Univera Healthcare Updates on COVID-19 (Coronavirus)
Last Updated: 09/10/2020
COVID-19 Information and Resources
We are closely monitoring Novel Coronavirus (COVID-19). Our top priority is the health and well-being of the members that we serve. We are also committed to sharing the information we have when it becomes available to us. Because information is changing and evolving daily, please check back regularly. We are in contact with local, state and federal health and other officials and we will implement applicable orders, regulations,and requirements as they become effective.
Please continue to refer to the following websites for up-to-date health information:
§ U.S. Centers for Disease Control and Prevention
§ New York State Department of Health
§ Your County Health Department
We also encourage you to check our News and Updates regularly for communication updates. Type COVID-19 in the Search area. Keep in mind that you must be logged in with your username and password to access all news updates.
THANK YOU for your patience, understanding and collaboration as we all rally to navigate this new health care landscape.
For all products and lines of business, the Health Plan will provide coverage with no member cost-share for COVID-19 diagnostic/viral testing as well as antibody testing. The testing must be medically appropriate for the diagnosis and treatment of an individual by an attending provider as evidenced by an order from the attending provider.
Attending providers should make individualized determinations regarding whether a test is medically appropriate for each patient based on a personally performed telehealth or face-to-face encounter with their patients, and in accordance with accepted medical standards and practice. Attending providers are responsible for monitoring medical appropriateness guidance issued by federal and state health authorities. The tests must be approved by the U.S. Food and Drug Administration (FDA) or must be the subject of an emergency use order request and the lab performing the testing must be appropriately certified.
Testing that is ordered or performed solely for purposes of pandemic control or re-opening the economy, and not based on a determination by an attending provider that the test is medically appropriate for the diagnosis and treatment of an individual member, is not covered. This includes tests performed on an asymptomatic individual solely to assess health status as required by parties such as a government/public health agency, employer, common carrier, school, camp, or when ordered upon the request of a member solely to facilitate the member’s desire to self-assess COVID-19 immune status.
The following important information regarding antibody testing and antigen testing should be considered when determining the appropriateness of these tests.
We also encourage you to review these testing guidelinesOpen a PDF.
- Antibody testing to diagnose acute infection is not recommended. Viral (nucleic acid or antigen) testing to diagnose acute infection is recommended by the Centers for Disease Control and Prevention.
- Antibody testing is not recommend for use as the sole basis for diagnosis or to rule out COVID-19. Please refer to the FDA website and Infectious Disease Society of America website for additional information.
- Please refer to the Infectious Diseases Society of America’s COVID-19 Antibody Testing Primer.
Key points from the Antibody Primer include, but are not limited to:
- The antibody response in affected patients remains largely unknown and the clinical values of antibody testing have not been fully demonstrated. .
- With the rapid release of numerous antibody tests, there are still issues that need to be addressed, including test quality, interpretation, and utility of antibody tests. These numerous antibody tests vary in the viral antigen(s) they target, and it is not yet clear which antibody responses, if any, are protective or sustained.
- Antibody tests are most useful as surveillance tools to estimate (with surrounding confidence intervals) relative proportions of different populations that have been exposed to SARS CoV2. They have less utility as diagnostic tools for individual patient assessment.
- Not all marketed serological (antibody) tests have been evaluated by the FDA. The FDA’s authorized tests, including serological tests, are listed on its Emergency Use Authorization (EUA) page. Tests being offered under a policy outlined in the FDA’s COVID-19 Diagnostic Policy Guidance are listed on the FDA’s FAQ page. Such tests have not been reviewed by the FDA, unless an EUA has also been submitted and reviewed by the FDA.
- Antibody testing should only be ordered by clinicians familiar with the use and limitations of the test, along with appropriate pre- and post-test counseling documented in the medical record.
CDC Interim Guidance for COVID-19 Antibody Testing
On May 23, 2020, the Center for Disease Control and Prevention issued interim guidelines for COVID-19 antibody testing, which include the following:
- Serologic testing should not be used to determine immune status in individuals until the presence, durability, and duration of immunity is established.
- Serologic test results should not be used to make decisions about grouping persons residing in or being admitted to congregate settings, such as schools, dormitories, or correctional facilities
- Serologic test results should not be used to make decisions about returning persons to the workplace.
- Additional data are needed before modifying public health recommendations based on serologic test results, including decisions on discontinuing physical distancing and using personal protective equipment.
