CurrentAnthemPolicy N/A

Coverage of COVID-19 Laboratory Testing Codes (Virginia Medicaid DMAS)

Updates to Virginia Medicaid (DMAS) coverage criteria and reimbursement requirements for selected COVID-19 laboratory test CPT/HCPCS codes, affecting providers and managed care organizations participating in Virginia Medicaid and FAMIS.

Policy Summary

PayerAnthem

PolicyCoverage of COVID-19 Laboratory Testing Codes (Virginia Medicaid DMAS)

Policy CodePolicy N/A

Change TypeUpdates, clarifications, and additions to coverage criteria

Effective DateN/A

Next Review DateN/A

Key ActionOrder and document provider-recommended COVID-19 tests that have FDA EUA or approval at the time of administration.

SourceLink

POLICY UPDATE CHANGES

Clinical criteria for coverage of 87426 were updated from the prior memo dated 11/5/2020.

Clinical criteria for coverage of U0003, U0004 and U0005 were clarified relative to prior memos.

Clinical criteria for coverage of 87635 were established.

4COVID-19 test codes updated/covered by this memo

1Max reimbursed tests per member per day

2 daysHigh-throughput CDLT turnaround

Coverage Criteria

General coverage criteria

Covered when ALL of the following are met:

Core clinical criteria: Test is recommended by a health care provider

Applies to 87426, U0003, U0004, U0005, 87635

Core clinical criteria: Test has FDA Emergency Use Authorization (EUA) or FDA approval at the time the test is administered

Applies to 87426, U0003, U0004, U0005, 87635

High-throughput testing criteria (U0005)

For U0005, coverage also requires ALL of the following:

High-throughput performance: COVID-19 Clinical Diagnostic Laboratory Test (CDLT) is completed in two (2) calendar days or fewer from the date of specimen collection

Policy Summary

PayerAnthem

PolicyCoverage of COVID-19 Laboratory Testing Codes (Virginia Medicaid DMAS)

Policy CodePolicy N/A

Change TypeUpdates, clarifications, and additions to coverage criteria

Effective DateN/A

Next Review DateN/A

Key ActionOrder and document provider-recommended COVID-19 tests that have FDA EUA or approval at the time of administration.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Applies to U0005 and labs using high-throughput technology

High-throughput performance: The majority of the laboratory's COVID-19 CDLTs performed using high-throughput technology in the previous calendar month were completed in two (2) calendar days or fewer for all patients2 days

Applies to U0005 and labs using high-throughput technology

No symptom-based eligibility is required for the COVID-19 test codes addressed in this policy. However, reimbursement is limited to one test per member per day for each covered code.

Tests that do not meet the stated clinical requirements — specifically those not recommended by a health care provider or those that do not have FDA Emergency Use Authorization (EUA) or FDA approval at the time the test is administered — are not eligible for reimbursement under this policy.

Covered Indications

Provider-recommended testing for SARS-CoV-2 using covered antigen or nucleic acid tests

Provider-recommended testing for SARS-CoV-2 using covered antigen or nucleic acid tests (no symptom-based limitations imposed):

Ordering requirement: Test is recommended/ordered by a health care provider

No symptom-based eligibility criteria will be imposed for the codes in this memo

Coding and Reimbursement Codes

Covered CPT/PLA CodesCPTCovered

87426

Infectious agent antigen detection by immunoassay technique; SARS-CoV-2.

Covered HCPCS Codes (high-throughput)HCPCSCovered

U0003	Infectious agent detection by nucleic acid (DNA or RNA); SARS-CoV-2, amplified probe technique using high throughput technologies.
U0004	2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes, non-CDC, making use of high throughput technologies as described by CMS-2020-01-R.

Covered HCPCS Codes (high-throughput with standards)HCPCSCovered

U0005

Infectious agent detection by nucleic acid (DNA or RNA); SARS-CoV-2, amplified probe technique, CDC or non-CDC, making use of high throughput technologies.

Covered CPT CodesCPTCovered

87635

Infectious agent detection by nucleic acid (DNA or RNA); SARS-CoV-2, amplified probe technique.

inv-09: Turnaround time for high-throughput CDLT

Turnaround time requirementCOVID-19 Clinical Diagnostic Laboratory Test (CDLT) must be completed in two calendar days or fewer from date of specimen collection.

Applies toU0005 and laboratories using high‑throughput technology.

