Neighborhood Health RI COVID-19 Testing Coverage Update

Coverage Criteria for COVID-19 Testing

Covered testing indications

Covered when ANY of the following clinical indications are met and the ordering provider determines the test is medically appropriate in accordance with accepted standards and Rhode Island Department of Health guidance:

Symptomatic individuals: Any individual identified by a healthcare provider as symptomatic with signs or symptoms consistent with COVID-19 (see policy symptom list).

Supported by chunks 5 and 4

Close contacts: Individuals identified as close contacts of confirmed or clinically diagnosed COVID-19 cases by public health authorities or a healthcare provider (close contact defined as being within less than 6 feet while the case was symptomatic or within 48 hours before symptom onset, direct contact with infectious secretions without appropriate PPE, or as otherwise defined by RI DOH).

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Asymptomatic testing when provider determines medically appropriate: Asymptomatic individuals may be tested when an ordering provider determines testing is medically appropriate per accepted standards and RI Department of Health guidance; non-traditional ordering (documented electronic/written survey or approved algorithm supervised by a licensed provider) may be used as described in policy.

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Testing for resolution or pre-admission: Testing to determine resolution of infection or testing prior to admission to a Rhode Island healthcare facility when ordered by a provider in accordance with accepted standards and RI Department of Health guidance.

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Member Cost-Share Waiver

Coverage and member cost-share waiver rules for Commercial plans

Pre-7/21/2020 waiver: From date of service to July 21, 2020 Neighborhood will waive all member cost share for Commercial plans for laboratory diagnostic testing, related outpatient visits for COVID-19, and treatment for members diagnosed with COVID-19.

Providers should NOT collect cost share from a member for services during this period.

Post-7/21/2020 waiver during RI State of Emergency: From July 21, 2020 and after, Neighborhood will waive all member cost share for Commercial plans throughout the duration of the Rhode Island COVID-19 State of Emergency for PCR and antigen laboratory diagnostic testing and the related outpatient visit for COVID-19 and treatment for members diagnosed with COVID-19.

Cost sharing will NOT be waived for antibody laboratory diagnostic testing after this date.

Diagnosis, testing, and treatment associated with COVID-19 mapped to listed ICD-10 codes

Diagnosis, testing, and treatment associated with COVID-19 (SARS‑CoV‑2), including symptomatic disease, exposure, and screening as mapped to listed ICD‑10 codes:

Covered ICD‑10 codes (examples): Use the listed ICD‑10‑CM diagnosis codes for COVID‑19-related diagnosis, testing, and treatment as applicable (examples include U07.1; B97.29; J12.89; J20.8; J22; J40; J80; J98.8; R05; R06.02; R50.9; Z03.818; Z20.822; Z20.828; Z11.59).

Supported by chunk 26 and coding listing in chunk 21

Tests that may appear to serve a secondary purpose (for example, meeting workplace health and safety requirements) are still covered when the primary purpose of the ordered test is the individualized diagnosis or treatment of COVID-19 or another health condition. The policy treats the ordering provider’s determination of medical appropriateness as decisive: when a licensed provider has determined the test is medically appropriate for the individual, coverage for the test and administration follows the criteria in this policy.

Neighborhood’s Commercial member cost-share waiver rules changed effective July 21, 2020. For dates of service on and after that date during the Rhode Island COVID-19 State of Emergency, Neighborhood will waive member cost share for PCR and antigen laboratory diagnostic testing and the related outpatient visit and treatment for COVID-19. Antibody laboratory diagnostic testing is excluded from the post-7/21/2020 commercial member cost-share waiver and therefore cost sharing applies for antibody tests.

Coverage is contingent on the ordering provider determining the test is medically appropriate in accordance with accepted standards of medical practice and Rhode Island Department of Health guidance. Tests that the ordering provider does not determine to be medically appropriate may be considered not covered or denied under this policy.