Recommendations for Use of Serologic/Antibody Testing
- Serologic assays that have Emergency Use Authorization (EUA) are preferred for public health or clinical use since their test performance data have been reviewed by FDA.
- Serologic testing can be offered as a method to support diagnosis of acute COVID-19 illness for persons who present late. For persons who present 9-14 days after illness onset, serologic testing can be offered in addition to recommended direct detection methods such as polymerase chain reaction. This will maximize sensitivity as the sensitivity of nucleic acid detection is decreasing and serologic testing is increasing during this time period.
- Serologic testing should be offered as a method to help establish a diagnosis when patients present with late complications of COVID-19 illness, such as multisystem inflammatory syndrome in children.
Limitations of Current Antibody Testing
- Some tests may exhibit cross-reactivity with other coronaviruses, such as those that cause the common cold. This could result in false-positive test results. Some persons may not develop detectable antibodies after coronavirus infection. In others, it is possible that antibody levels could wane over time to undetectable levels.
- Definitive data are lacking, and it remains uncertain whether individuals with antibodies (neutralizing or total) are protected against reinfection with SARS-CoV-2, and if so, what concentration of antibodies is needed to confer protection.
- While antigen tests are thought be very specific for the virus, they are not as sensitive as molecular tests and therefore have a higher chance of false negatives; a negative antigen test result does not rule out infection and may need to be confirmed with a molecular test prior to making treatment decisions or to prevent possible spread of the virus due to a false negative. Please review the FDA’s General FAQs section.
Administrative Policy and Coding Guidance for COVID-19 Viral and Antibody Testing
The Health Plan has implemented Administrative Policy 26 ̶ COVID-19 Viral and Antibody Testing, to define the coverage, reimbursement and billing guidelines for COVID-19 viral and antibody testing. This policy applies to participating and non-participating practitioners, facilities, laboratories and pharmacies and all lines of business effective March 13, 2020, the date of the national state of emergency declaration. This retrospective application is intended to capture all relevant testing claims that were addressed in subsequent federal legislation and guidance.
The Health Plan provides coverage in full for diagnostic/viral testing as well as antibody testing that is determined to be medically appropriate for the diagnosis and treatment of an individual by an attending provider as evidenced by an order from the attending provider. The tests must be FDA approved or the subject of an emergency use order request and the lab performing the testing must be appropriately certified.
For purposes of commercial or Medicaid Managed Care member testing, attending providers are limited to physicians, nurse practitioners, physician assistants and pharmacists. For purposes of Medicare Advantage member testing, attending providers include any health care provider who is authorized to order laboratory tests under New York State law.
Provider claims for medically appropriate COVID-19 testing MUST be submitted with one of the following codes: CPT® codes U0001, U0002, U0003, U0004, 0202U, 86328, 87635, and/or 86769. These codes may be billed with diagnoses of B97.29, U07.1, Z03.818, and/or Z20.828 when appropriate.
Laboratories MUST bill G2023 and G2024 for the purpose of specimen collection of patients at skilled nursing facility or for homebound patients. Again, these codes may be billed with diagnoses of B97.29, U07.1, Z03.818, and/or Z20.828 when appropriate.
Pharmacies providing medically appropriate COVID-19 testing for Medicaid members may submit claims using the National Council for Prescription Drug Programs COVID-19 testing billing methodology. For additional information, please refer to the billing guidance document, NYS Medicaid COVID-19 Sample Collection and Testing Claims Submission.
For additional information, please visit the ESI Pharmacy Resource Center, or contact the ESI Pharmacy Technical Help Desk at 1-800-922-1557.
When the sole purpose of the test is for pandemic control such as testing of asymptomatic individuals to assess health status as required by an employer, school, camp, common carrier, government/public health agency, or research/epidemiologic study, any submitted testing codes (CPT codes U0001, U0002, U0003, U0004 0202U, 86328, 87635, and/or 86769) MUST be accompanied by EITHER one of these encounter codes - Z02.0, Z02.1, Z02.4, Z02.5, Z02.79, Z02.89 Z02.9, Z56.89, and/or Z56.9, OR modifier-CG. These testing claims are not ordered by attending providers as medically appropriate for the diagnosis or treatment of an individual(s) and are not covered.
