Audience: Participating Physicians, Hospitals, Facilities and Laboratories
For its commercial members, the Health Plan provides coverage with no member cost-share for COVID-19 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.
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.
Important Information Regarding COVID-19 Testing
Attending providers should use clinical judgment to determine whether COVID-19 testing is appropriate for the individual and which test(s) (i.e., diagnostic or serologic) should be obtained.
The following important information regarding antibody testing and antigen testing should be considered when determining the appropriateness of these tests.
- 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.
- 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 General FAQs section.
Coding and Reimbursement for COVID-19 Testing for our Commercial Members
- Additional, detailed coding guidance for COVID-19 testing will be issued separately.
- 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.
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.