Supporting performance metricMajority of the lab's high‑throughput COVID‑19 CDLTs in the previous calendar month must have been completed in two calendar days or fewer for all patients.

Definitions

inv-15: 87426

Code87426

DescriptionInfectious agent antigen detection by immunoassay technique; SARS‑CoV‑2 (qualitative or semiquantitative).

Coverage date11/5/2020

inv-16: U0003 / U0004 / U0005

CodesU0003, U0004, U0005

DescriptionNucleic acid detection (DNA or RNA) for SARS‑CoV‑2 using amplified probe technique and high‑throughput technologies per CMS definitions.

High‑throughput requirementU0005 claims must meet CDLT turnaround and monthly lab performance standards (see high‑throughput testing criteria).

inv-17: 87635

Code87635

DescriptionInfectious agent detection by nucleic acid (amplified probe technique) for SARS‑CoV‑2.

Coverage date3/13/2020

Frequency Limits

inv-19: All listed COVID-19 test codes

Maximum reimbursed tests1 test per member per day

Applies toAll listed COVID‑19 test codes (87426, U0003, U0004, U0005, 87635)

Symptom‑based limitationsNo symptom‑based criteria imposed for these codes at this time.

Provider Actions and Billing

Prior Authorization

No prior authorization requirement stated; reimbursement will be allowed when claims meet the specified requirements below.

Reimbursement limited to a maximum of one (1) test per member per day.
Providers should follow CMS guidance around COVID-19 testing during the PHE: https://www.cms.gov/files/document/clia-sars-cov-2-pointcare-test-enforcement-discretion.pdf

Note

Provider Action Highlight

Providers should ensure claims meet clinical and program requirements before submission. Resubmit claims that were previously denied for non-coverage if they now meet the updated coverage criteria.

For managed care members, contact the member's MCO for questions on coverage and resubmission procedures.
PLA codes should not be billed in conjunction with any other Category I AMA codes.

Documentation Required

Required Documentation

Documentation must show the test was recommended by a health care provider and that the test had FDA Emergency Use Authorization (EUA) or FDA approval at the time the test was administered. For U0005 (high-throughput testing), documentation must also support the lab's turnaround performance.

Evidence of provider recommendation must be retained in the medical record.
Record the test's EUA/approval status and administration date.
For U0005: clinical diagnostic laboratory test (CDLT) completed within two calendar days of specimen collection, and the laboratory's majority of high-throughput CDLTs in the prior calendar month were completed in two calendar days or fewer for all patients.

Denial Risk

Denial Triggers

Claims that do not meet the clinical or program requirements may be denied. Denial triggers include failure to document provider recommendation, lack of FDA EUA/approval at time of administration, exceeding the one-per-member-per-day limit, or not meeting U0005 high-throughput standards.

Claims lacking documentation of provider recommendation or EUA/approval may be denied.
Claims for more than one test per member per day may be denied.
U0005 claims that do not meet the two-calendar-day completion requirement or the laboratory performance standard may be denied.

Ordering Requirements

Step Therapy

Provider recommendation/ordering required

The test must be recommended or ordered by a health care provider for the claim to be reimbursable under this policy.

Not Covered

Tests that lack FDA EUA or FDA approval at the time of administration, or tests that were not recommended by a health care provider, are not covered and are not eligible for reimbursement.

Background

This policy covers SARS-CoV-2 antigen and nucleic acid tests represented by the codes listed in the memo. High-throughput nucleic acid tests (HCPCS codes such as U0003, U0004, and U0005) are subject to specific performance and turnaround expectations: for U0005, the COVID-19 Clinical Diagnostic Laboratory Test (CDLT) must be completed within two calendar days or fewer from the date of specimen collection, and a laboratory's majority of high-throughput CDLTs in the prior calendar month must also have been completed within two calendar days or fewer for all patients. Providers should follow CMS guidance on CLIA and point-of-care SARS-CoV-2 testing during the public health emergency.

Revision History

2021-07-01policy_updateLatest

DMAS updated clinical criteria: operationalized coverage conditions and reimbursement requirements for 87426, clarified criteria for U0003, U0004, U0005, and established clinical criteria for 87635 (effective for listed dates of service).

2021-02-01coverage_effective_date

Coverage conditions for U0005 effective 02/01/2021 as listed in updated coverage conditions for select COVID-19 testing codes.

2020-11-05coverage_effective_date

Coverage conditions for 87426, U0003, and U0004 effective 11/05/2020 as listed in updated coverage conditions for select COVID-19 testing codes.