CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Temporary COVID-19 testing, diagnosis, and treatment reimbursement policy

Temporary Neighborhood Health Plan of Rhode Island policy governing coverage and reimbursement for COVID-19 diagnostic testing, related outpatient visits, and inpatient/outpatient treatment across all lines of business who meet CDC guidelines.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyCOVID-19 testing, diagnosis, and treatment reimbursement (temporary)

Policy CodePolicy N/A

Change TypeAdded codes and updated claim/authorization guidance

Effective DateN/A

Next Review DateN/A

Key ActionDo not require prior authorization for treatment services for confirmed COVID-19 cases; submit claims using required diagnosis codes and timing rules.

SourceLink

POLICY UPDATE CHANGES

Added treatment services criteria and prior authorization language and updated claim submission criteria; added new CMS G-codes.

ICD-10 code U07.1 effective 04/01/20 incorporated for COVID-19 claims.

CPT code 87635 effective 03/13/20 added for SARS-CoV-2 testing.

waivedcommercial member cost share for COVID-19 testing and related outpatient visit

Prior auth waivedprior authorization waived for treatment services for confirmed COVID-19

90 daystimeframe providers must submit complete claims

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Coverage Criteria for COVID-19 Services

Coverage criteria for COVID-19 diagnosis, testing, and treatment

Coverage applies when CDC guidelines for testing are met and for treatment of diagnosed members; specific diagnosis and testing codes must be used as described.

Coverage applies to members who meet CDC guidelines for COVID-19 testing or who are diagnosed with COVID-19

Confirmed diagnosis — coding by date of service

For dates of service prior to April 1, 2020: bill confirmed COVID-19 cases using the listed combination of symptom/condition codes PLUS B97.29 as the cause code (examples include J12.89 + B97.29 for pneumonia, J20.8 + B97.29 for acute bronchitis, J40 + B97.29 for bronchitis NOS, J22 + B97.29 for unspecified acute lower respiratory infection, J98.8 + B97.29 for other specified respiratory disorders, J80 + B97.29 for ARDS)
For dates of service April 1, 2020 and after: use ICD-10-CM code U07.1 (2019-nCoV acute respiratory disease) in the primary diagnosis field on professional and facility claims; on professional claims append modifier 'CR' to service codes

ALL of the following

Exposure/screening outcomes
- Exposure ruled out after evaluation: Z03.818
- Contact with confirmed case: Z20.828
- Asymptomatic screening with no known exposure (results unknown or negative): Z11.59
- Symptomatic screening
  - Symptomatic members being screened (results unknown or negative): bill symptom codes such as R05 (cough), R06.02 (shortness of breath), or R50.9 (fever) and/or Z03.818 or Z20.828 as applicable

ALL of the following

Medicaid testing codes
- U0001 (CDC SARS-CoV-2 testing), U0002 (non-CDC SARS-CoV-2 testing), or 87635 (SARS-CoV-2 nucleic acid detection; effective 03/13/20)
Integrity and Commercial specimen collection codes
- G2023 (specimen collection, any source) or G2024 (specimen collection for SNF/HHA contexts, any source); covered testing codes (U0001, U0002, 87635) also apply

ALL of the following

Prior authorization requirements are waived for treatment services for confirmed COVID-19 cases; prior authorization does not apply to diagnostic laboratory testing for COVID-19
Providers must submit complete claims for payment within 90 days of the date services are provided

ALL of the following

For Commercial plans during the period of heightened concern, Neighborhood will waive all member cost share for laboratory diagnostic testing, the related outpatient visit, and treatment for members diagnosed with COVID-19; providers should not collect cost share

ALL of the following

On professional claims for confirmed cases on/after 2020-04-01, append modifier 'CR' (catastrophe/disaster related) to service codes as specified

ALL of the following

Use U07.1 for confirmed COVID-19 for dates of service April 1, 2020 and after

ALL of the following

This coverage policy applies across all lines of business (Medicaid, Commercial, INTEGRITY); Extended Family Planning (EFP) members have a limited benefit package—refer to EFP payment policy for coverage specifics

Covered Diagnosis, Testing, and Specimen Collection Codes

Covered COVID-19 diagnosis, testing, and specimen collection codesmixedCovered

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

1–10 of 19

1/2

ICD-10 effective date threshold

Required diagnosis codeICD-10-CM code U07.1 (2019-nCoV acute respiratory disease) is required in the primary diagnosis field for dates of service April 1, 2020 and after

Effective date thresholdApplies to claims with dates of service on or after April 1, 2020

Claim types affectedApplies to both professional and facility claims — U07.1 in primary diagnosis; on professional claims append modifier 'CR' to service codes

Provider Authorization and Billing Actions

Prior Authorization

Prior authorization waived for COVID-19 treatment; not required for COVID-19 testing

Prior authorization requirements will be waived for treatment services for confirmed cases of COVID-19. Prior authorization does not apply for diagnostic laboratory testing for COVID-19.

Definitions and Billing Modifiers

Extended Family Planning (EFP)

DefinitionExtended Family Planning (EFP) members have a limited benefit package

Coverage referenceRefer to the Extended Family Planning Payment Policy for coverage details

Scope noteThis policy applies to laboratory diagnostic testing, related outpatient visits, and treatment for members who meet CDC testing guidelines; EFP members remain subject to their limited benefits

CR modifier

Modifier meaningModifier 'CR' indicates catastrophe/disaster related

Usage on professional claimsAppend 'CR' to service codes on professional claims for confirmed COVID-19 services when U07.1 is used in the primary diagnosis field