Provider Information on COVID-19 Coverage

Updated May 05, 2022
 

 

Provider Information on COVID-19 Coverage

Blue Cross and Blue Shield of New Mexico (BCBSNM) is closely monitoring activity around the Novel Coronavirus 2019 (COVID-19). We’ve taken steps to help lower costs and provide our members easier access to care related to COVID-19.

Testing and Treatment Coverage

During the public health emergency (PHE), we are covering FDA-authorized testing to diagnose COVID-19 with no prior authorization needed. COVID-19 tests are covered with no member copays, deductibles or co-insurance when an individual’s health care provider determines that it is medically appropriate to treat or diagnose COVID-19. Testing coverage include tests for pneumonia and influenza with no member cost share.

We also cover testing-related visits with in-network providers with no member copays, deductibles or coinsurance. For fully insured and IBAC members, and pursuant to the OSI cost share waiver rule, cost share is waived for COVID-19-related testing.

Over-the-Counter (OTC) Tests: We cover COVID-19 diagnostic tests members buy without a provider’s involvement or prescription, starting Jan. 15, 2022, through the end of the federal public health emergency. OTC tests must be FDA-authorized. This applies to fully insured, self-insured and individual and family plans. Members can be reimbursed for up to eight tests per covered member every 30 days. This program is through BCBSNM and Prime TherapeuticsTM pharmacy benefits. If a member does not have benefits through Prime Therapeutics, they should contact their pharmacy benefit administrator. More information is on our member microsite.

Not Covered:  Testing for surveillance reasons is not eligible for coverage, including:

  • Return to work
  • School requirements
  • Travel requirements
  • Recreational requirements

 

If testing a member for surveillance reasons, unless they have symptoms or have a known or suspected exposure to COVID-19, claims for such testing are not eligible for reimbursement and should not be submitted.

COVID-19 Treatment: We cover treatment of COVID-19 in accordance with the terms of the member’s benefit plan. Copays, deductibles and coinsurance apply for some members.

For fully insured and IBAC members, the cost-share waiver that began on March 12, 2020, remains in effect. Fully insured and IBAC members will not pay copays, deductibles or coinsurance for COVID-19 testing or treatment. This OSI cost share waiver rule currently has no end date.

Follow our “COVID-19 Coverage for Members” web page for updates.

Note on self-insured groups: Many of our members are covered under a health plan that is self-insured by their employer. Some of these members may have cost-share waived for treatment of COVID-19 depending on their employer’s decision about its benefit plan.

Some members may not have access to out-of-network benefits. In addition, if members receive treatment at out-of-network providers, any cost-share waiver does not protect a member from provider balance or surprise billing. Members may be subject to balance or surprise billing depending on their benefit terms and state or federal laws since a provider may not accept the amount covered under the benefit plan as payment in full.

Medicare members: Medicare (excluding Part D) and Medicare Supplement members won't pay copays, deductibles or coinsurance for:

  • Medically necessary lab tests to diagnose COVID-19 that are consistent with CDC guidance
  • Testing-related visits related to COVID-19 with in-network providers, including at a provider's office, urgent care clinic, emergency room and by telehealth

Blue Cross Group Medicare SupplementSM and Blue Cross Medicare SupplementSM members do not have network restrictions unless otherwise noted on their plans.

Members should always call the number on their ID card for answers to their specific benefit questions. See our FAQs for Medicare Providers for more details.

Check Member Eligibility and Benefits

Use Availity® Essentials  or your preferred vendor for eligibility and benefit verifications.

COVID-19 Vaccine

For information about our COVID-19 vaccination policy, see our News & Update article.

Claims for COVID-19 Testing

If you are collecting a COVID sample from a member, have a lab capable of testing, or are a lab testing a member, submit the claim using the appropriate collection or lab code. Member cost-share for the test will be waived during PHE. Testing must be:

  • For individualized diagnosis or treatment of COVID-19, not for surveillance reasons
  • Medically appropriate
  • In accordance with generally accepted standards of care, including the Centers for Disease Control (CDC) guidance

For more detail on COVID-19 coding and guidance, refer to the American Medical Association  website or the Centers for Disease Control and Prevention .