This portion of the policy does not use explicit language labeling specific services as 'not medically necessary.' Instead, the policy emphasizes coding, coverage criteria, and temporary member cost-share waivers, while making clear that coverage and payment remain subject to benefit terms, member eligibility, coding and documentation, provider contracts, and applicable regulations.

Coding: CPT/HCPCS/ICD-10 and Modifiers

Diagnosis codes and guidanceICD-10

U07.1	2019-nCoV acute respiratory disease
J12.89	Other viral pneumonia (used for pneumonia due to COVID-19 prior to U07.1)
B97.29	Other coronavirus as the cause of diseases classified elsewhere
J20.8	Acute bronchitis due to other specified organisms
J40	Bronchitis, not specified as acute or chronic
J22	Unspecified acute lower respiratory infection
J98.8	Other specified respiratory disorders
J80	Acute respiratory distress syndrome (ARDS)
Z03.818	Encounter for observation for suspected exposure to other biological agents ruled out
Z20.828	Contact with and (suspected) exposure to other viral communicable diseases

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Testing CPT/HCPCS/Lab codesmixedCovered

0202U	Infectious disease pathogen-specific nucleic acid, 22 targets including SARS-CoV-2, qualitative RT-PCR
0223U	Infectious disease pathogen-specific nucleic acid, 22 targets including SARS-CoV-2, qualitative RT-PCR
0225U	Pathogen-specific DNA and RNA, 21 targets including SARS-CoV-2, probe technique
0226U	Surrogate viral neutralization test (sVNT), SARS-CoV-2, ELISA
0240U	Pathogen RNA 3 targets (SARS-CoV-2, influenza A/B)
0241U	Pathogen RNA 4 targets (SARS-CoV-2, influenza A/B, RSV)
87635	Infectious agent detection by nucleic acid; SARS-CoV-2, amplified probe technique
87636	Infectious agent detection by nucleic acid; SARS-CoV-2 and influenza A/B, multiplex
87637	Infectious agent detection by nucleic acid; SARS-CoV-2, influenza A/B, RSV, multiplex
87426	Infectious agent antigen detection by immunoassay; SARS-like coronaviruses

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ModifiersModifier

CR	Modifier - Catastrophe/disaster related (professional claims when U07.1 in primary diagnosis)
CS	Modifier - Cost-sharing waived (accepted on laboratory codes and on claims for unconfirmed cases)

Covered CPT/HCPCS CodesmixedCovered

0224U	Antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), includes titer(s), when performed
86328	Immunoassay for infectious agent antibody(ies) qualitative or semi-quantitative, single step method
86408	Neutralizing antibody, SARS-CoV-2; screen
86409	Reporting SARS-CoV-2 neutralizing antibody titer
86413	SARS-CoV-2 antibody, quantitative
86769	Antibody; SARS-CoV-2
0202U	Pathogen-specific nucleic acid (DNA or RNA), 22 targets including SARS-CoV-2, qualitative RT-PCR
0223U	Pathogen-specific nucleic acid (DNA or RNA), 22 targets including SARS-CoV-2, qualitative RT-PCR
0225U	RNA, 21 targets including SARS-CoV-2, amplified probe technique; multiplex reverse transcription
0240U	Surrogate viral neutralization test (VNT), SARS-CoV-2, ELISA, plasma, serum

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Covered ICD-10-CM Diagnosis CodesICD-10Covered

B97.29	Other coronavirus as the cause of diseases classified elsewhere
J12.89	Other viral pneumonia
J20.8	Acute bronchitis due to other specified organisms
J22	Unspecified acute lower respiratory infection
J40	Bronchitis, not specified as acute or chronic
J80	Acute respiratory distress syndrome
J98.8	Other specified respiratory disorders
R05	Cough
R06.02	Shortness of breath
R50.9	Fever; unspecified

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Close contact distance/time window — inv-12

DistanceLess than 6 feet from a COVID-19 case

Time windowWhile the case was symptomatic or within 48 hours before symptom onset

