Coverage for COVID-19 (SARS-CoV-2) testing
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This bulletin sets the Division of Insurance expectations for commercial carriers operating in Massachusetts about coverage, prior authorization, cost-sharing, and related requirements for COVID-19 PCR, antigen, and antibody testing for insured members.
No material clinical or coverage changes in this revision.
Coverage Criteria and Indications
Division coverage expectations
Coverage expectations stated by the Division:
Specimen collection and laboratory processing costs associated with COVID-19 should be reimbursed at a rate greater than the MassHealth rate when individually reimbursed.
The Division requires carriers to relax out-of-network requirements only when in‑network access to testing or urgent treatment is unavailable and such relaxation is consistent with DPH and CDC requirements. When in‑network testing is unavailable, carriers should permit out‑of‑network access for testing or urgent treatment and apply the same out‑of‑network relaxation described in the bulletin. The Division also expects carriers to forego any cost‑sharing (copayments, deductibles, or coinsurance) for medically necessary COVID‑19 testing, counseling, and vaccinations at in‑network facilities and at out‑of‑network facilities when in‑network access is unavailable, per DPH/CDC guidance.
Pursuant to M.G.L. c.176O, carriers may develop and apply medical necessity criteria and utilization review systems to COVID‑19 testing. Carriers that are accredited managed care companies may employ utilization review techniques (for example, ambulatory review, prospective review, second opinion, certification, concurrent review, case management, discharge planning, or retrospective review) to determine clinical necessity. Tests that do not meet an established medical necessity criterion may be denied as not medically necessary.
Any symptom of COVID-19 or known exposure to COVID-19 for PCR or antigen testing — covered indications
Covered when ALL of the following are met:
Covers PCR and antigen tests designed to detect the novel Coronavirus.
Specimen collection and laboratory processing costs should be reimbursed at a rate greater than MassHealth when billed individually.
Specific Covered Indications
Any symptom of COVID-19 or known exposure to COVID-19 for PCR or antigen testing
Covered when ALL of the following are met:
Applies to PCR and antigen tests.
Carriers' applicable specimen collection and lab processing practices shall otherwise apply.
Provider Actions, Prior Authorization, and Utilization Review
No prior authorization for PCR and antigen tests
The Division expects carriers to eliminate prior approval requirements for antigen and PCR testing for COVID-19 in accordance with DPH and CDC guidelines.
Permitted utilization review systems
Carriers may develop utilization review systems to evaluate clinical necessity for COVID-19 tests, including ambulatory review, prospective review, second opinion, certification, concurrent review, case management, discharge planning, or retrospective review, provided the systems comply with M.G.L. c.176O and applicable regulations.
- Ambulatory review
- Prospective review
- Second opinion
- Certification
- Concurrent review
- Case management
- Discharge planning
- Retrospective review
Utilization review may trigger denial
Carriers may employ utilization review and medical necessity criteria when making coverage decisions for COVID-19 tests; tests not meeting those criteria may be deemed not medically necessary and denied consistent with M.G.L. c.176O.
Communicate and post medical necessity guidelines
If carriers establish medical necessity criteria for COVID-19 testing, they should explain relevant testing provisions and procedures to members and all network providers and keep guidance up-to-date and accessible as required under M.G.L. c.176O.
- Inform members and network providers of testing requirements before services are provided
- Post up-to-date medical necessity guidelines on the carrier's website
Ordering and Documentation Requirements
Ordering requirement by treating physician
Carriers may require that a COVID-19 test be ordered by a treating physician based on the health plan's medical necessity criteria.
- Ordering by a treating clinician is permitted when tied to plan medical necessity rules
Not Covered / Exclusions
The bulletin does not enumerate specific tests or indications that are categorically excluded from coverage. Instead, carriers should follow the Division's coverage expectations for PCR, antigen, and antibody testing and may apply medical necessity criteria under state law. Where carriers adopt utilization review or medical necessity guidelines, those guidelines should be consistent with M.G.L. c.176O and communicated to members and network providers.
Specimen Collection, Processing, and Reimbursement
The Division expects carriers to reimburse specimen collection and laboratory processing costs associated with COVID‑19 testing at a rate greater than the MassHealth rate when those items are billed and reimbursed individually. Routine carrier specimen collection and lab processing practices otherwise apply.
Test Type Definitions
The Division describes three types of COVID‑19 tests: PCR tests detect the presence of the novel Coronavirus RNA; antigen tests detect a unique viral protein (for example, a spike protein); and antibody (serology) tests detect host antibodies that may indicate an immune response. The Division expects coverage for PCR or antigen tests when a covered patient has any COVID‑19 symptom or known exposure, and expects antibody tests to be covered when performed consistent with DPH and CDC guidance and when medically necessary to support treatment.
Frequency Limits
Revision History
Division issued Bulletin 2020-16 setting expectations for carrier coverage of COVID-19 PCR, antigen, and antibody testing, including elimination of prior authorization for PCR and antigen tests and expectations around cost-sharing and reimbursement rates.
Bulletin updates Bulletin 2020-02 to clarify that carriers should cover PCR or antigen tests for symptomatic or exposed patients and cover antibody tests when consistent with DPH/CDC guidance and medically necessary to support treatment.
Division advised carriers they may develop utilization review systems and medical necessity criteria for COVID-19 testing consistent with M.G.L. c.176O, and must post any medical necessity guidelines on their websites.
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