 

COVID-19 Collection Codes

For details about the collection codes, see CMS' Frequently Asked Questions (FAQs) on Medicare Fee-for-Service Billing

Codes

Description

C9803

For use by hospital outpatient departments: Hospital outpatient clinic visit specimen collection for severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]) any specimen source

G2023

For use by independent clinical diagnostic labs: Specimen collection for severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]), any specimen source

G2024

For use by independent clinical diagnostic labs: Specimen collection for severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]) from an individual in a SNF or by a laboratory on behalf of a HHA, any specimen source

 

COVID-19 Lab Codes

Codes

Description

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

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

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

0226U

Surrogate viral neutralization test (sVNT), severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), ELISA, plasma, serum

0240U

Infectious disease (viral respiratory tract infection), pathogen-specific RNA, 3 targets (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2], influenza A, influenza B), upper respiratory specimen, each pathogen reported as detected or not detected

0241U

Infectious disease (viral respiratory tract infection), pathogen-specific RNA, 4 targets (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2], influenza A, influenza B, respiratory syncytial virus [RSV]), upper respiratory specimen, each pathogen reported as detected or not detected

87426

Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative, multiple-step method; severe acute respiratory syndrome coronavirus (eg, SARS-CoV, SARS-CoV-2 [COVID-19])

87428

Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; severe acute respiratory syndrome coronavirus (eg, SARS-CoV, SARS-CoV-2 [COVID-19]) and influenza virus types A and B

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

87636

Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) and influenza virus types A and B, multiplex amplified probe technique

87637

Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), influenza virus types A and B, and respiratory syncytial virus, multiplex amplified probe technique

87811

Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19])

U0001

CDC 2019 Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel

U0002

2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC

U0003

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

U0004

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

U0005

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, cdc or non-cdc, making use of high throughput technologies, completed within 2 calendar days from date of specimen collection

 

COVID-19 Testing Before Non-COVID-19 Treatment or Procedures

When screening for COVID-19 before elective procedures or treatment not related to COVID-19 active disease or suspicion, bill the test on a separate claim from the rest of the services being rendered. By doing this, our members receive the cost-share waiver for COVID testing and the claim will be processed promptly. The appropriate benefits will apply to the remainder of each member’s non-COVID related care.

At-Home Tests

We cover at-home collection methods for COVID-19 testing if the tests are FDA-authorized and are clinically indicated for the member as determined by the member’s health care provider. We encourage members to consult with their health care provider to determine whether the test is medically appropriate for their condition. Medical or invoice records may be requested to support if an antibody test is FDA authorized or if EUA approval has been requested.

Emergency Room COVID-19 Testing with No Presenting Symptoms

Testing for COVID-19 should be for individualized treatment or diagnosis. If testing is used to screen for COVID-19 before emergency room services not related to COVID-19 active disease or suspicion, bill the test on a separate claim from the rest of the services being rendered. By doing this, we will be able to identify when members should receive the cost-share waiver for COVID-19 testing, and the claim will be processed promptly. The remainder of each member’s non-COVID-19 related emergency room care will be processed according to the member’s benefit plan.

Claims for COVID-19 Antibody Testing

Submit claims for COVID-19 antibody testing to us using the appropriate code. Member cost-share (copay, deductibles and coinsurance) will be waived for antibody tests that are FDA authorized, including tests with Emergency Use Authorized (EUA), regardless of the diagnosis. This waiver will last through the end of the PHE. Medical or invoice records may be requested to support if an antibody test is FDA authorized or if EUA approval has been requested.

Antibody Testing Requirements

Antibody tests must be FDA-authorized, including EUA. Antibody testing should be medically appropriate for the member and ordered by a health care provider. We encourage members to consult with their health care provider to determine the best, medically appropriate test for their condition. Refer to the current FDA position on antibody testing . Medical or invoice records may be requested to support if an antibody test is FDA authorized or if EUA approval has been requested.

Code

Description

0224U

Antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), includes titer(s), when performed

86318

Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative, single step method

86328

Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative, single step method, severe acute respiratory syndrome coronavirus (SARS-CoV-2) (Coronavirus disease COVID-19)

86408

Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]); screen

86409

Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]); titer

86413

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) antibody, quantitative

86769

Severe Acute Respiratory Syndrome Coronavirus 2 [SARS-CoV-2] [Coronavirus disease {COVID-19}] testing via multiple-step method

 

In-Network Providers and Lab Testing

Network physicians are encouraged, and may be contractually required, to inform members as to noncovered services and/or refer our members to participating, in-network providers. Check our online Provider Finder® for labs that are in-network for each member, according to their benefit plan. Informing members as to noncovered services and referring to in-network providers helps members control their health care costs and avoid balance billing by out-of-network providers.

