not standardized and the majority have not undergone FDA review and testing, so their reliability is unknown. Many of these tests could be cross-reactive with other viruses resulting in false positives for example. Finally, it is unknown what immunity antibodies provide to the novel coronavirus.  

The American Medical Association1 has warned doctors against using these tests designed to identify people already exposed to the coronavirus to make healthcare decisions for individual patients, and Highmark aligns with this guidance.

HCPC/CPT Code

Description

Who Can Use

86328

Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative, single step method (e.g., reagent strip); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) Laboratories and physician offices

86769

Antibody; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19])

Independent and facility labs

1 American Medical Association, “AMA cautions about limitations of antibody testing for SARS-CoV-2,” American Medical Association, May 14, 2020; https://www.ama-assn.org/press-center/press-releases/ama-cautions-about-limitations-antibody-testing-sars-cov-2.

Last updated on 12/21/2020

 

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