Posted in EmblemHealth NY, NY Providers, Training, Updates

EmblemHealth NY: Covid 19 Testing reimbursement policy update 06/01/22

If your office accepts emblemhealth members and provides COVID-19 testing services, then this blog post is for you!

COVID-19 Tests:

There are 3 main types of tests for COVD-19 (SARS-CoV-2) virus- diagnostic (viral), antigent test and serologic test (antibody.

A diagnostic (molecular and antigen tests tells if you likely have a current infection, by looking for parts of the virus itself in samples taken from an individual’s respiratory system secretion (eg. nasal swab).

A serologic, or anitybody test tells you if you have had a previous infection of COVID-19 by looking at the antibody responses in the blood sample. (In general a serologic test cannot be used for a diagnostic purposes. Antibodies can be detected in individuals that had a distant infection of the virus)


The following policy applies to Commercial, Medicare and Medicaid lines of business: via EmblemHealth Policy#: RPC20210016

Per the CDC, “Cliniciansshould use their judgment to determine if a patient hassigns orsymptoms compatible with COVID-19 and whether the patient should be tested. Most patients with confirmed COVID-19 have developed fever and/or symptoms of acute respiratory illness (e.g., cough) but some infected patients may present with other symptoms as well.”
▪ Symptomatic individual suspected of having COVID-19.
▪ Testing of asymptomatic patients used as part of a pre-surgical or facility pre-admission screening,
prior to an immunosuppressive procedure, or when a patient is admitted to a Skilled Nursing
Facility in accordance with CMS and CDC testing guidelines.
▪ Known or suspected prolonged, close contact, with an individual with a laboratory confirmed case
of COVID-19 as defined by CDC guidelines.
▪ Coronavirus COVID-19 (SARS-CoV-2) respiratory panel (up to 5 respiratory pathogens) test when
member has signs and symptoms of COVID-19.


SARS-CoV-2 Serology Testing
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) serology (antibody) testing may beconsidered a covered service when the following criteria are met:
▪ An individual seeks and receives a COVID-19 diagnostic test from a licensed or authorized health care provider, OR
• A licensed or authorized health care provider refers an individual for a COVID-19
diagnostic test. AND
▪ FDA approved or cleared or Emergency Use Authorization (EUA) AND
▪ Performed by a CLIA-accredited high or medium-complexity laboratory (per test Instructions for Use) AND
One of the following three conditions is present:
▪ Results of a molecular or antigen test is non diagnostic for COVID-19 and the results of the test will be used to aid in the diagnosis of a condition related to COVID-19 infection (e.g., Multisystem Inflammatory Syndrome [MIS]). OR
▪ Used as a method to support the clinical assessment of acute COVID-19 illness for persons who are being tested 3–4 weeks after illness onset, in addition to recommended direct detection methods such as polymerase chain reaction (PCR). OR
▪ Used as a method to help establish a clinical picture when patients have late complications of COVID-19 illness, such as multisystem inflammatory syndrome in children.


Coding/Billing Information:
Effective 6/1/2022 – EmblemHealth and ConnectiCare will amend the billing
instructions to align with CMS’ instructions on how to bill for COVID-19 test related
services. The plan will require the use of modifier CS when identifying services that
are related to the need determination for a COVID-19 test.

Partial List of CPT/HCPCS codes:

*NY Medicaid covered codes may differ and follow NYS guidelines
CPT/HCPCS Description
U0001* CDC 2019 Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel
U0002(QW) 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes(includes all targets), non-CDC
U0003 Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) amplified probe technique, making use of high throughput technologies as described by CMS-2020-01-R
U0004 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC, making use of high throughput technologies as described by CMS-2020-01-R
U0005- 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, CDC or non-CDC, making use of high throughput technologies, completed within 2 calendar days from date and time of specimen collection.(List separately in addition to either HCPCS code U0003 or
U0004)
0224U -Antibody, severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID19]),includes titer(s), when performed
0240U- Infectious disease (viral respiratory tract infection), pathogen-specific RNA, 3 targets (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2], influenza A, influenza B), upper respiratory specimen, each pathogen reported as detected or not detected (Xpert® Xpress SARSCoV-2/Flu/RSV (SARS-CoV-2 & Flu Targets only), Cepheid)
0241U-Infectious disease (viral respiratory tract infection), pathogen-specific RNA, 4 targets (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2], influenza A, influenza B, respiratory syncytial virus [RSV]), upper respiratory specimen, each pathogen reported as detected or not detected (Xpert® Xpress SARSCoV-2/Flu/RSV(all targets), Cepheid)
86328- Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative, single step method (eg, reagent strip); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19])

For a complete list of codes, please click here for the complete reimbursement policy.


