Coronavirus (COVID-19) Testing
Coronavirus (COVID-19) diagnostic and antibody (serology) testing is a covered benefit when medically necessary. Beneficiaries suspected to have COVID-19 should be tested following Centers for Disease Control and Prevention (CDC) guidelines. COVID-19 diagnostic and antibody tests must meet Families First Coronavirus Response Act (FFCRA) criteria.
To be considered for coverage, antibody tests must be rendered to diagnose and/or treat beneficiaries. Antibody tests are not a covered benefit when performed:
- on asymptomatic patients;
- to satisfy patient curiosity;
- to determine a patients ability to return to work or school;
- to determine a donor’s ability to donate blood or plasma; and/or
- as part of epidemiological research, surveillance studies or for other public health reason.
There are no approval requirements specific to COVID-19 diagnostic and antibody testing from Health Net Federal Services, LLC.
- Diagnostic testing includes the use of Healthcare Common Procedure Coding system (HCPCS) codes U0001 and U0002 for dates of service on or after Feb. 4, 2020, as well as Current Procedural Terminology (CPT®) code 87635 for dates of service on or after March 13, 2020.
- Antibody testing includes CPT codes 86328 and 86769 for dates of service on or after April 10, 2020.
Beneficiary copayments/cost-shares are waived for COVID-19 diagnostic and antibody testing and related services, and office visits, urgent care or emergency room visits (to include covered telemedicine) during which tests are ordered or administered.
See scenarios below for additional clarification.
- Example 1: Patient visits a provider with flu-like symptoms. A flu test is administered and tests positive. Provider does not order a COVID-19 diagnostic test.
Result: Copayments and cost-shares shall not be waived.
- Example 2: Patient visits an out-of-network primary care provider with flu-like symptoms. A flu test is administered and tests negative. Patient is referred for a COVID-19 diagnostic test. Because the patient is diabetic, the physician orders a laboratory test for an A1C level check and the patient is evaluated for a diabetic ulcer.
Result: The out-of-network cost-share for the visit, the flu test and the COVID-19 diagnostic test shall be waived. The cost-share for the out-of-network A1C test shall not be waived.
- Example 3: Patient visits the emergency room with a broken leg. While evaluating the patient, the doctor identifies symptoms of COVID-19 and orders a COVID-19 diagnostic test.
Result: The copayment/cost-share for the visit and the test shall be waived, but any copayments/cost-shares associated solely with the diagnosis and treatment of the broken leg shall not be waived (for example, X-rays and casting of the leg, DME-related cost-shares for crutches).