Claims will be reviewed pre-payment and post-payment. Pre-payment review is claim review prior to payment. A pre-payment review results in an initial determination. Post-payment review is claim review after adjudication. A post-payment review may result in no change to the initial determination or a revised determination. Pre- and post-payment reviews are to ensure claim/billing accuracy and completeness and are not medical necessity reviews.
These services are subject to audit and policy updates at the Health Plan’s discretion. Commercial members will be held liable for claims that deny based upon this policy. Providers will bear responsibility for testing claim denials of Medicare Advantage, Medicaid Managed Care and Health and Recovery Plan members.
You can access this administrative policy in its entirety under the Policies & Guidelines tab. You must log in with your username and password to access our administrative policies.
- Viral testing to rule out an active COVID-19 infection in patients prior to elective procedures is considered a component of pre-admission testing and is not reimbursed separately.
- Viral testing during an inpatient hospital stay prior to transfer to post-acute care (skilled nursing facility or long-term care) is considered part of the hospital DRG.
CDC Interim Guidelines for COVID-19 Antibody Testing:
American Medical Association’s Serological Testing for SARS-CoV-2 Antibodies:
Infectious Diseases Society of America’s IDSA COVID19 Antibody Testing Primer:
Association of Public Health Laboratories and Council of State and Territorial Epidemiologists, Public Health Considerations: Serologic Testing for COVID-19, Version 1 – May 7, 2020:
PLEASE NOTE: During the state of emergency, state and federal governments are issuing frequent COVID-19-related guidance. Our Health Plan’s policies and communications are subject to change accordingly.
The American Medical Association (AMA) has released CPT® codes to streamline COVID-19 testing offered by hospitals, health systems, and laboratories in the United States.
AMA COVID-19 Diagnostic Test Released March 13, 2020:
- CPT Code 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.
AMA COVID-19 Antibody Tests Released April 10, 2020:
- CPT Code 86328: Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative, single step method (e.g., reagent strip); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19])
- CPT Code 86769: Antibody; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), multiple-step method
Coverage for the antibody tests is subject to change. You will be notified if the coverage of antibody testing changes.
AMA COVID-19 CPT Lab Panel Test Released May 20, 2020:
- CPT Code 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
Coverage for the 0202U lab panel is subject to change. You will be notified if the coverage of the 0202U lab panel testing changes.
AMA COVID-19 CPT Lab Test Released June 25, 2020:
- CPT Code 0223U: 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 (Note: QIAstat-Dx Respiratory SARS CoV-2 Panel, QIAGEN Sciences)
- CPT Code 0224U: Antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), includes titer(s), when performed
Important: Do not report 0224U in conjunction with 86769 (Mount Sinai Laboratory; refer to Appendix O in the CPT code set)
- CPT Code 87426: Infectious agent antigen detection by immunoassay technique, (e.g., enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative, multiple-step method; severe acute respiratory syndrome coronavirus (e.g., SARS-CoV, SARS-CoV-2 [COVID-19])
Coverage for the 0223U lab panel, 0224U antibody test, 87426 antigen test is subject to change. You will be notified if the coverage of the Lab testing changes.
CMS HCPCS COVID-19 Diagnostic Laboratory Test Codes
- HCPCS Code U0001: Released February 4, 2020 CDC 2019 novel coronavirus (2019-ncov) real-time rt-pcr diagnostic panel (COVID-19).
- HCPCS Code U0002: Released February 4, 2020 2019-ncov coronavirus, sars-cov-2/2019-ncov (covid-19), any technique, multiple types or subtypes (includes all targets), non-CDC.
- HCPCS Code U0003: Released April 14, 2020 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, making use of high throughput technologies as described by CMS-2020-01-R.
- HCPCS Code U0004: Released April 14, 2020 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC, making use of high throughput technologies as described by CMS-2020-01-R.
COVID-19 Diagnostic Laboratory Testing
- Report U0001, U0002, U0003, U0004 or 87635, as directed by AMA guidance (refer to AMA links below and CMS link below).
- To report a confirmed COVID-19 diagnosis, use U07.1 (COVID-19), as directed by guidance from the U.S. Centers for Disease Control and Prevention (refer to CDC 4.1.2020 link below).
HCPCS COVID-19 New Specimen Collection Codes for Laboratory Only Billing for COVID-19 Released March 1, 2020
- HCPCS Code G2023: Specimen collection for severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]), any specimen source.
