CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Payment Policy | COVID-19 Monoclonal Antibody Treatment and Antiviral IV Medications

Governs BCBSRI reimbursement and billing rules for COVID-19 monoclonal antibody therapies and certain IV antiviral medications for Medicare Advantage and commercial members during the policy timeframe.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyCOVID-19 Monoclonal Antibody Treatment and Antiviral IV Medications (Payment Policy)

Policy CodePolicy N/A

Change TypeNo material change

Effective Date01|01|2022

Next Review DateN/A

Key ActionDo not bill BCBSRI for listed drug codes when providers receive the product at no cost; follow CMS billing guidelines and bill BCBSRI for Medicare Advantage services effective 1/1/2022.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

No cost sharingno cost sharing

10-12 daystreatment window

>12minimum age

1/1/22MA billing date

4HCPCS codes

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.

No reimbursementno reimbursement if free

Coverage Criteria and Billing Rules

Coverage criteria and billing rules

Monoclonal antibody therapy and outpatient IV antiviral treatments for COVID-19 are covered under BCBSRI Medicare Advantage and Commercial products when the following coverage and billing rules are met. Cost sharing is waived for monoclonal antibody drugs and related administration services for the timeframe this policy is in effect.

ALL of the following

Positive COVID-19 test result (laboratory-confirmed)
Applies to monoclonal antibody therapy for mild-to-moderate COVID-19.
Age > = 12 years
Per clinical eligibility for monoclonal antibody therapies unless specific product labeling differs.
Clinical high risk for progression to severe COVID-19 and/or hospitalization
Provider must document risk factors in the medical record.
Administration given within 10–12 days of symptom onset as applicable to product EUA/labeling
Patient not currently hospitalized for COVID-19
Policy covers outpatient administration.

Reimbursement criteria when products supplied at no cost

Reimbursement rules when monoclonal antibody or antiviral products are supplied to providers at no cost. These rules outline when drug and supply codes will be reimbursed or denied and provide code-level guidance for billing.

ALL of the following

If a product is supplied to the provider at no cost, BCBSRI will not reimburse the drug/NDC line item when billed to BCBSRI
Providers may not receive reimbursement for the drug itself when product was provided at no cost; member has no cost share liability.
Providers who elect to submit a claim for the drug code should append modifier 22 to indicate the drug was purchased by the provider
Modifier 22 is recommended to indicate increased procedural services when applicable.
Administration and infusion codes for covered products are separately reimbursed when effective dates and payer-specific CMS guidance allow (see code-specific guidance)

Codes and Coding Guidance

Monoclonal antibody and related administration codesCPT | HCPCS | mixedCovered

M0220	Administration of tixagevimab and cilgavimab (various guidance by plan and timeframe)
M0221	Administration of tixagev and cilgavimab, intramuscular injections (Covered and Separately Reimbursed effective 1/1/22)
M0222	Intravenous injection, bebtelovimab, includes injection and post administration monitoring (Covered and Separately Reimbursed; Medicare Advantage effective 2/11/22)
M0223	Intravenous injection, bebtelovimab in the home, includes injection and post administration monitoring in the home or residence (Covered and Separately Reimbursed; Medicare Advantage effective 2/11/22)
M0239	Intravenous infusion, bamlanivimab-xxxx, includes infusion and post administration monitoring (Per CMS billing guidelines submit to Original Medicare 11/20/20-4/16/21; Not covered for DOS on or after 4/17/21)
M0240	Intravenous infusion or subcutaneous injection, casirivimab and imdevimab, includes infusion or injection and post administration monitoring (Per CMS billing guidelines submit to Original Medicare 11/09/20-12/31/21; Covered and Separately Reimbursed effective 1/1/22)
M0241	Infusion/injection casirivimab and imdevimab in home, includes infusion/injection and post administration monitoring in the home or residence (Per CMS billing guidelines submit to Original Medicare 11/09/20-12/31/21; Covered and Separately Reimbursed effective 1/1/22)
M0243	Intravenous infusion, casirivimab and imdevimab, includes infusion and post administration monitoring (Per CMS billing guidelines submit to Original Medicare 11/09/20-12/31/21; Covered and Separately Reimbursed effective 1/1/22)
M0244	Infusion/injection casirivimab and imdevimab in home, includes infusion or injection and post administration monitoring in the home or residence (Per CMS billing guidelines submit to Original Medicare 11/09/20-12/31/21; Covered and Separately Reimbursed effective 1/1/22)
M0245	Intravenous infusion, bamlanivimab and etesevimab, includes infusion and post administration monitoring (Per CMS billing guidelines submit to Original Medicare 11/09/20-12/31/21; Covered and Separately Reimbursed effective 1/1/22)

