One procedure code reimbursed per date of service

Only one procedure code reimbursed per date of service for the same clinical indication; when multiple COVID-19 test CPT/HCPCS codes are submitted for the same patient, date of service, and indication, reimbursement is limited to a single eligible test per date of service.

• Affected codes (examples): 87635, 87426, 87811, 86318, 0001U

Specimen collection incidental

Specimen collection is considered incidental to the laboratory test(s) and is not paid separately unless a separately payable collection code is specifically allowed by the member's benefit or by contract.

• Specimen collection is incidental — do not bill separately in routine outpatient testing

Pooling limitations

Pooling of specimens may be permissible only where explicitly supported by the test's EUA/IFU and only when pooling is performed by the laboratory per validated methods; limits on pool size and patient populations apply. Claims for pooled testing may be denied if pooling exceeds allowable pool sizes or is performed contrary to EUA/IFU.

• Pooling limitations: adhere to EUA/IFU; common pool-size limits (e.g., pools of 4–5) vary by assay

Test-specific platform requirements

Some NAAT or antigen codes may be restricted to specific platforms or test methods per the manufacturer's EUA and payer rules. Verify that the billed code matches the testing method and that the platform is authorized for the specimen type and intended use.

• Test-specific platform requirements: ensure billed code matches EUA/IFU platform authorization

NAAT vs antigen guidance (codes)

NAATs and antigen tests have different codes and clinical uses. Use the appropriate code for the test performed; reimbursement follows coverage for the specific modality. Antigen testing is generally for symptomatic individuals and NAATs for diagnostic confirmation or higher-sensitivity needs.

• NAAT codes: 87635 (SARS-CoV-2 NAAT)
• Antigen/point-of-care codes: 87426, 87428, 87811

Limitations based on benefit coverage

Coverage and documentation must reflect the benefit limitations and patient eligibility; confirm that testing meets the policy's clinical indications (symptoms, exposure, MIS-C/MIS-A evaluation, PASC, or other covered reasons) before submitting claims.

• Limitations based on benefit coverage: document clinical indication and member benefit eligibility

Antigen test negative results are presumptive

A negative antigen test result in a symptomatic person is considered presumptive and may require confirmation with a NAAT (molecular) test based on clinical judgment and policy guidance.

• Antigen test negative results are presumptive — consider confirmatory NAAT in symptomatic individuals

Antigen/serology timing considerations

Timing of antigen and serology testing affects interpretation. Antigen tests perform best early in symptomatic infection; serology is most informative ≥14 days after symptom onset and is not useful for diagnosing acute infection.

• Antigen/serology timing considerations: antigen — early symptomatic period; serology — ≥14 days post-symptom onset

Panel test limitations and follow-up

Multiplex respiratory panel tests are limited by this policy (covered up to 5 targets for symptomatic respiratory infections). Larger panels or broad panel testing may not be covered and may necessitate targeted testing or follow-up testing when clinically indicated.

• Panel test limitations and follow-up: multiplex PCR panels ≤5 targets covered; panels ≥6 targets not covered — consider targeted testing or follow-up NAATs

Specimen type selection and documentation

Document specimen type and source clearly in the medical record and on the claim as some assays are authorized only for specific specimen types; incorrect specimen type may place the claim at risk for denial.

• Specimen type selection and documentation: record source (NP, nasal swab, saliva, etc.) and ensure assay EUA/IFU supports chosen specimen

Use of antibody testing

Antibody (serology) testing is useful for supporting diagnosis of MIS-C/MIS-A or assessing past infection in specific clinical contexts but is not appropriate for acute diagnosis of active infection or for general population screening under this policy.

• Use of antibody testing: covered for MIS-C/MIS-A and PASC evaluation when clinically indicated; not for acute diagnosis

Use of Ag-RDTs per WHO

Use of Ag-RDTs should follow WHO recommendations for point-of-care antigen-detecting rapid diagnostic tests, including proper patient selection (symptomatic persons within appropriate time window) and adherence to IFU to reduce false results.

• Use of Ag-RDTs per WHO: follow WHO guidance on appropriate use and IFU compliance

Isolation/testing guidance

Isolation and testing guidance should follow public health recommendations; testing may be indicated to inform isolation duration or return-to-work decisions when aligned with clinical and public health criteria.

• Isolation/testing guidance: align testing with current public health and CDC guidance for isolation and return-to-work

MIS-C initial evaluation and testing

For suspected MIS-C, document clinical criteria (fever, multisystem involvement, inflammatory markers) and obtain initial screening labs and SARS‑CoV‑2 testing per CDC guidance; include documentation of criteria and tests performed in the medical record.

• MIS-C initial evaluation and testing: document clinical criteria and initial labs (CRP, ESR, CBC, d-dimer, ferritin, troponin) and SARS‑CoV‑2 NAAT/serology as indicated

Specimen selection and timing

Select specimens and timing consistent with the test's performance characteristics and EUA/IFU. For highest sensitivity, collect appropriate upper respiratory specimens early in symptomatic disease for antigen tests and as directed for NAATs; serology timing should reflect expected antibody kinetics.

• Specimen selection and timing: follow EUA/IFU for specimen type and optimal collection window (e.g., early nasal/NP for antigen; ≥14 days for serology)

Specimen and indication constraints — denial risk

Claims for testing may be at risk when tests are used in populations or with specimen types not authorized by the EUA/IFU, or when clinical indications fall outside covered scenarios. Verify EUA authorization and document medical necessity to mitigate denial risk.

• Specimen and indication constraints: do not use tests outside EUA/IFU populations or specimen types; document medical necessity