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Posted in #Medicareadvantage, #unitedhealthcare, Training, Updates

UHC: Payment for COVID-19 testing coverage, outpatient SNF

Previously, UHC would not reimburse for COVID-19 testing when done outside of a skilled inpatient stay at a SNF.

However, during the PHE, starting Jan 27,2020 and then renewed on April 21,2021, subject to further extension, UHC is going to pay for the COVID-19 testing that is done outside of the skilled inpatient stay at a SNF.


This change applies to the following Medicare Advantage Plans:

  • Medicare Advantage Plans
  • Dual Eligible Special Needs Plans (DSNP)
  • Chronic Special Needs Plans (CSNP)
  • UnitedHealthcare Assisted Living Plans (IE-SNP)
  • FIDE/MMP Plans

Plans that this change DOES NOT APPLY TO:

  • UnitedHealthcare Nursing Home Plans (ISNP)
  • UnitedHealthcare commercial plans
  • UnitedHealthcare Community Plans (Medicaid Only Plans)

UHC will re-process the claims, there is no further action needed.

UHC will reprocess claims previously paid at $0 to be reimbursed at 100% of the Medicare fee schedule. No action is required from affected SNFs for these adjustments.


The following codes are going be reimbursed at 100% of Medicare Fee Schedule:

Reminder!

COVID-19 testing performed during an approved skilled stay are subject to Centers for Medicare and Medicaid Services (CMS) consolidated billing rules and are not separately reimbursable, except for the UnitedHealthcare Nursing Home Plan (ISNP). New applicable CMS covered COVID-19 testing codes may be added periodically. We may add or remove codes from the following list, in accordance with CMS coverage guidelines.


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Posted in MVP (NY/VT) Insurance Payer, Training, Updates

MVP (NY/VT): COVID-19 Treatment and Virtual Care, Cost-Share Update

Below policy will apply to MVP plans that are located in New York and Vermont.

New York Virtual Care Cost-Share: Telemedicine

For MVP Medicare Advantage Plans- MVP will continue to apply the cost sharing waver for audio/visual and audio only until the DOS (dates of service) Dec 31,2021.

For MVP Commercial Plans- Starting August 1,2021 and thereafter the patients will have to pay their “in-person visit” cost-share for audio/visual and audio only visits according to their plan details.


Vermont Virtual Care Cost-Share: Telemedicine

For MVP Medicare Advantage Plans- MVP will continue to apply the cost sharing waver for audio/visual and audio only until the DOS (dates of service) Dec 31,2021.

For MVP Commercial Plans- Starting August 1,2021 and thereafter the patients will have to pay their “in-person visit” cost-share for audio/visual and audio only visits according to their plan details.


New York Covid-19 Treatment member Cost-Share:

Effective August 1, 2021, MVP will no longer waive the cost-share for COVID-19 treatment.


***Vermont Covid-19 Treatment member Cost-Share: ***

MVP will continue to cover COVID-19 treatment in full until March 1, 2022 as is required by
Vermont Rules.



COVID-19 Testing Member Cost-Share: NY &VT

MVP will continue to cover COVID-19 testing in full in New York and Vermont


COVID -19 Testing Coding and Billing Corner:

As of January 1, 2021 claims billed with a diagnosis code Z03.818 in conjunction with a COVID19 testing procedure code will be denied

MVP will retain the expanded set of codes eligible for telehealth, consistent with CMS guidance, and will continue to monitor state and federal guidelines and regulations. In addition, MVP supports continued telehealth reimbursement and is currently reviewing coding guidance.


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