Neighborhood Health Plan RI COVID-19 Testing Coverage

Coverage Criteria

inv-01: Coverage criteria for diagnostic testing

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

Covered testing indications: 1) Symptomatic individuals with signs or symptoms consistent with COVID-19 as identified by a healthcare provider (examples include fever/chills, cough, shortness of breath, new loss of taste or smell, fatigue, myalgia, headache, sore throat, congestion/rhinorrhea, gastrointestinal symptoms, inflammatory conditions including MIS-C, thromboembolic events, altered mental status, hypoxia).; 2) Individuals identified as close contacts of a confirmed or clinically diagnosed COVID-19 case by state public health, a contact tracing program, or a healthcare provider (close contact defined per RI Dept. of Health guidance); 3) Testing to determine resolution of COVID-19 infection when ordered by the provider; 4) Testing prior to admission to a Rhode Island healthcare facility when ordered by the provider; 5) Testing prior to a medical procedure when ordered by the provider; 6) Non-traditional determinations (asymptomatic or symptomatic) where a licensed provider, using an approved survey/algorithm or clinical judgment, determines the test is medically appropriate.

Ordering provider must determine medical appropriateness; primary purpose is considered individualized diagnosis or treatment even if the test may also meet workplace requirements.

inv-02: Antibody testing and treatment coverage

Covered services for antibody testing and treatment:

Antibody testing and treatment coverage: Antibody (serology) testing codes (for example 0224U, 86328, 86408, 86409, 86769) are covered as outlined in this policy. PCR and antigen diagnostic testing and administration are covered when the ordering provider determines the test is medically appropriate. Treatment for members diagnosed with COVID-19 is covered.

Modifier CS (cost-sharing waived) is accepted on listed laboratory codes; Neighborhood will waive member cost share for Commercial plans for PCR/antigen testing, related outpatient visits, and treatment during the Rhode Island COVID-19 State of Emergency.

inv-03: Coverage stance

Coding and claims considerations: Claims for COVID-19 testing and related services are governed by member eligibility, benefit coverage, coding and documentation guidelines, authorization policies, provider contract agreements, and applicable state and federal regulations.

Informational: specific medical necessity criteria are not present in this excerpt; policy is informational and subject to amendment or rescission.

Cost sharing for Commercial plans is generally waived for PCR and antigen diagnostic testing and related outpatient visits, and for treatment of members diagnosed with COVID-19 during the Rhode Island State of Emergency. Cost sharing is not waived for certain Commercial plan services — the document notes exceptions to the waiver (not fully enumerated in this excerpt) and instructs providers not to collect cost share when the waiver applies.

This payment policy is informational and not a guarantee of reimbursement. Neighborhood reserves the right to amend or rescind this temporary policy, and claims remain subject to benefit coverage, member eligibility, coding and documentation rules, authorization policies, provider contracts, and applicable state and federal regulations.

When an ordering provider determines a COVID-19 diagnostic test is medically appropriate for an individual, the test's primary purpose is considered individualized diagnosis or treatment, even if the test also appears to meet a secondary purpose such as workplace screening. Coverage and administration will follow the policy when the provider has made that individualized medical determination.

Within the provided excerpt there are no explicit statements listing services as Not Medically Necessary. The policy emphasizes that coverage depends on the ordering provider's individualized medical determination and other payer and regulatory rules.

Covered Indications

inv-28: Symptomatic individuals and asymptomatic close contacts, testing for resolution, pre-admission and pre-procedure testing when provider determines medically appropriate.

Covered indications when the ordering provider determines the test is medically appropriate:

Covered individuals and scenarios: Symptomatic individuals with signs/symptoms consistent with COVID-19; Asymptomatic individuals identified as close contacts of a confirmed or clinically diagnosed COVID-19 case; Testing to determine resolution of infection; Testing prior to admission to a Rhode Island healthcare facility; Testing prior to a medical procedure; Non-traditional testing scenarios when a licensed provider determines medical appropriateness per RI Dept. of Health-approved survey/algorithm or clinical judgment.