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Monoclonal antibody and antiviral HCPCS/Codes referencedHCPCSCovered

Q0245	Injection, bamlanivimab and etesevimab, 2100 mg
Q0247	Injection, sotrovimab, 500 mg
Q0249	Injection, tocilizumab, for hospitalized COVID-19 patients, 1 mg
J0248	Injection, remdesivir, 1 mg

CMS submission window for Medicare Advantage (2020–2021)

CMS submission window (MA, 2020-2021)Per CMS billing guidelines, for dates in 11/09/20–12/31/21 certain monoclonal antibody administration and related vaccine codes for Medicare Advantage enrollees were to be submitted to Original Medicare (Do Not Bill BCBSRI).

Post-window billing (effective 1/1/22)Effective 1/1/22 providers should bill BCBSRI for Medicare Advantage Plan services for the listed administration codes (covered and separately reimbursed as noted).

Examples of affected administration codesM0220, M0221, M0239, M0240 and related Q-codes had CMS submission instructions for the 11/09/20–12/31/21 period (see code listings for specifics).

Effective date notes

11/09/2020–12/31/2021 guidancePer CMS billing guidelines, for the period 11/09/20–12/31/21 certain monoclonal antibody administration and product codes were to be submitted to Original Medicare (Do Not Bill BCBSRI).

Provider Actions and Billing Pathways

Prior Authorization

Prior Authorization: Not applicable.

Billing Rule

Billing pathway for Medicare Advantage

Medicare Advantage Plans: Per CMS billing guidance for 2020–2021, vaccine and COVID-19 vaccine administration codes were to be submitted to Original Medicare for members enrolled in Medicare Advantage. Effective 1/1/2022, providers should bill Blue Cross Blue Shield of Rhode Island (BCBSRI) for Medicare Advantage plan services.

CMS billing guidance: submit vaccine and administration codes to Original Medicare for 2020–2021
Effective 1/1/2022: Bill BCBSRI for Medicare Advantage services

Definitions and Terms

Monoclonal antibodies

DefinitionMonoclonal antibodies are laboratory-made proteins that mimic the immune system's ability to fight harmful antigens such as viruses.

Example (bamlanivimab)Bamlanivimab is a monoclonal antibody directed against the SARS‑CoV‑2 spike protein intended to block viral attachment and entry into human cells.

Policy classificationMonoclonal antibody products are considered COVID-19 vaccines per CMS for billing purposes during the public health emergency.

Emergency Use Authorization (EUA) — bamlanivimab

EUA issuance (bamlanivimab)On 11/09/2020 the FDA issued an Emergency Use Authorization (EUA) for bamlanivimab for treatment of mild-to-moderate COVID-19 in high-risk adults and pediatric patients.

Limitations of use under EUA

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyCOVID-19 Monoclonal Antibody Treatment and Antiviral IV Medications (Payment Policy)

Policy CodePolicy N/A

Change TypeNo material change

Effective Date01|01|2022

Next Review DateN/A

Key ActionDo not bill BCBSRI for listed drug codes when providers receive the product at no cost; follow CMS billing guidelines and bill BCBSRI for Medicare Advantage services effective 1/1/2022.

