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 6:06:07 PM