A licensed ordering provider must determine medical appropriateness in accordance with accepted standards and RI Dept. of Health guidance; primary purpose is individualized diagnosis/treatment even if testing also satisfies workplace requirements.

inv-29: Diagnosis and treatment related to COVID-19 testing as represented by listed ICD-10 codes.

Diagnosis and treatment related to COVID-19 testing should be reported using the following ICD-10 codes where clinically appropriate:

Coding (CPT / HCPCS / ICD-10)

Covered CPT/HCPCS CodesmixedCovered

0202U	Infectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid, 22 targets including SARS-CoV-2, qualitative RT-PCR
0223U	Infectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid, 22 targets including SARS-CoV-2, qualitative RT-PCR
0225U	Infectious disease (bacterial or viral respiratory tract infection) pathogen-specific DNA and RNA, 21 targets, including SARS-CoV-2, probe technique, including multiplex reverse transcription for RNA targets, each analyte reported as detected or not detected
0226U	Surrogate viral neutralization test (sVNT) for SARS-CoV-2, ELISA, plasma/serum
87635	Infectious agent detection by nucleic acid; SARS-CoV-2, amplified probe technique
87426	Infectious agent antigen detection by immunoassay; SARS-CoV-2
C9803	Hospital outpatient clinic specimen collection for SARS-CoV-2, any specimen source
G2023	Specimen collection for SARS-CoV-2, any specimen source
G2024	Specimen collection for SARS-CoV-2 from an individual in a SNF or by a laboratory on behalf of an HHA, any specimen source
U0002	Non-CDC laboratories test for SARS-CoV-2 (COVID-19)

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Covered ICD-10-CM CodesICD-10Covered

U07.1	2019-nCoV acute respiratory disease
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

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Covered COVID-19 test and specimen collection codesCPT|HCPCS|mixedCovered

C9803	Hospital outpatient clinic specimen collection for SARS-CoV-2, any specimen source
G2023	Specimen collection for SARS-CoV-2, specimen source Any
G2024	Specimen collection for SARS-CoV-2 from an individual in a SNF or by a laboratory on behalf of an HHA, any specimen source
U0002	SARS-CoV-2/2019-nCoV (COVID-19) CDC laboratory testing
U0003	SARS-CoV-2/2019-nCoV (COVID-19) non-CDC laboratory testing
U0004	U0004

Historically added lab codesCPT|HCPCS|mixed

0225U	Lab code added 08/10/20
0226U	Lab code added 08/10/20
86408	Lab code added 08/10/20
86409	Lab code added 08/10/20
87426	Lab code added 06/25/20
0223U	Lab code added 06/25/20
0224U	Lab code added 06/25/20
0202U	Lab code added 06/24/20
87635	CPT code effective 03/13/20
C9803	Added 5/21/20

Covered ICD-10 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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Symptomatic criteria — Symptoms consistent with COVID-19

Symptoms (selected list)Fever or chills; Cough; Shortness of breath or difficulty breathing; New loss of taste or smell; Sore throat; Congestion or runny nose; Nausea, vomiting, or diarrhea

Additional respiratory/critical signsLowered oxygen saturation; Trouble breathing; Bluish lips or face; Persistent chest pain or pressure

Systemic and neurologic manifestationsFatigue; Muscle or body aches; Headache; New confusion or other alterations in mental status; Inability to wake or stay awake

Pediatric and vascular presentationsChildren with multisystem inflammatory syndrome; Inflammatory conditions such as 'COVID toes'; Thromboembolic events

Not applicable

Provider Actions & Operational Requirements

Prior Authorization

Prior Authorization and Claims Review

Prior authorization does not apply to diagnostic laboratory testing for COVID-19. Claims for COVID-19 testing and related services remain subject to Neighborhood Health Plan of Rhode Island benefit coverage, member eligibility, coding and documentation guidelines, claims payment edits, authorization policies (when applicable), provider contract terms, and state and federal regulations. Providers must submit complete claims within contractual timeframes.

