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    v1.0.28
    OpenPayerPolicy UpdatesReimbursement/Payment PolicySendero Health COVID-19 Coverage 2021 | OpenPayer
    Ask Trek AI about this page
    CurrentSendero Health PlansPolicy N/A

    COVID-19 Response - Provider Guidance

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    Guidance for providers on Sendero coverage, cost-sharing, claims submission, authorization, coding, and telehealth requirements for COVID-19-related services.

    Policy Summary
    PayerSendero Health Plans
    PolicyCOVID-19 Response - Provider Guidance
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateMarch 1, 2020
    Next Review DateN/A
    Key ActionAppend place of service code 02 to in-network telehealth and telemedicine services; no telehealth modifier is required.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    No cost-sharingCOVID-19 testing and specimen collection
    No cost-sharingIn-network COVID-19 treatment, including hospitalization
    No prior authorizationCOVID-19 vaccinations
    13 codesCOVID-19 testing and antibody testing codes

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    POS 02 requiredIn-network telehealth and telemedicine

    COVID-19 Coverage

    COVID-19 Testing Coverage

    COVID-19 testing and testing-related services are covered for Sendero members without cost-sharing, subject to the applicable dates of service and claim-submission requirements below.

    COVERED WHEN ALL OF THE FOLLOWING APPLY

    • ONE OR MORE OF THE FOLLOWING COVERED SERVICES

      • COVID-19 testing using CPT/HCPCS codes U0001, U0002, or 87635.
      • COVID-19 specimen collection using codes G2023, G2024, or C9803.
      • COVID-19 testing using codes U0003 or U0004.

        Covered for dates of service April 14, 2020 and after.

      • COVID-19 testing using code U0005.

        Covered for dates of service January 1, 2021 and after.

      • COVID-19 testing using code 0202U.

        Covered for dates of service May 20, 2020 and after.

      • COVID-19 testing using codes 87426, 0223U, or 0224U.

        Covered for dates of service June 25, 2020 and after.

      • COVID-19 testing using code 86413.

        Covered for dates of service September 8, 2020 and after.

      • COVID-19 antibody testing using codes 86328 or 86769.
      • COVID-19 testing-related office visits, telehealth/telemedicine visits, urgent care visits, or emergency room visits.
    • The service is provided to a Sendero member.
    • No co-insurance or deductible is charged to the member.

    ACCEPTED COVID-19 CLAIM DESIGNATIONS

    • For professional claims submitted using the ASC X12 837 professional claim format or paper Form CMS-1500, append modifier CR (catastrophe/disaster related).
    • For institutional claims submitted using the ASC X12 837 institutional claims format or paper Form CMS-1450, report condition code DR.
    • Modifier CS may be used in lieu of CR or DR to designate COVID-19 testing-related services.

    COVID-19 Treatment Coverage

    In-network COVID-19 treatment, including hospitalization, is covered for Sendero members without cost-sharing.

    COVERED WHEN ALL OF THE FOLLOWING APPLY

    • The treatment is for COVID-19.
    • The treatment is provided in network, including inpatient or outpatient hospitalization when applicable.
    • The service is provided to a Sendero member.
    • No co-insurance or deductible is charged to the member.

    CLAIM-SUBMISSION REQUIREMENTS

    • For professional claims submitted using the ASC X12 837 professional claim format or paper Form CMS-1500, append modifier CR (catastrophe/disaster related).

    COVID-19 Vaccination Coverage

    COVID-19 vaccinations are covered as a preventive service without cost-sharing during the public health emergency.

    COVERED WHEN ALL OF THE FOLLOWING APPLY

    • The service is a COVID-19 vaccination.

    • NETWORK STATUS

      • The vaccination is provided in network.
      • The vaccination is provided out of network.
    • The vaccination is furnished during the public health emergency.
    • The vaccination is covered as a preventive service with no cost-sharing.

    Telehealth and Telemedicine Coverage

    Sendero covers in-network telehealth and telemedicine services, including phone consultations, for all specialties except the specified therapy services. Billing and non-billable-call requirements apply.

    COVERED TELEHEALTH SERVICES

    • The service is an in-network telehealth or telemedicine service, including a phone consultation.
    • The service is provided for any specialty, except Home Health PT/OT/ST and ABA therapy services addressed in Sendero's guidance document 'Billing for Telehealth Therapy Services during the COVID-19 Response.'

      The referenced guidance document is located in the News tab at https://www.senderohealth.com/providers.

