ORDER REGARDING CRITERIA FOR COVID-19 TESTING FOR SYMPTOMATIC AND ASYMPTOMATIC PERSONS
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Administrative Order establishing criteria requiring availability of COVID-19 testing for persons who work in high-risk settings, persons at high risk for complications, or persons recently exposed, and permitting testing without a clinician order up to once every 7 days during the public health emergency.
No material clinical or coverage changes in this revision.
Coverage Criteria
Eligible persons for COVID-19 testing
Covered when ANY of the following conditions are met:
No clinician order or prior medical necessity determination required during the public health emergency.
This Order remains in effect only during the period of the Public Health Emergency declared by the Mayor and may be rescinded or superseded earlier if so ordered. Providers should apply the testing availability rules and relaxed ordering requirements only for the duration of that emergency declaration or until a subsequent directive replaces this Order.
Covered Indications
Testing for SARS-CoV-2 infection for persons who work in high-risk congregate settings; persons at high risk for complications; and asymptomatic persons recently exposed
Testing is covered for these indications with the stated frequency limit:
Coverage conditions
- Frequency limit: Testing may be provided no more than once per seven (7) day period.
- Ordering requirement: No physician or other health care provider order or prior determination of medical necessity is required for eligible persons during the public health emergency.
Frequency Limits
Provider Actions and Operational Notes
Prior authorization waived for eligible persons
Prior determination of medical necessity or a clinician order is not required for persons who work in high‑risk settings, are at high risk for complications from COVID‑19, or were recently exposed; testing may be provided up to once every seven (7) days during the public health emergency.
Provider must follow Order for eligible persons
No additional provider action text was specified in the inventory item; follow the Order's requirements for eligible persons (testing availability and no clinician order up to once per seven days).
Order/Documentation requirement
No physician or other health care provider order is required for eligible persons to receive testing no more than once per seven (7) day period during the public health emergency.
- Testing may be performed without prior determination of medical necessity by an attending provider.
- Frequency limit: no more than once per seven (7) day period.
Denial triggers if eligible persons are not tested
Testing shall be made available to eligible persons; there is a denial risk if testing is not provided to persons who work in high‑risk settings, are at high risk for complications, or were recently exposed.
- Eligible persons include workers in high‑risk congregate settings, persons at high risk for complications, and recently exposed asymptomatic persons.
- Failure to provide testing up to once per seven (7) days to these groups would risk denial or non‑compliance with the Order.
Ordering Requirements
Ordering requirements — who can order
No physician or other health care provider order is required for eligible persons during the public health emergency; eligible persons may present for testing without an attending provider’s order.
- Who can order: Not required — individuals meeting eligibility criteria may be tested without a provider order during the public health emergency.
Definitions
Background
The Order identifies populations at increased risk for contracting or experiencing complications from COVID-19, including residents and workers in high-risk congregate settings (for example, long-term care, skilled nursing facilities, assisted living residences, intermediate care facilities, community residential facilities, detention centers, homeless shelters, and dormitories/residence halls) and persons with underlying health conditions that raise risk for severe disease (examples include cancer, chronic kidney disease, COPD, immunocompromised state from solid organ transplant, Type 2 diabetes, serious heart conditions, sickle cell disease, and obesity). The Order also covers asymptomatic persons recently exposed to someone diagnosed with COVID-19, recognizing that such individuals may transmit infection and that routine access to testing supports identification of cases and prevention of spread.
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