CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

COVID-19 coverage and reimbursement for testing and treatment

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

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyCOVID-19 coverage and reimbursement for testing and treatment

Policy CodePolicy N/A

Change TypeMultiple additions and revisions (codes addedcost-share and prior auth updates)

Effective DateN/A

Next Review DateN/A

Key ActionPrior authorization is waived for treatment services for confirmed COVID-19 cases.

SourceLink

POLICY UPDATE CHANGES

Added CPT code 0202U to covered testing codes.

Added code C9803 for hospital outpatient clinic specimen collection.

Accepted modifier 'CS' (Cost-sharing Waived) on laboratory testing codes and added language regarding 'CS' modifier.

Incorporated ICD-10-CM code U07.1 for confirmed COVID-19 cases effective April 1, 2020.

Added CMS G-codes (G2023, G2024) and U0003/U0004 high-throughput testing codes to covered codes.

~20diagnosis and testing codes listed

90 daysclaim submission window

Commercial

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria for COVID-19 Testing and Treatment

COVID-19 coverage criteria

Coverage applies when members meet CDC testing guidelines, and for inpatient/outpatient treatment of diagnosed COVID-19.

Member and service meet the scope of this policy: applies to all lines of business (Medicaid, Commercial, INTEGRITY) and to members who meet United States CDC testing guidelines; applies to inpatient and outpatient services required for treatment of members diagnosed with COVID-19.

ALL of the following

Diagnostic laboratory testing for SARS-CoV-2/COVID-19 is covered when billed with one of the listed CPT/HCPCS codes.
Prior authorization is not required for diagnostic laboratory testing for COVID-19.
Modifier 'CS' (Cost-sharing Waived) is accepted on laboratory testing codes to waive member cost share when policy applies.
Specimen collection is considered part of testing and is not separately reimbursable when billed on the same day by the same supplier as an E&M service or laboratory test.
Providers must submit complete claims for testing within 90 days of the date services are provided.

ALL of the following

Treatment services for confirmed COVID-19 cases are covered.
For dates of service on or after April 1, 2020, professional and facility claims for confirmed cases must use ICD-10-CM code U07.1 (2019-nCoV acute respiratory disease) in the primary diagnosis field and the 'CR' (Catastrophe/disaster related) modifier as applicable.
Prior authorization requirements will be waived for treatment services for confirmed cases of COVID-19.

ALL of the following

Encounters for suspected exposure, screening, or symptomatic evaluation where COVID-19 is not yet confirmed should be billed with Z11.59, Z03.818, Z20.828 or appropriate symptom codes (e.g., R05, R06.02, R50.9).
Modifier 'CS' may be accepted to waive member cost share for testing-related outpatient visits and certain unconfirmed encounters per policy guidance; providers should not collect cost share when the policy indicates a waiver.

Member cost share waiver: Neighborhood will waive all member cost share for Commercial plans for laboratory diagnostic testing and the related outpatient visit for COVID-19 and for treatment of members diagnosed with COVID-19 during the period of heightened concern; providers should NOT collect cost share in accordance with this policy.

Diagnosis, Testing, and Billing Codes

Covered COVID-19 diagnosis and testing codesmixedCovered

0202U	Infectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected.
86328	Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative, single step method (eg, reagent strip; severe acute respiratory syndrome coronavirus2 (SARS-CoVID-19) (Coronavirus disease [COVID-19]).
86769	Antibody; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]).
87635	Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique.
C9803	Hospital outpatient clinic specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID19]), any specimen source.
G2023	Specimen collection for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]). Any specimen source.
G2024	Specimen collection for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) from an individual in a SNF or by a laboratory on behalf of an HHA, any specimen source.
U0001	SARS-CoV-2/2019-nCoV (COVID-19) CDC laboratory testing.
U0002	SARS-CoV-2/2019-nCoV (COVID-19) non-CDC laboratory testing.
U0003	CDC testing laboratories to test for (high-throughput) SARS-CoV-2 (as referenced in CMS guidance).

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Testing code effective dates and notes

0202UEffective 5/20/20 — Infectious disease pathogen-specific nucleic acid test (22 targets) including SARS-CoV-2; qualitative RT‑PCR

86328Effective 4/10/20 — Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative (SARS‑CoV‑2)

86769Effective 4/10/20 — Antibody; SARS‑CoV‑2 (Coronavirus disease [COVID‑19])

87635Effective 3/13/20 — Infectious agent detection by nucleic acid; SARS‑CoV‑2, amplified probe technique

C9803No effective date listed in code table — Hospital outpatient clinic specimen collection for SARS‑CoV‑2 (any specimen source)

G2023/G2024/U0001/U0002/U0003/U0004Laboratory/CMS specimen collection and high‑throughput testing codes; modifier 'CS' accepted on these laboratory testing codes

Provider Billing and Authorization Actions

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. For dates of service April 1, 2020 and after, report ICD-10-CM code U07.1 in the primary diagnosis field (and modifier CR for professional claims); prior authorization is not required for those treatment services.

Billing Rule

Cost-share waiver and 'CS' modifier guidance

Modifier CS (Cost-sharing Waived) is accepted to waive member cost share on claims for applicable laboratory testing codes and for unconfirmed cases of COVID-19; providers should not collect member cost share when the waiver applies.

CS is accepted on claims for unconfirmed cases (see Z03.818, Z20.828, Z11.59, symptom codes) (chunk 4).

Key Definitions

Confirmed case

DefinitionA confirmed COVID‑19 case is billed using ICD‑10‑CM code U07.1 (2019‑nCoV acute respiratory disease) in the primary diagnosis field for dates of service on/after 2020‑04‑01; prior to 2020‑04‑01, report applicable respiratory diagnosis codes with B97.29 as the causal agent.

Prior authorizationPrior authorization requirements are waived for treatment services for confirmed COVID‑19 cases.

Claim presentationFor professional and facility claims on/after 2020‑04‑01 include U07.1 in the primary diagnosis field and apply modifier 'CR' (Catastrophe/disaster related) as indicated.

Unconfirmed case

DefinitionUnconfirmed cases include encounters for suspected exposure, screening, or symptomatic evaluation where COVID‑19 is not yet confirmed; bill with Z03.818, Z20.828, or Z11.59 (as applicable) or symptom codes R05, R06.02, R50.9.