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COVID-19 Testing and Testing Related Services

Reimbursement Policy:
COVID-19 Testing and Testing Related Services

Effective Date:
November 15, 2021

Purpose:
Provide guidelines for the reimbursement of COVID-19 Testing and Testing Related Services.

Scope:
All products are included, except:

  • FEP
  • Flex Link
  • MPL

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, that is 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 or treatment of COVID-19 or another health condition is beyond the scope of section 6001 of the FFCRA. Accordingly, Horizon BCBSNJ shall not consider for reimbursement COVID-19 testing that is not for the purpose of individualized diagnosis or treatment, such as testing conducted to screen for general workplace safety, public surveillance, residency requirements, and/or other personal leisure activities, including travel. Therefore, Horizon BCBSNJ will require a claim submission to contain appropriate ICD10 diagnosis codes as outlined below, when applicable:

Horizon requires a claim submission to contain an ICD-10 diagnosis code related to encounters for administrative examination including, but not limited to, those on the following list, when testing is being 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 or treatment of COVID-19 or another health condition:

  • Z02 - Encounter for administrative examination
  • Z02.0 - Encounter for examination for admission to educational institution
  • Z02.1 - Encounter for pre-employment examination
  • Z02.2 - Encounter for examination for admission to residential institution
  • Z02.3 - Encounter for examination for recruitment to armed forces
  • Z02.4 - Encounter for examination for driving license
  • Z02.5 - Encounter for examination for participation in sport
  • Z02.6 - Encounter for examination for insurance purposes
  • Z02.7 - Encounter for issue of medical certificate
  • Z02.71 - Encounter for disability determination
  • Z02.79 - Encounter for issue of other medical certificate
  • Z02.8 - Encounter for other administrative examinations
  • Z02.81 - Encounter for paternity testing
  • Z02.82 - Encounter for adoption services
  • Z02.83 - Encounter for blood-alcohol and blood-drug test
  • Z02.89 - Encounter for other administrative examinations
  • Z02.9 - Encounter for administrative examinations, unspecified

In addition, as of November 15, 2021, Horizon shall no longer consider reimbursement, for COVID-19 Testing and “related services” submitted with any of the following ICD 10 codes, individually, or in combination. This list reflects correct coding guidance from CMS and will be expanded or modified to reflect the most current guidance. Please utilize 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

Procedure:
Horizon BCBSNJ shall deny claims for COVID-19 testing and/or testing related services (including delivery and collection of the specimen for testing) when the purpose of the testing is employment screening, public surveillance, personal medical certification, residency requirement, and/or other personal leisure activities. These services will be denied according to a member benefit exclusion. Horizon BCBSNJ may evaluate claim submissions prior to Nov 15, 2021, to assess the services rendered to Horizon BCBSNJ members.

In denied instances the member’s liability may be up to the provider’s charge.

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.

Resources:

History:
11/04/2021: Policy approved

Policy150_V4.0_11022021