ModifiedBlue Cross Blue Shield - Rhode IslandPolicy N/A

TEMPORARY Encounter for Determination of Need for COVID-19 Diagnostic Testing

Temporary BCBSRI policy waiving member cost-share for office, urgent care, emergency department, telehealth and telephone encounters that result in an order for or administration of COVID-19 diagnostic testing or determine the need for such testing. Applies to Commercial and Medicare Advantage products for specified dates of service.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyTEMPORARY Encounter for Determination of Need for COVID-19 Diagnostic Testing

Policy CodePolicy N/A

Change TypeModified — withdrawal dates added

Effective Date03/18/2020

Next Review DateN/A

Key ActionRefer to BCBSRI.com for current Authorization and Referral Guidelines requirements.

SourceLink

POLICY UPDATE CHANGES

Policy will no longer be in effect for Commercial Products beginning with dates of service on or after May 12, 2023 and for Medicare Advantage Plans on or after July 1, 2023.

03/18/2020Policy effective date

05/03/2023Policy last updated

05/12/2023Commercial end

07/01/2023Medicare Advantage end

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.

Cost-share Waiver Coverage Criteria

Cost-share waiver criteria

Criteria for no-cost-share treatment of qualifying encounters while policy is in effect:

Encounter type: An in-person, telemedicine/telehealth/telephone encounter, urgent care visit, or emergency department visit.

ALL of the following

The encounter must result in an order for, or administration of, a COVID-19 diagnostic test, OR be for determination of the need for such testing.
Waiver applies only to services that relate to furnishing the COVID-19 diagnostic test or to the evaluation to determine the need for such testing (services not related to the testing encounter are not eligible for the waiver).

ALL of the following

Accepted E/M codes: professional E/M services billed with CPT codes 99201-99215 or emergency department E/M codes 99281-99285 when filed with an applicable diagnosis from this policy will have no cost share.
Diagnosis requirement: For dates of service on or after 2020-08-01, when professional services are billed on a CMS-1500 (or electronic equivalent), one of the policy-listed diagnoses must be reported as the primary/first diagnosis on the line level for any service the provider determines is part of or related to the encounter for determination of COVID-19 testing to qualify for the cost-share waiver.

ALL of the following

Diagnosis list (examples in policy): B34.2; B97.21; B97.29; U07.1; Z03.818; Z11.52; Z11.59; Z20.822; Z20.828.

ALL of the following

Modifier rules
- For Medicare Advantage members, BCBSRI will accept modifier CS for qualifying medical visits furnished between March 18, 2020 and the end of the PHE that result in an order for or administration of a COVID-19 test and are related to furnishing or administering the test or evaluation to determine need.
- For Telemedicine/Telehealth/Telephone services for Medicare Advantage members, BCBSRI requires the CR modifier; adding CR for these services is recommended for tracking and consistency.

ALL of the following

Temporal limits: This is a temporary policy effective beginning March 18, 2020; services are covered with no cost share only while the policy is in effect (policy termination dates specified elsewhere).

Diagnosis and Procedure Coding Requirements

Covered E/M CPT CodesCPTCovered

99201-99215	Evaluation & Management Services
99281-99285	Emergency Department Evaluation & Management Services

Covered ICD-10 Diagnosis CodesICD-10Covered

B34.2	Coronavirus infection, unspecified
B97.21	SARS-associated coronavirus as the cause of diseases classified elsewhere
B97.29	Other coronavirus as the cause of diseases classified elsewhere
U07.1	COVID-19
Z03.818	Encounter for observation for suspected exposure to other biological agents ruled out
Z11.52	Encounter for screening for COVID-19
Z11.59	Encounter for screening for other viral diseases
Z20.822	Contact with and (suspected) exposure to COVID-19
Z20.828	Contact with and (suspected) exposure to other viral communicable diseases

Diagnosis placement requirement

RequirementFor dates of service on or after 2020-08-01, professional providers must list one of the policy’s specified diagnoses as the primary/first diagnosis on the line level of the CMS-1500 (or equivalent) for any service determined to be part of or related to the encounter for determination of COVID-19 testing in order for member cost-share to be waived.

Claim filing detailUse the diagnosis pointer so claims submitted are processed accurately; for line items not associated with the COVID-19 determination encounter, use the primary diagnosis for that service and the appropriate diagnosis pointer.

Applies toProfessional services billed on CMS-1500 or equivalent electronic format.

Provider Billing and Authorization Guidance

Prior Authorization

Prior authorization — check BCBSRI.com

Please refer to BCBSRI.com for the most current Authorization and Referral Guidelines to determine prior authorization requirements for services described in this policy.

Definitions and Modifier Guidance

Encounter for Determination of Need

DefinitionEncounter for Determination of Need: an in-person, telehealth/telemedicine, urgent care, or emergency visit to evaluate an individual for the purpose of determining the need for a COVID-19 diagnostic test.

ScopeIncludes visits that result in an order for or administration of a COVID-19 diagnostic test or services that relate to furnishing/administering the test.

Temporary policy timeframePolicy effective from 03/18/2020 while temporary; providers should follow Subscriber Agreement/Evidence of Coverage after policy termination dates.

Modifier guidance

Medicare Advantage modifier acceptanceBCBSRI will accept modifier CS for medical visits furnished to Medicare Advantage members between March 18, 2020 and the end of the Public Health Emergency when the visit results in an order for or administration of a COVID-19 test and is related to furnishing or evaluating for that test.