Other contextsClose contact can occur while caring for, visiting, or sharing a space (e.g., waiting area, restaurant, workspace) with a case

High-throughput turnaround — inv-13

Turnaround standardHigh-throughput testing completed within 2 calendar days from date of specimen collection

Scope

Provider Actions, Billing, and Documentation Requirements

Denial Risk

Medical appropriateness required

Tests may be denied if the ordering provider has not determined the test is medically appropriate for the individual in accordance with accepted standards of medical practice, inclusive of guidance issued by the Rhode Island Department of Health. Providers must ensure clinical rationale supporting medical appropriateness is documented in the medical record and available on request.

Applies to PCR and antigen testing, including asymptomatic and non-traditional ordering scenarios
Includes testing for close contacts, return-to-facility, resolution of infection, and other documented clinical indications

Documentation Required

Non-traditional ordering documentation allowed

Providers may use documented electronic or written survey responses or algorithm-driven determinations approved by a licensed provider to establish medical appropriateness when ordering COVID-19 testing, provided the licensed provider reviewed and approved the process and the individual determination.

Ordering and Clinical Determination Requirements

Prior Authorization

Licensed provider must determine medical appropriateness

A licensed ordering provider must determine that the COVID-19 test is medically appropriate for the individual in accordance with accepted standards of medical practice and Rhode Island Department of Health guidance.

Medical appropriateness may be based on direct evaluation or review of documented surveys/approved algorithms supervised by a licensed provider.

Note

No additional clinician ordering restrictions specified

No specific clinician ordering restrictions are stated; standard practice applies and prior authorization is not required for diagnostic laboratory testing for COVID-19.

Ordering limited by requirement that a licensed provider determine medical appropriateness, but no additional clinician-type restrictions are specified.

Not Covered or Excluded Services

When testing is ordered primarily for non-clinical secondary purposes (for example, routine workplace screening) the policy directs reviewers to determine the primary purpose of the test. If the primary purpose is not the individualized diagnosis or treatment of the member, coverage may differ; conversely, tests ordered for individualized clinical care remain covered even if they also satisfy other institutional or employer requirements.

For Commercial members, the cost-share waiver does not apply to antibody (serology) diagnostic laboratory testing after July 21, 2020. Antibody tests are explicitly excluded from the post-7/21/2020 member cost-share waiver, so member cost sharing may be collected for antibody laboratory diagnostic testing for dates of service on or after that date.

Key Definitions

Close contact definition — inv-23

Primary definitionBeing within less than 6 feet of a COVID-19 case

TimingContact while the case was symptomatic or within 48 hours before symptom onset

Direct exposureDirect contact with infectious secretions (e.g., coughed on) without appropriate PPE

RI DOHOr as otherwise determined/defined by the Rhode Island Department of Health

Frequency Limits and Testing Limits

No explicit frequency limits stated — inv-27

Frequency limits (statement)No explicit frequency limits stated in this portion of the policy.

Policy focusDocument emphasizes coding, coverage, and temporary cost-share waivers rather than numeric test frequency limits

Claims subject to rulesTesting remains subject to benefit coverage, member eligibility, coding and documentation, and contract rules

Frequency and coverage conditions — inv-28

Frequency limits (practical note)No frequency limits specified; testing is subject to benefit coverage and contract rules.

Claims timingProviders must submit complete claims for payment within 90 days of the date services are provided

Background and Test Types

The policy describes three categories of COVID-19 diagnostic tests: nucleic acid amplification (PCR) tests that detect viral RNA, antigen tests that detect viral proteins, and antibody (serology) tests that detect host antibodies. Coverage and coding guidance in the policy enumerate PCR and antigen testing codes and also list antibody tests and related CPT/HCPCS codes; clinical use and coverage depend on the ordering provider’s determination of medical appropriateness and the member cost-share rules described elsewhere in this policy.

OpenPayer

COVID-19 testing and related outpatient visit coverage