COVID-19 Testing and Testing Related Services Reminder: Official Policy
Effective November 15, 2021, Horizon will enforce how we consider and reimburse certain claims for COVID-19 testing and related services based on the guidelines of the COVID-19 Testing and Testing Related Services reimbursement policy.
The Family First Coronavirus Response Act (FFCRA) and the Coronavirus Aid, Relief, and Economic Security Act (CARES Act) require coverage of items and services only for diagnostic purposes. Clinical decisions about testing are made by the individual’s attending health care provider and may include testing of individuals with signs or symptoms compatible with COVID-19, as well as asymptomatic individuals with known or suspected recent exposure to SARS-CoV-2. This should be determined to be medically appropriate by the individual’s health care provider, consulting CDC guidelines as appropriate.
Testing conducted to screen for general workplace health and safety (such as employee “return to work” programs), for public health surveillance for SARS-CoV-2, or for any other purpose not primarily intended for individualized diagnosis, treatment of COVID-19 or another health condition is beyond the scope of section 6001 of the FFCRA. Accordingly, Horizon shall not consider reimbursement of COVID-19 testing that is not for the purpose of individualized diagnosis or treatment. Claims for COVID-19 testing and/or testing related services (including delivery and collection of the specimen for testing) will be denied when the purpose of the testing is:
- Employment screening,
- Public surveillance,
- Personal medical certification,
- Residency requirement, and/or
- Other personal leisure activities.
COVID-19 testing and/or testing related services will be denied according to a member benefit exclusion when the services are determined to be for asymptomatic individuals with no known or suspected recent exposure to COVID-19, such as for public health surveillance or employment purposes. The diagnosis and procedure codes submitted on the claim will be reviewed to determine the purpose of the testing and eligibility for coverage. For detailed information, please review the COVID-19 Testing and Testing Related Services reimbursement policy. Testing is not covered for population screening (for example, back-to-school or return-to-work purposes) or in preparation for travel, for public health surveillance for SARS-CoV-2, or for any other purpose not primarily intended for individualized diagnosis, or treatment of COVID-19 or another health condition.
In addition, as of November 15, 2021, Horizon shall no longer consider reimbursement for COVID-19 testing and “related services”¹ submitted with any of the following ICD-10 codes, individually, or in combination.² This list reflects correct coding guidance from CMS and will be expanded or modified to reflect the most current guidance. Please use appropriate ICD-10 diagnosis codes when submitting claims for COVID-19 testing and related services:
- Z11.52 - Encounter for screening for COVID-19. Per CMS 2021 ICD-10 Coding Guideline, during the COVID-19 pandemic, a screening code is generally not appropriate. Do not assign code Z11.52, Encounter for screening for COVID-19.
- Z11.59 - Encounter for screening for other viral diseases
- Z0000 - Encounter for general examination without complaint, suspected or reported diagnosis and without abnormal findings
The guidelines of this policy apply to claims for patients enrolled in Horizon fully insured commercial plans, Administrative Services Only (ASO) group employer plans (including New Jersey State Health Benefits Program/School Employees’ Health Benefits Program [SHBP/SEHBP] plans) and Horizon Medicare Advantage plans (including Braven Health℠ plans).
We encourage you to review our COVID-19 Testing and Testing Related Services reimbursement policy.
² See ICD-10-CM Official Guidelines for Coding and Reporting FY 2021 – UPDATED January 1, 2021.