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Updated Federal Guidance Related to COVID-19 Viral and Antibody Testing

Audience: Physicians, Hospitals, Facilities and Laboratories

The Health Plan implemented Administrative Policy AP-26, COVID-19 Viral and Antibody Testing and Supplies, at the start of the pandemic to define coverage, reimbursement, and billing guidelines for COVID-19 viral and antibody testing, consistent with the Families First Coronavirus Response Act and Coronavirus Aid, Relief and Economic Security Act (CARES Act), as well as the Centers for Medicare & Medicaid Services, Current Procedural Terminology, and Healthcare Common Procedure Coding System guidelines.

On February 26, 2021, the Departments of Labor, Health and Human Services, and the Treasury issued new guidance about the coverage of COVID-19 testing in asymptomatic individuals who have had no known or suspected exposure to COVID-19. To review the frequently asked questions document and accompanying press release, visit https://www.cms.gov/files/document/faqs-part-44.pdfOpen an External PDF.

This guidance provides that the COVID-19 testing of asymptomatic individuals with no known or suspected exposure to the virus should be covered in full, except when the test is conducted for pandemic control (e.g., testing required by the government, an employer, school, camp, etc.).  This guidance is effective February 26, 2021, and pertains to all lines of business, including individuals with coverage through a self-funded employer group.

What this means for your practice/facility

  • All COVID-19 viral and antibody testing and related services provided or referred by a health care provider to an asymptomatic individual with no known or suspected exposure to the virus will be covered in full with no cost-share, with the exception of testing conducted solely for the purpose of surveillance or pandemic control, which is not covered by the Health Plan. 
  • COVID-19 testing conducted as part of a lab panel for pre-operative reasons or otherwise will be covered in full, with all other tests within the panel subject to cost-share, depending on the member’s benefit.
  • This guidance applies to COVID-19 testing claims in any state of processing/adjudication as of February 26, 2021, and to all new COVID-19 claims filed on or after that date. Any affected claims that process between February 26, 2021, and the date that system updates are completed in late March will be reprocessed to conform with the new guidance.
  • COVID-19 testing claims must include a “referring provider” indicating the attending provider who performed or ordered the testing.  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.
  • These services are subject to audit and policy updates at the Health Plan’s discretion. 
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