(Note: Homebound patient per CMS)
- HCPCS Code G2024: Specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), from an individual in a skilled nursing facility or by a laboratory on behalf of a home health agency, any specimen source; https://www.cms.gov/files/document/covid-final-ifc.pdf
The rule specifies that these codes are only billable by independent laboratories and only in instances where trained personnel from the lab travel to collect the specimens from patients who are either homebound or are non-hospital inpatients.
HCPCS COVID-19 New Specimen Collection Code for Hospital Outpatient Billing for COVID-19 Released July 1, 2020 for March 1, 2020:
- HCPCS Code C9803: Hospital outpatient clinic visit specimen collection for severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]), any specimen source; https://www.cms.gov/files/document/covid-19-laboratories.pdf
Coverage for C9803 collection is subject to change. You will be notified if the coverage of C9803 collection changes.
AMA CPT Code Specimen Collection Code for Provider Billing for COVID-19 Released May 6, 2020-Update:
- CPT Code 99211*: Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services.
*99211 is a limited evaluation and management (E & M) service by a non-physician for the adaptive purpose of the COVID-19 assessment questionnaire and collection of the COVID-19 swab. There are diagnosis restrictions such as U07.1, B97.29, Z03.818, Z20.828 for the COVID-19-related service coverage eligibility and 99211 is subject to the applicable administrative policy and editing guidelines.
AMA COVID-19 Lab Panel Test Released August 10, 2020:
- CPT Code 0225U: Infectious disease (bacterial or viral respiratory tract infection) pathogen-specific DNA and RNA, 21 targets, including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), amplified probe technique, including multiplex reverse transcription for RNA targets, each analyte reported as detected or not detected. Note: ePlex® Respiratory Pathogen Panel 2, GenMark Dx, GenMark Diagnostics, Incb (diagnostic testing)
Coverage for the 0225U is subject to change. You will be notified if the coverage of the Lab testing changes.
COVID-19 Office Visit, Urgent Care or Emergency Room Services
- Report Z20.828* or Z03.818 for exposure to COVID-19. Use U07.1 if diagnosis is confirmed. Please follow the updated CDC guidelines (refer to CDC 4.1.2020 link below)
*Z20.828 should be used when the provider indicates that COVID-19 is “suspected,” “possible,” or “probable.”
- CPT Assistant August 2020 Update, Special Edition
- CPT Assistant June 2020 Update, Special Edition
- CPT Assistant May 2020 Update, Special Edition
- AMA CPT Lab Guidelines 4.1.2020
- AMA CPT Lab guidelines 3.13.2020
- CDC Release 4.1.2020 through 9.30.2020: Guidelines for U07.1
- CDC Release 3.18.2020: U07.1 effective April ,1, 2020 COVID-19 confirmed diagnosis
- CDC Release 2.20.2020: B97.29 interim code February 20,2020 COVID-19 confirmed diagnosis
- CMS HCPCS Quarterly Update (please refer to the April and July 2020 links)
Please also review the Health Plan’s Administrative Policy, AP-26 Viral and Antibody Testing, (select the Administrative Policies card. User name and password required).
The following information outlines the steps that we are taking to address state requirements and guidance. We have also included information on the additional efforts we are taking as a health plan to ensure member access to care and the reduction in administrative burden on our participating providers, hospitals and facilities.
Complying with Regulatory Guidance
(Please refer to NYS Dept of Financial Services Supplement No. 2 to Insurance Circular Letter No. 8 and our communication dated July 6, 2020)
- The Health Plan will resume retrospective review for non-COVID-related services for inpatient and outpatient hospital, mental health and substance use disorder treatment facilities provided on and after June 19, 2020. We are committed to ensuring that our request for medical records in support of these reviews will be reasonable.
- The Health Plan will not deny emergency department and/or inpatient hospital services as not medically necessary on retrospective review if the services were provided to our members to diagnose or treat COVID-19 during the declared state of emergency.
- We continue to work diligently to ensure that hospital claims processing is completed expeditiously, while following all required steps and processes to confirm member eligibility, coverage and cost-share responsibility.
- While the prompt pay provisions of New York’s Insurance Law allow health plans 30 days to process electronic claims and 45 days to process paper claims, we are making good faith efforts to reduce these processing time frames during the state of emergency.
Health Plan Efforts During the COVID-19 State of Emergency
The Health Plan is taking the following steps to ensure member access to care and assist in alleviating some of the burden on our participating providers, hospitals and facilities during the State of Emergency.
