COVID Testing Policy
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Policies governing medically necessary SARS-CoV-2 viral testing and payment rules for members residing in nursing homes, aligning Longevity Health Plan of Colorado with CDC/CMS guidance and applicable local mandates.
No material clinical or coverage changes in this revision.
Coverage Criteria for SARS-CoV-2 Testing in Nursing Homes
Medically Necessary Testing Criteria
Covered testing and criteria (aligned with CDC/CMS guidance) include the following situations:
NAAT (molecular) single negative is sufficient in most circumstances; if using antigen to discontinue precautions, confirm negative antigen with negative NAAT or repeat antigen 48 hours later.
If using antigen instead of NAAT, use three antigen tests spaced 48 hours per FDA recommendations.
Consider second NAAT if high clinical suspicion; clinical judgement governs continuation of precautions.
Routine serial PCR testing and public health surveillance viral testing are excluded from reimbursement. Longevity Health Plan follows CMS and CDC policy that does not pay for public health surveillance testing, and serial PCR testing has not been demonstrated to be clinically appropriate or medically necessary.
Routine standing orders for PCR testing are not medically necessary and will not be reimbursed. Individual PCR tests must be ordered by a licensed medical provider and meet medical necessity requirements; blanket or standing orders for serial PCR screening are not payable.
Provider Ordering, Testing Sequence, and Billing Rules
Order and medical necessity for PCR
Individual PCR tests require a licensed medical provider's order and must meet medical necessity requirements for reimbursement; routine standing orders for PCR testing are not reimbursed.
POC antigen preferred before PCR
Point-of-care (POC) viral antigen testing is preferred as the first-line test prior to PCR unless CDC guidelines or local/state/county/city mandates explicitly require PCR testing.
Provider order and reimbursement requirement
Individual member PCR testing must be ordered by a licensed medical provider and meet medical necessity requirements to be eligible for reimbursement.
Denial for surveillance or serial PCR testing
Claims for routine serial PCR testing and public health surveillance viral testing will not be reimbursed by Longevity Health Plans.
- Serial PCR testing has not been demonstrated to be clinically appropriate or medically necessary.
- Routine standing orders for PCR testing will not be reimbursed.
Background and Clinical Context
Anyone with even mild COVID-19 symptoms should receive viral testing as soon as possible. Testing decisions and payment follow current CDC/CMS guidance adopted by Longevity Health Plan. Where there are no local or federal mandates requiring PCR, point-of-care (POC) antigen testing is preferred as first-line before PCR. Individual PCR testing must be ordered by a licensed provider and meet medical necessity criteria. As with CMS policy, routine surveillance testing and serial PCR testing are excluded from payment.
Key Definitions
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