CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

COVID-19 coverage and reimbursement requirements

Temporary policy describing Neighborhood Health Plan of Rhode Island coverage and reimbursement for COVID-19 testing, related outpatient visits, and treatment for members across lines of business, including Medicaid and Commercial, and inpatient/outpatient services for diagnosed members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyCOVID-19 coverage and reimbursement requirements

Policy CodePolicy N/A

Change TypeAdded coding and billing guidancewaived prior authcost-share waivers

Effective DateN/A

Next Review DateN/A

Key ActionPrior authorization requirements will be waived for treatment services for confirmed cases of COVID-19.

SourceLink

POLICY UPDATE CHANGES

Added language regarding 'CS' modifier (cost-sharing waived).

Added new laboratory CPT/HCPCS codes for SARS-CoV-2 testing (e.g., 86328, 86769, 87635, G2023, G2024, U0001, U0002, U0003, U0004).

Prior authorization requirements will be waived for treatment services for confirmed cases of COVID-19.

ICD-10-CM code U07.1 must be billed in the primary diagnosis field for confirmed COVID-19 on professional and facility claims, with modifier 'CR' applied.

90 daystimeframe to submit complete claims

Commercial, Medicaid, INTEGRITYlines of business covered

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COVID-19 Coverage and Reimbursement Criteria

COVID-19 coverage criteria

Covered when ALL of the following criteria are met:

The service is one of the covered diagnostic laboratory, specimen collection, outpatient visit, or treatment services for COVID-19 as specified in this policy (see covered CPT/HCPCS/U-codes and ICD-10-CM guidance).

Diagnostic laboratory testing is ordered and performed consistent with U.S. Centers for Disease Control and Prevention (CDC) testing guidelines for SARS‑CoV‑2 (COVID‑19).

Claims for diagnostic laboratory testing are billed with one of the specified CPT/HCPCS/U-codes listed in the policy (e.g., 86328, 86769, 87635, G2023, G2024, U0001, U0002, U0003, U0004).

ALL of the following

Prior authorization is not required for diagnostic laboratory testing for COVID-19.
Prior authorization requirements will be waived for treatment services for CONFIRMED cases of COVID-19.

ALL of the following

Professional and facility claims for confirmed COVID-19 should list ICD‑10‑CM code U07.1 in the primary diagnosis field.
Apply modifier 'CR' (Catastrophe/disaster related) on claims for confirmed cases where indicated.

ALL of the following

Use observation/exposure/screening ICD‑10‑CM codes (e.g., Z03.818, Z20.828, Z11.59) and symptomatic codes as applicable for possible exposure or ruled‑out cases.
Modifier 'CS' (Cost‑sharing Waived) is accepted on claims for unconfirmed cases and on laboratory testing codes to waive member cost share where policy applies.

ALL of the following

For Commercial plans, Neighborhood will waive member cost share for laboratory diagnostic testing and the related outpatient visit and for treatment of members diagnosed with COVID‑19 during the policy period of heightened concern.
Providers are required to submit complete claims within 90 days of the date services are provided.

ALL of the following

This policy applies to all lines of business (Commercial, Medicaid, INTEGRITY) for testing, related outpatient visits, and inpatient/outpatient treatment services for members diagnosed with COVID‑19; Extended Family Planning (EFP) members have a limited benefit package—refer to the EFP payment policy for details.

Diagnosis, Testing, and Procedure Codes

Covered COVID-19 diagnosis and testing codesmixedCovered

86328	Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative, single step method (SARS-CoV-2)
86769	Antibody; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)
87635	Infectious agent detection by nucleic acid (DNA or RNA); SARS-CoV-2, amplified probe technique
G2023	Specimen collection for SARS-CoV-2, any specimen source
G2024	Specimen collection for SARS-CoV-2 from SNF or by lab on behalf of HHA, any specimen source
U0001	CDC testing laboratories to test for SARS-CoV-2/2019-nCoV
U0002	Non-CDC testing laboratories to test for SARS-CoV-2/2019-nCoV
U0003	Infectious agent detection by nucleic acid; SARS-CoV-2 using high throughput technologies
U0004	2019-nCoV Coronavirus, SARS-CoV-2 any technique; multiple types or subtypes, high throughput
U07.1	2019-nCoV acute respiratory disease

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Code effective dates

CPT/HCPCS code 87635Effective 2020-03-13

CPT code 86328Effective 2020-04-10

CPT code 86769Effective 2020-04-10

CMS U‑codes (U0001, U0002, U0003, U0004)Use per CMS interim guidance and as listed in testing code table

Billing, Authorization, and Modifier Guidance for Providers

Prior Authorization

Prior authorization waived for confirmed COVID-19 treatment

Prior authorization requirements will be waived for treatment services for confirmed cases of COVID-19.

Prior Authorization

No prior authorization for COVID-19 diagnostic lab testing

Prior authorization does not apply to diagnostic laboratory testing for COVID-19; providers should bill the appropriate COVID-19 testing CPT/HCPCS/U-codes for these services.

Billing Rule

Apply modifier CS to waive member cost share

Key Terms and Modifiers

Confirmed case

TermConfirmed case

Meaning in policyA case with diagnosis of COVID-19 to be billed with ICD-10-CM U07.1 in the primary diagnosis field on professional and facility claims

Operational notePrior authorization requirements will be waived for treatment services for confirmed cases of COVID-19

Unconfirmed case / possible exposure

TermUnconfirmed case

Meaning in policyPossible exposure or screening where COVID-19 is not confirmed; use observation/exposure/screening ICD-10-CM codes (e.g., Z03.818, Z20.828, Z11.59)

Billing note