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    v1.0.30
    OpenPayerPolicy UpdatesLaboratory/PathologyIdaho COVID-19 Testing Coverage Policy | OpenPayer
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    CurrentIdaho Department of InsurancePolicy 20-13

    COVID-19 Virus Testing Coverage Expectations

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    Establishes expectations for health insurance carriers to facilitate and cover medically necessary COVID-19 diagnostic and antibody testing, including access, prior authorization, network, and cost-sharing practices.

    Policy Summary
    PayerIdaho Department of Insurance
    PolicyCOVID-19 Virus Testing Coverage Expectations
    Policy CodePolicy 20-13
    Change TypeNo material change
    Effective DateJuly 10, 2020
    Next Review DateN/A
    Key ActionCarriers should relax prior approval requirements for medically necessary COVID-19 testing or treatment.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    2Testing categories
    0Test frequency limit
    0Covered testing cost-sharing
    3Non-covered purposes
    4Asymptomatic testing examples

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Medical Necessity and Coverage Criteria

    Medically necessary diagnostic and antibody testing

    COVID-19 diagnostic and antibody testing should be covered when all applicable criteria are met.

    Covered COVID-19 testing

    • Medical necessity

      • Examples of asymptomatic medical necessity: The individual is being hospitalized; is preparing for a potential aerosol-generating procedure; had likely contact with a confirmed or probable case; or is in another situation determined appropriate by the attending health care provider.

        These are examples and are not an exhaustive list.

    • Test authorization: The test meets applicable federal or state regulatory authorization requirements.

      Includes FDA approval, clearance, or authorization for patient use, including emergency use pathways, or state regulatory approval for tests developed and administered under state requirements.

    Testing not medically necessary

    Coverage is not medically necessary when testing is performed solely for a non-individualized purpose.

    Not medically necessary testing purposes: Testing is solely directed or requested by an employer as part of a return-to-work or other employer-directed program; is for public health surveillance; or is for another purpose not intended for individualized diagnosis or treatment of COVID-19 or another health condition.

    COVID-19 virus testing is not medically necessary for these purposes.

    Testing is not medically necessary when it is solely directed or requested by an employer for a return-to-work requirement or another employer-directed program.

    Testing performed for public health surveillance, rather than for an individualized clinical purpose, is excluded from medical necessity.

    Testing is not medically necessary when it is performed for any purpose other than the individualized diagnosis or treatment of COVID-19 or another health condition.

    Tests must be approved, cleared, or authorized for patient use under applicable federal or state regulatory requirements. This includes federal premarket approval or emergency use pathways, or development and administration in accordance with state regulatory approval. Tests that do not meet these requirements do not meet the policy's coverage expectation.

    COVID-19 testing is not medically necessary when its sole purpose is an employer-directed program, public health surveillance, or another non-individualized purpose unrelated to diagnosing or treating COVID-19 or another health condition.

    Carrier and Provider Administration

    Prior Authorization

    Relax prior approval for medically necessary testing

    Carriers are recommended to relax prior approval requirements and procedures for medically necessary COVID-19 testing or treatment so that individuals who may have been exposed can receive timely testing and treatment.

    Documentation Required

    Document individualized medical necessity

    The attending health care provider should document an individualized clinical assessment determining that the test is medically necessary for the individual and consistent with current accepted standards of medical practice.

    Documentation Required

    Use a qualified attending health care provider

    Testing Background

    COVID-19 testing includes two primary categories: diagnostic testing and antibody or serologic testing. Molecular RT-PCR and antigen tests detect unique genetic material or specific proteins associated with the virus and are more useful for identifying active infection. Antibody tests detect antibodies that bind to viral proteins and may indicate current or past infection, but their clinical or diagnostic use is more limited. The FDA recommends that antibody testing not be used as the sole basis for diagnosis; nevertheless, the policy applies the same individualized medical-necessity standard to diagnostic and antibody testing.

    Key Definitions

    Attending health care provider
    Who qualifiesAn individual licensed or otherwise authorized under applicable law who is acting within the scope of the provider’s license or authorization and is responsible for providing care to the patient.
    Authorization to assessA provider need not be directly responsible for providing care if the provider makes an individualized clinical assessment determining that testing is medically necessary for the individual.
    Clinical standardThe individualized assessment must determine medical necessity in accordance with current accepted standards of medical practice.
    Authorized COVID-19 test
    Federal pathwaysApproved, cleared, or authorized for patient use under the Federal Food, Drug, and Cosmetic Act.
    Premarket approval

    Covered Testing Indications

    Individualized diagnosis or treatment

    Covered when the test is intended for individualized diagnosis or treatment and the attending health care provider determines that it is medically necessary for the individual.

    Individualized medical necessity

    • Examples for asymptomatic individuals: The individual is being hospitalized; is preparing for a potential aerosol-generating procedure; had likely contact with a confirmed or probable case; or is in another situation determined appropriate by the attending health care provider.

      These are examples of situations in which testing may be medically necessary; the list is not exhaustive.

    Testing Frequency

    Frequency limits
    Test typeCOVID-19 virus testing, regardless of type.
    Numerical limitNo limit should be placed on the number of covered tests for an individual.
    Medical necessityEach test must be medically necessary for the individual, based on an individualized assessment by an attending health care provider.
    AuthorizationEach test must be approved, cleared, or authorized for patient use under applicable federal or state regulatory requirements.
    PeriodNo specified period.

    Test Ordering Requirements

    Documentation Required

    Meet ordering requirements

    Testing should be ordered or supported by an attending health care provider who is licensed or otherwise authorized under applicable law, acts within the scope of the provider's authorization, and makes an individualized medical-necessity assessment.

    Excluded Testing Purposes

    The policy does not cover testing when the sole purpose is employer-directed return-to-work or other employer-program testing, public health surveillance, or another purpose not intended for individualized diagnosis or treatment. Tests also must have applicable federal or state approval, clearance, or authorization for patient use.

    Policy Summary
    PayerIdaho Department of Insurance
    PolicyCOVID-19 Virus Testing Coverage Expectations
    Policy CodePolicy 20-13
    Change TypeNo material change
    Effective DateJuly 10, 2020
    Next Review DateN/A
    Key ActionCarriers should relax prior approval requirements for medically necessary COVID-19 testing or treatment.
    SourceLink
    On This Page
    Medical Necessity and Coverage CriteriaCarrier and Provider AdministrationTesting BackgroundKey DefinitionsCovered Testing IndicationsTesting FrequencyTest Ordering RequirementsExcluded Testing Purposes

    The ordering or assessing provider must be licensed or otherwise authorized under applicable law, act within the scope of the provider's license or authorization, and be responsible for providing care or make an individualized clinical assessment of medical necessity.

    Denial Risk

    Avoid denial for unsupported or unauthorized testing

    Testing may be denied when it is not medically necessary for the individual, is not supported by an individualized clinical assessment from an attending health care provider, or is not approved, cleared, or authorized for patient use under applicable federal or state regulatory pathways.

    Denial Risk

    Do not submit non-individualized testing as medically necessary

    Testing is not medically necessary when it is solely requested by an employer for return-to-work or another employer-directed program, performed for public health surveillance, or performed for another purpose unrelated to individualized diagnosis or treatment of COVID-19 or another health condition.

    Authorization may include a premarket approval pathway.
    Emergency useAuthorization may include an emergency use pathway.
    State pathwayTests developed and administered in accordance with state regulatory approval also qualify.