COVID-19 Test Quantity Limit
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Defines medical necessity and approval criteria for coverage of COVID-19 test kits in excess of the standard allowance for Meridian (Medicaid) members, and documents required from providers to support such requests.
No material clinical or coverage changes in this revision.
Coverage Criteria for Excess COVID-19 Test Kits
inv-01: Initial Approval Criteria — Excess Tests
COVID-19 test kits in excess of 8 kits per 365 days are medically necessary when ONE of the following initial criteria is met:
Approval duration: duration of request or 3 months (whichever is less)
inv-02: Continued Therapy Criteria — Excess Tests
Continued therapy for coverage of >8 tests/365 days (renewal):
Approval duration: duration of request or 3 months (whichever is less)
Coverage for indications that are not FDA‑approved is not authorized under this policy unless the provider submits sufficient documentation demonstrating efficacy and safety in accordance with Meridian’s Off‑label Use Policy (CP.PMN.53) or other applicable evidence of coverage documents. Requests for off‑label use should follow the requirements described in the off‑label policy to be considered for coverage.
Standard Allowance and Frequency Limits
Prior Authorization and Documentation Requirements
Prior authorization required for quantities >8 kits/365 days
Prior authorization is required for any request that exceeds the standard allowance of 8 COVID-19 test kits per 365 days. Approval duration will be the duration requested or 3 months, whichever is less.
Step therapy — Not applicable
Step therapy does not apply to this policy; coverage is based on meeting quantity-limit criteria and specific approval conditions rather than a step-wise trial of lower quantities or alternatives.
Supportive documentation — examples
Submit clinical documentation to support that the member meets the approval criteria for >8 kits/365 days.
- Office chart notes
- Laboratory results
- Other clinical information (e.g., provider recommendations or test-related orders)
Documentation required — risk of denial if not provided
Requests for COVID-19 test kits beyond 8 kits per 365 days must be supported by the required documentation; lack of supporting documentation may result in denial of the request.
How to Order and Submit Requests
Ordering requirements — submit supporting documentation for quantities beyond allowance
Provider must order the excess kits and submit supporting documentation (such as chart notes, lab results, or other clinical information) that justifies quantities beyond the 8-kit per 365-day allowance.
- Justification should demonstrate the member meets one of the initial approval criteria (e.g., immunocompromised status, need for frequent testing, recent exposure/recurring symptoms, or high‑risk residence/employment).
- For continued therapy, include prior authorization history or a letter of medical necessity explaining ongoing need.
Non‑covered Situations
Non‑FDA approved indications are not covered by this policy unless there is adequate documentation of efficacy and safety per the Meridian Off‑label Use Policy (CP.PMN.53) or applicable evidence of coverage. Absent that documentation, requests for coverage for non‑FDA indications will be denied.
Background and Test Description
At‑home FDA‑authorized over‑the‑counter (OTC) COVID‑19 test kits are intended for self‑testing to detect current SARS‑CoV‑2 infection. Most of these kits are antigen tests that provide rapid results, typically within 15–30 minutes; however, a negative antigen result does not fully exclude infection and repeat testing (for example, 48 hours apart) may be recommended per FDA or manufacturer guidance.
Definitions
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