Add-on Payment for COVID-19 Diagnostic Testing Run on High Throughput Technology (U0005)

Reimbursement Policy:
Add-on Payment for COVID-19 Diagnostic Testing Run on High Throughput Technology (U0005)

Effective Date:
January 1, 2021

Purpose:
To provide guidelines for additional reimbursement of COVID-19 diagnostic testing run on high throughput technology.

Scope:
All products are included, except:

• Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap).
• COB

Policy:
Effective January 1, 2021 and throughout the period of public health emergency, Horizon BCBSNJ shall consider an additional add-on payment (U0005) for COVID-19 diagnostic testing run on high throughput technology, when billed with procedure code U0003 or U0004, and when the following conditions are met:

• U0003 or U0004 COVID-19 testing is completed in two (2) calendar days or less for the specific test billed, and
• The laboratory can certify that 51% of the previous months U0003 and U0004 COVID-19 diagnostic testing was completed within two (2) calendar days or less.

It is the responsibility of the laboratory to maintain self-certification of the above conditions. Failure to adhere to the above conditions while continuing to bill U0005 shall be considered inappropriate billing inconsistent with this policy, and Horizon BCBSNJ may not consider add-on payments eligible for reimbursement.

Horizon BCBSNJ reserves the right to perform post service audit to ensure the above requirements are being met. If audit results determine that the billed test turnaround time or the 51% criteria in the previous month was not met, all claims reimbursed within the audit period for procedure code U0005 shall be adjusted with payment recaptured and no future payments made for U0005 until such time as Horizon BCBSNJ is satisfied the conditions for reimbursement are being met.

The procedure codes and nomenclature used in this Policy are subject to revision and/or change by the American Medical Association. In the event of such changes, the Policy will continue to be in force, albeit applied to the new or amended coding so issued until such time as the Policy is reviewed and updated to reflect the new or amended coding.

Procedure:
Horizon BCBSNJ shall reimburse add-on procedure code U0005.

Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:

• Group or Individual benefit
• Provider Participation Agreement
• Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
• Mandated or legislative required criteria will always supersede.

History:
12/21/2020: Policy approved

Policy143_v1.0_12212020