SourceLink

On This Page

For Medicare Advantage members, follow CMS claims filing guidelines where specified (certain dates/codes required submission to Original Medicare rather than BCBSRI)

Examples in policy: M0220/M0221 submissions per CMS guidance during 11/09/20–12/31/21 and other specified date ranges; follow CMS direction for Original Medicare submission when indicated.

Specific HCPCS/Q-codes: some Q- and M- codes are marked 'Covered and Separately Reimbursed' effective 1/1/22 (e.g., Q0220/Q0221/Q0222/Q0247/Q0249/J0248 when not supplied at no cost) and paired codes indicating 'no reimbursement' when products are received at no cost

Refer to coding section for exact code-to-status mapping and effective dates.

When CMS guidance requires submission to Original Medicare (do not bill to BCBSRI) for specified date ranges, providers must follow those instructions to avoid denials

See coding/case examples in policy for dates and affected codes.

Effective 1/1/2022Effective 1/1/22 many monoclonal antibody and antiviral HCPCS/CPT codes are Covered and Separately Reimbursed by BCBSRI for commercial and Medicare Advantage plans (unless product received at no cost).

Remdesivir specific dateJ0248 (remdesivir) - CMS guidance indicates submit to Original Medicare for certain earlier dates; effective 12/23/21–1/1/22 it is listed as Covered and Separately Reimbursed thereafter per notes.

Billing Rule

Billing action when product supplied at no cost

Monoclonal antibody drugs received by providers at no cost: Do not bill BCBSRI for the drug product line-item when the monoclonal antibody drug was supplied to the provider at no cost. If a provider submits a claim for the drug code, the drug line will be denied as provider liability with no member liability. Providers should append modifier 22 to the monoclonal antibody drug codes listed to indicate the drug was purchased by the provider when applicable. Specific coding notes: Q0245 (bamlanivimab and etesevimab 2100 mg), Q0247 (sotrovimab 500 mg), Q0249 (tocilizumab per inpatient COVID-19 indication) — Effective 11/09/2020–12/31/2021 submit to Original Medicare for Medicare Advantage members; effective 1/1/2022 these codes are covered and separately reimbursed by BCBSRI when not supplied at no cost.

Do not bill BCBSRI for monoclonal antibody drug codes when product received at no cost
If billed, drug line item will deny as provider liability with no member liability
Append modifier 22 when provider purchased the monoclonal antibody drug
Codes referenced: Q0245, Q0247, Q0249

Bamlanivimab under EUA was not authorized for hospitalized patients due to COVID-19 or those requiring oxygen therapy; administration must be in settings with immediate access to treatment for severe infusion reactions.

EUA revocation contextOn 04/16/2021 the FDA revoked the EUA for bamlanivimab when administered alone due to increased prevalence of resistant SARS‑CoV‑2 variants; the known and potential benefits no longer outweighed risks.

Covered and Separately Reimbursed — definition/context

MeaningCovered and Separately Reimbursed indicates the drug and its administration are eligible for coverage and the drug line item is reimbursed separately from the administration fee effective the noted date (e.g., Effective 1/1/22 for many codes).

Examples of codes with this statusM0221, M0222, M0240, Q0245, Q0247, Q0249 and J0248 are listed as Covered and Separately Reimbursed effective on the dates shown in the policy text.

Plan applicabilityApplies to Commercial Products and, after the CMS submission window closed, to Medicare Advantage Plans per the effective dates listed in the policy document.

No reimbursement when product supplied at no cost

Core ruleIf health care providers receive monoclonal antibody or antiviral products at no cost, BCBSRI will not reimburse claims for the product line item (no reimbursement to provider; member not liable).

Claim handlingProviders may submit a claim for the drug code but the drug line will be denied as a provider liability with no member liability when the product was provided at no cost.

Modifier guidanceProviders should append modifier 22 to monoclonal antibody drug codes when the provider purchased the monoclonal antibody drug (per policy note).