Claims for COVID-19 Testing- and Antibody-Related Services

Use the following coding process for services that are related to COVID-19 testing or antibody testing.

COVID-19 Diagnosis Codes

To indicate services performed in conjunction with the testing for COVID-19 or COVID-19 antibodies, include one of the following diagnosis codes:

Code

Description

B34.2

Coronavirus infection, unspecified

B97.29

Other coronavirus as the cause of diseases classified elsewhere

U07.1

COVID-19 acute respiratory disease

Z03.818

Encounter for observation for suspected exposure to other biological agents ruled out (possible exposure to COVID-19)

Z11.52

Encounter for screening for COVID-19

Z20.822

Contact with and (suspected) exposure to COVID-19

Z20.828

Contact with and suspected exposure to other viral communicable diseases (actual exposure to COVID-19)

 

Modifier CS

For services furnished on March 18, 2020, through the end of the PHE, please use the CS modifier on applicable claim lines to identify the service as subject to the cost-sharing waiver for COVID-19. This is for testing-related services that result in an order for or administration of COVID-19 testing or antibody testing. Use the CS modifier only on the codes specified by the Centers for Medicare & Medicaid Services.  The following types of claims do not need the CS modifier:

  • Screenings before procedures that aren’t related to COVID-19
  • COVID-19 tests
  • Treatment of COVID-19.

Telemedicine

For information about our 2021 telemedicine coverage see our News & Update article.

Pharmacy

We recommend members:

  • Keep supplies of their medications on hand and not wait until last-minute to get refills.
  • Contact their pharmacies to ask about delivery or curb-side/drive-thru options
  • Use their 90-day supply fill benefits (if applies) for non-specialty medications at select retail pharmacies or mail order

Member cost share applies according to their benefit plan. All pharmacy practice safety measures, and prescribing and dispensing laws, remain in force and effect.

Note on Medicare members: Members of these plans can get 90-day fills through mail order:

  • Blue Cross Group Medicare Advantage (HMO)SM
  • Blue Cross Group Medicare Advantage (PPO)SM
  • Blue Cross Group Medicare Advantage Open Access (PPO)SM
  • Blue Cross Group MedicareRx (PDP)SM
  • Blue Cross Medicare Advantage HMO/HMO SNP
  • Blue Cross Medicare Advantage HMO/HMO POS
  • Blue Cross Medicare Advantage (PPO)SM
  • Blue Cross Medicare Rx (PDP)SM
  • Blue Cross Medicare Advantage Dual Care (HMO SNP)SM

Credentialing Process Simplified for COVID-19

BCBSNM is temporarily updating our credentialing policy and processes in response to the COVID-19 emergency. This complies with emergency state and federal regulations and is effective April 3, 2020. The temporary modifications are only in place during the PHE and subject to change based on modifications to state and federal regulations. Thereafter, standard credentialing and processes will apply.

What’s Changing? We are simplifying the process of joining our network.

Subject to state actions on licensing and practice requirements, we will credential providers who meet the following conditions for the duration of the state-declared emergency or as specified by state requirements:

  • We will accept practitioners who hold a full unrestricted license to practice granted by any state subject to the state’s emergency provider licensure laws. We will accept temporary licenses.
  • We will waive accreditation requirements, CMS certification and site visits for institutional providers.
  • We will accept expired documents if they have been inactive or expired for less than six-months and the provider is unable to obtain a current document from the issuer due to the COVID-19 emergency. Licenses, accreditations or certifications that have been revoked for cause will not be accepted.

Credentialing criteria and verification sources may change. Please check back often for updates

What is the risk of COVID-19?

According to recent reports from the CDC, the infection rate from COVID-19 is a rapidly evolving situation. The risk assessment may change daily. The latest updates are available on the CDC’s Coronavirus Disease 2019 (COVID-19) website. We are ready to help you serve our members and the community in understanding, preventing and potentially treating people who have been affected by COVID-19.

We've developed a member-facing flier about COVID-19 that you may share with your patients.

More Information

Because this is a rapidly evolving situation, you should continue to use Centers for Disease Control guidance  on COVID-19, as the CDC has the most up-to-date information and recommendations. In addition, watch for updates on BCBSNM News and Updates.

If you have any questions or if you need additional information, please contact your BCBSNM Provider Relations Representative.

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