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Billing Requirements for Administrative Policy AP-26 – COVID-19 Viral and Antibody Testing; Reimbursement Information

Audience: Physicians, Hospitals, Facilities and Laboratories

Excellus BlueCross BlueShield implemented Administrative Policy AP-26 COVID-19 Viral and Antibody Testing effective March 13, 2020, to define the coverage, reimbursement and billing guidelines for this testing when it is determined to be medically appropriate for the diagnosis and treatment of an individual by an attending provider as evidenced by an order from the attending provider.  The tests must be approved by the Food and Drug Administration or the subject of an emergency use order request, and the lab performing the testing must be appropriately certified.   

This policy is in line with Centers for Medicare & Medicaid Services, Current Procedural Terminology (CPT), and Healthcare Common Procedure Coding System (HCPCS) guidelines and applies to all lines of business. 

Billing Requirements

The following provides claim billing requirements for COVID-19 testing effective August 17, 2020:  

Administrative Policy 26 – COVID-19 Viral and Antibody Testing:

  • The referring or attending provider’s information must be completed on all submitted claim forms. This is Box 17 on the CMS- 1500 claim form and Box 76 on the CMS UB-04 form
  • Referring/attending providers are limited to physicians, nurse practitioners, physician assistants, and pharmacists. For Medicare Advantage members, a referring/attending provider is any provider who is authorized to order lab tests under New York state law.

This policy will be reviewed pre-payment and post-payment. Pre-payment review means that claims are reviewed prior to payment. A pre-payment review results in an initial determination. Post-payment review means that claims are reviewed after adjudication. A post-payment review may result in either no change to the initial determination or a revised determination.   Pre-payment and post-payment reviews are to ensure claim/billing accuracy and completeness and are not medical necessity reviews.
These services are subject to audit and policy updates at the Health Plan’s discretion. You can access the individual policies at Note: You must login with your username and password to access our administrative policies.

If you are not currently registered to view the secure section of our website, we encourage you to register today. If you need assistance registering, contact the Web Security Help Desk at 1-800-278-1247. In addition, your Provider Relations representative is available to assist with website registration and functionality training. 

Reimbursement Information

The following information explains Excellus BCBS’s reimbursement methodology for COVID-19 diagnostic and antibody testing codes in circumstances where contractual pricing does not apply.

  • For the Safety Net line of business/products (HMOBlue Option, Blue Choice Option, Premier Option, Blue Option Plus, Premier Option Plus, Child Health Plus and Premier Child Health Plus, Healthy NY and the Essential Plan), the Health Plan will mirror New York State Medicaid rates. When NYS Medicaid does not have an established rate, the Health Plan will use the reimbursement rate used by the Centers for Medicare & Medicaid Services (CMS).   
  • For all other products and lines of business, the Health Plan will mirror the reimbursement rates used by CMS. 

We will re-evaluate our reimbursement methodology for COVID-19 testing in September. 

We encourage you to review our administrative policy and our June 8, 2020 communication for additional details related to the coverage of COVID-19 diagnostic and antibody testing. 

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