- Increasing payment levels for and expanding telehealth services. (Please refer to our March 20, 2020 mailed communication. Contact your Provider Relations representative to request a copy.)
- Waiving member cost-share responsibility for telehealth services.
- Extending the time frame to submit an initial clinical editing dispute and a second level grievance. The initial dispute time frame will change from 120 days to 210 days. The second level grievance time frame will change 90 days to 180 days. Please remember to attach medical records with your initial submission to avoid additional submission requests.
- Facility claim recovery audits for both inpatient and outpatient claims will be suspended for 90 days. Claims currently in the appeal process will be extended 90 days.
- Physician claim audit appeal time frames will be extended to 90 days.
- Suspending timely filing requirements for claims with dates of service from March 16, 2020 through September 16, 2020.
- Suspending medical record requests for HEDIS reviews for our commercial and Medicaid members.
- Providers who can bill for evaluation and management services and feel that an at-home visit with a member is necessary can bill CPT codes 99341-99350 for all health plan members. Reimbursement rates for CPT codes 99341-99350 are included in the physician fee schedules posted on our website.
- During the State of Emergency, the health plan is suspending the credentialing requirement that a physician be licensed in New York state if he/she is licensed in another state. The health plan reserves the right to recommend to our Credentialing Committee certain individuals be accepted for temporary participation during the State of Emergency on a fast-track basis.
- Voluntarily electing not to pass through the New York State Medicaid 1% sequestration payment reductions for affected services at this time.
- Health plan-employed clinicians registering to volunteer their time and expertise to assist during the State of Emergency.
We will waive the cost-share for all telehealth visits (not just those related to COVID-19) for all of our members from March 13, 2020 until the State of Emergency has been lifted.
A telehealth visit is an option for initial screenings when an in-office visit is not an option. Telehealth services are covered under all product lines.
During the COVID-19 State of Emergency declared by Governor Cuomo, electronic information and communication technologies for telehealth include “telephonic and video modalities including technology commonly available on smart phones and other devices (e.g., Skype, FaceTime, Zoom), when medically appropriate to deliver health care services.”
In-network telehealth visits
In-network telehealth visits will be covered with no member cost-share when the services would have been covered under the member’s policy if delivered in-person, including behavioral health treatment. To be covered as an office visit, the telehealth consultation must include all elements necessary for the service to be considered an office visit.
Telehealth services provided from March 13, 2020 until the State of Emergency has been lifted
We will reimburse all telehealth visits at the same rate as in-person visits for the same CPT code, and we will use the higher non-facility (office) relative value units for dates of service from March 13, 2020 until the State of Emergency has been lifted.
Please refer to our telehealth coding guidance gridOpen a PDF for assistance with the appropriate modifier and place of service code to use for the service rendered. This grid will be updated as needed, so please check back regularly.
The patient must provide consent prior to rendering telehealth services. The consent can be written or verbal and must be documented in the patient’s medical record.
Please review our corporate medical policy related to telehealth services.
Corporate Medical PolicyOpen a PDF
To learn more about telehealth services, including training on the use of telehealth technology, please send an email to UniveraPR@univerahealthcare.com. Please include any questions you have about telehealth so that we can make every effort to provide information that is relevant to you.
We are closely monitoring the supply of medications that are available during the COVID-19 outbreak.
We have implemented early refill overrides for prescription medications. Pharmacists can make the override at the point of sale.
We are increasing access to prescription medications by waiving early medication refill limits on 30-day prescription maintenance medications (consistent with a member’s benefit plan).
Members are also encouraged to use their 90-day mail order benefit for prescription medications.
We will ensure formulary flexibility if shortages or access issues do occur. Emergency prescription drug overrides are also available as part of our standard exception process on an individual member basis.
On August 5, 2020, the New York State Department of Financial Services (“DFS”) issued Circular Letter No. 14 (2020) regarding charges for personal protective equipment (“PPE”) by health care and dental care providers. The Circular Letter addresses complaints received from some individuals who have been charged for PPE used by their health care/dental care provider and reminds providers that they are limited to collecting applicable patient health plan cost-sharing and prohibited from balance billing.
The Circular Letter also advises health care and dental care providers that they must refund health plan members for any fees collected for PPE. To review the Circular Letter, please visit the DFS website.
The Health Plan has not changed its reimbursement policy related to PPE, supplies or materials; they are not covered and are considered inclusive to the service provided.