Prior authorization waived for diagnostic laboratory testing for COVID-19.
Claim payments subject to benefit coverage, member eligibility, claims payment edit rules, coding and documentation guidelines, authorization policies, provider contract agreements, and state/federal regulations.
Providers must submit complete claims for payment within contractual timeframes (e.g., within 90 days when applicable).
Specimen collection is considered part of and not separately reimbursable when billed the same day by the same supplier as an E&M service or laboratory test.
Communication of test results is standard practice and is not separately billable.

Ordering Requirements

Note

Licensed ordering provider must determine medical appropriateness

A licensed ordering provider must determine the test is medically appropriate in accordance with accepted standards of medical practice and Rhode Island Department of Health guidance; non-traditional determinations (survey/algorithm) are permitted if approved and within provider scope.

Applies to symptomatic, close-contact, resolution, pre-admission, and pre-procedure testing scenarios.

Prior Authorization

Follow payer authorization policies and provider contract terms

Ordering and any necessary authorization must follow payer-specific authorization policies and the provider's contract terms; claims remain subject to payer edits and authorization processes despite the prior authorization waiver for diagnostic lab testing.

Document history and disclaimer note that claims processing and authorization rules continue to apply.
Prior authorization waiver applies to diagnostic lab testing codes, but other authorization or contractual requirements may still affect claim payment.

Frequency Limits

Frequency limits

Frequency limitsNo explicit frequency limits stated in this excerpt

Claim submission timeframeProviders required to submit complete claims within 90 days of service (billing/reimbursement note)

Reimbursement caveatBillable services are subject to contractual agreements and payer edits

Frequency limits (placeholder)

PlaceholderNo frequency restriction detail provided in this policy excerpt

Action for providersFollow payer-specific authorization and contract terms for any frequency or repeat testing rules

Documentation

Not Covered / Coverage Exclusions

Specimen collection and communication of test results are considered integral to testing services. Specimen collection is not separately reimbursable when billed the same day by the same supplier as an E&M service or a laboratory test, and communication of results is not separately billable. Billable services remain subject to contractual terms and must be submitted within 90 days of the date of service.

The excerpt does not enumerate specific tests or clinical indications that are categorically not covered. Instead, claims remain subject to coverage determinations, eligibility, coding and documentation guidelines, authorization policies, and provider contract terms.

Background

During the Rhode Island COVID-19 State of Emergency, diagnostic testing covered under this temporary policy includes nucleic acid amplification tests (PCR/NAAT) that detect viral RNA, antigen tests that detect viral proteins, and antibody (serology) tests that detect host immune response. Coverage and reimbursement are tied to the ordering provider's determination of medical appropriateness and to applicable state public health guidance.

Definitions

Nucleic Acid Amplification tests (PCR/NAAT)

DefinitionTests that detect the unique RNA of the COVID-19 virus (commonly called PCR or nucleic acid amplification tests)

ExamplesHigh-throughput nucleic acid testing represented by codes such as U0002/U0003/U0004 and other SARS-CoV-2 amplified probe techniques

Clinical useUsed for diagnosis of active SARS-CoV-2 infection when ordered by a licensed provider

Antigen tests

DefinitionTests that detect a unique part of the COVID-19 virus, such as a viral protein (antigen tests)

Clinical useUsed to detect active infection; coverage dependent on provider determination of medical appropriateness

Revision History

08/17/20code_additionLatest

Added codes 0225U, 0226U, 86408, and 86409 effective 08/10/20 and incorporated OHIC/EOHHS guidance regarding PCR and antigen testing (7/21/20).

07/13/20code_addition

Added codes 87426, 0223U, and 0224U effective 06/25/20.

06/24/20code_addition

OpenPayer

COVID-19 diagnostic testing and related treatment coverage (temporary policy)