    • The claim reports place of service code 02 (Telehealth) to indicate that health services are provided or received through a telecommunication system.

    BILLING REQUIREMENTS

    • No modifier is required for telehealth/telemedicine services.

    Codes and Claim Submission

    Initial COVID-19 testing codesCPTCovered
    U0001COVID-19 testing
    U0002COVID-19 testing
    87635COVID-19 testing
    COVID-19 specimen collection codesHCPCSCovered
    G2023COVID-19 specimen collection
    G2024COVID-19 specimen collection
    C9803COVID-19 specimen collection
    Additional COVID-19 testing codesCPTCovered
    U0003COVID-19 testing
    U0004COVID-19 testing
    U0005COVID-19 testing
    0202UCOVID-19 testing
    87426COVID-19 testing
    0223UCOVID-19 testing
    0224UCOVID-19 testing
    86413COVID-19 testing
    COVID-19 antibody testing codesCPTCovered
    86328COVID-19 antibody testing
    86769COVID-19 antibody testing
    COVID-19 claim modifiers and condition codeModifier
    CRCatastrophe/disaster-related modifier for professional claims
    DRCatastrophe/disaster-related condition code for institutional claims
    CSAccepted alternative COVID-19 designation modifier
    Telehealth place of serviceRevenue
    02Telehealth place of service
    Testing Coverage Effective Dates
    U0003 and U0004Covered for dates of service April 14, 2020 and after
    0202UCovered for dates of service May 20, 2020 and after
    87426, 0223U, and 0224UCovered for dates of service June 25, 2020 and after
    86413Covered for dates of service September 8, 2020 and after
    U0005Covered for dates of service January 1, 2021 and after

    Required Provider Actions

    Prior Authorization

    No prior authorization for COVID-19 vaccination

    Do not obtain prior authorization for in-network or out-of-network COVID-19 vaccinations.

    Billing Rule

    Use the required COVID-19 claim designation

    For COVID-19 testing-related services and treatment claims, append modifier CR to professional claims or use condition code DR for institutional claims. Sendero also accepts modifier CS in lieu of CR or DR.

    • CR: ASC X12 837 professional claims or paper Form CMS-1500
    • DR: ASC X12 837 institutional claims or paper Form CMS-1450
    • CS: accepted alternative COVID-19 designation
    Policy Summary
    PayerSendero Health Plans
    PolicyCOVID-19 Response - Provider Guidance
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateMarch 1, 2020
    Next Review DateN/A
    Key ActionAppend place of service code 02 to in-network telehealth and telemedicine services; no telehealth modifier is required.
    SourceLink
    On This Page
    COVID-19 CoverageCodes and Claim SubmissionRequired Provider Actions
  1. For institutional claims submitted using the ASC X12 837 institutional claims format or paper Form CMS-1450, report condition code DR.
  2. Modifier CS may be used in lieu of CR or DR to designate COVID-19 treatment claims.

    3. NO PRIOR AUTHORIZATION

    • Sendero does not require prior authorization for in-network or out-of-network COVID-19 vaccinations.
  3. POS code 02 is required on the claim.

    4. NOT BILLABLE

    • A telephone call with office staff.
    • An administrative call, including a request for refills, scheduling, payment, or billing issues.
    Testing Claim Format
    CR modifierRequired for professional claims submitted using the ASC X12 837 professional claim format or paper Form CMS-1500
    DR condition codeRequired for institutional claims submitted using the ASC X12 837 institutional claims format or paper Form CMS-1450
    CS modifierAccepted in lieu of CR or DR to designate COVID-19 testing-related services and treatment claims
    Billing Rule

    Do not charge member cost-sharing

    Do not charge members coinsurance or deductible amounts for covered COVID-19 testing-related services or treatment claims.

    Billing Rule

    Submit telehealth services with POS 02

    For in-network telehealth and telemedicine services, append place of service code 02. No telehealth modifier is required.

    • Use POS code 02 to identify telehealth services.
    • Do not add a telehealth modifier.
    Denial Risk

    Administrative calls are not billable

    Do not bill telephone calls with office staff or calls for administrative purposes. This includes refill requests, scheduling, payment, and billing issues.

    Denial Risk

    Follow separate guidance for therapy services

    The telehealth coverage guidance excludes Home Health PT/OT/ST and ABA therapy services. Follow the separate Sendero guidance, “Billing for Telehealth Therapy Services during the COVID-19 Response,” for those services.

    • Excluded services: Home Health PT/OT/ST
    • Excluded services: ABA therapy