Billing/Coverage for COVID-19

Below is member coverage and billing information for COVID-19 treatments and testing: 

• COVID-19 Vaccines
• Inpatient Hospital Care
• Office Visits
• Associated Services
• Testing 

COVID-19 VACCINES

The Food and Drug Administration (FDA) has granted full approval to the Pfizer-BioNTech COVID-19 vaccine for people 16 and older and emergency authorized use (EAU) of several other COVID-19 vaccines. The rollout and distribution of the vaccines will be determined by each state and the Centers for Disease Control and Prevention (CDC) helped to set those guidelines.

MEMBER COVERAGE AND CLAIMS SUBMISSION

During the Public Health Emergency (PHE), the federal government will pay for the cost of the COVID-19 vaccine for all individuals, as long as the vaccine administered is among those granted full approval or emergency authorized use by the FDA. The federal government will pay for the cost of the COVID-19 vaccine for Medicare Advantage members throughout 2021, regardless of when the PHE ends. Additional costs associated with administering the vaccine (such as vaccine supplies, storage and provider costs) will be covered by either the federal government or the member’s health plan, depending on the member.

See the following table for more information regarding coverage and claims submission.

See Reimbursement Policy RP-064 Government Supplied Vaccinations and Antibody Treatments for more detailed information and coding guidance.

OUT-OF-NETWORK PROVIDERS

Highmark will cover vaccine administration fees for out-of-network (OON) providers during the public health emergency. Current state and/or federal regulations prohibit any provider from balance billing patients for the COVID-19 vaccine.

INPATIENT HOSPITAL CARE 

MEMBER COVERAGE

Highmark members who receive inpatient hospital care for COVID-19 from an in-network facility will not incur any deductibles, co-insurance and co-pays, effective for dates of service from February 1, 2020 through December 31, 2021. The decision applies to members with group employer coverage (self-funded groups may elect to opt into the program), as well as ACA.

Medicare Advantage members will see no copays for COVID-related hospital admissions for the duration of the public health emergency (PHE).

Additional Information:

• Waiver applies to inpatient claims with a confirmed diagnosis (after positive COVID-19 test).
• Benefit limits/maximums (e.g., SNF days) still apply.
• Standard prior authorizations still apply.
• Waiver applies to covered services from in-network providers. 
• Upon discharge, routine medical benefit coverage will apply.

*For COVID-19 treatment

** For COVID-19 testing and associated visit

BILLING

Please remember to use the new CMS diagnosis code, U07.1, for COVID-19 on claims as appropriate. 

OFFICE VISITS

In alignment with the Families First Coronavirus Response Act, Highmark will waive the member cost share for office visits (including telehealth), urgent care visits and Emergency Department visits when the visit results in a COVID-19 test being ordered or administered.

This means copayments, deductibles, and coinsurance do not apply for COVID-19 testing. This applies to all Medicare Advantage, ACA, and select employer plans. (Members should contact Member Services to see if this applies to their plan using the number on the back of their card.)

If the visit does not result in the COVID-19 diagnostic test being ordered or administered, the visit will be paid based on the member’s benefit plan and standard cost sharing will apply.

ASSOCIATED SERVICES

Additionally, Highmark will waive member cost share for any items or services provided during the visit in which the COVID-19 test is ordered or administered. Items or services unrelated to the evaluation of whether a patient should be tested for COVID-19 will be paid based on the member’s benefit plan.

A service will be considered related to COVID-19 diagnosis or treatment if:

• The COVID-19 test is attached to the claim OR the COVID-19 diagnosis code is on the claim when the provider is not also performing the test (e.g., when the Health department performs the test for the patient)
• The service falls into one of the following categories:
  • Evaluation and Management (Office Visit, Urgent Care, Emergency Department)
  • Consultation
  • Chest X-ray
  • Chest CT
  • Respiratory Panel
  • Influenza Test
  • Breathing Treatment, including drugs administered in the office as part of the treatment
  • Nebulizer Treatment, including drugs administered in the office as part of the treatment

The following service categories are examples of those considered non-related to COVID-19 diagnosis or treatment in the outpatient setting*, where applicable member cost share liability remains in effect. This list may be revised as new information becomes available.

• Allergy Testing
• Ambulance
• Anesthesia
• Behavioral Health
• Chemotherapy
• DME
• Self-administered Prescription and Non-Prescription Drugs
• Occupational Therapy
• Physical Therapy
• Surgery

*Cost sharing for inpatient services will be waived based on Highmark’s decision to pay in-network, inpatient claims for COVID-19 treatment, except for self-funded groups that elected out of the program.

TESTING

SPECIMEN-ONLY COLLECTION

The following codes may be used when collecting specimens for the diagnostic purposes of COVID-19. Reimbursement for specimen collection will, in general, only be separately reimbursed if it is the ONLY code billed on the claim. If billed with another code, such as an E&M code, no separate reimbursement will be allowed.

COVID-19 MOLECULAR TESTING

The following codes have been created for providers and laboratories to allow billing for COVID-19 patient diagnostic tests. Highmark will reimburse each code at the contracted rate or Highmark established Fee Schedule for that service.

When filing the COVID-19 testing and office visits claims, only use one code for COVID-19 testing. Other services provided during the visit may be billed on the same claim but as a separate claim line with the appropriate CPT/HCPC codes. Testing collection code may bundle and not be separately reimbursed when billed with some other services as per standard edit procedure.

For additional coding guidance, CPT Assistant has provided a fact sheet for the SARS-CoV-2 (COVID-19) test in relation to the use of the new CPT code.

ANTIBODY TESTING

While serological tests are becoming more available, these tests have only received emergency use authorization. Serological tests are not standardized and the majority have not undergone FDA review and testing, so their reliability is unknown. Many of these tests could be cross-reactive with other viruses resulting in false positives for example. Finally, it is unknown what immunity antibodies provide to the novel coronavirus.  

The American Medical Association¹ has warned doctors against using these tests designed to identify people already exposed to the coronavirus to make healthcare decisions for individual patients, and Highmark aligns with this guidance.

¹ American Medical Association, “AMA cautions about limitations of antibody testing for SARS-CoV-2,” American Medical Association, May 14, 2020; https://www.ama-assn.org/press-center/press-releases/ama-cautions-about-limitations-antibody-testing-sars-cov-2.