Participating Hospital Covid-19 Reimbursement

Effective for Dates of Service beginning January 1, 2021

This guide provides information for Independent Health’s participating hospitals on reimbursement rates for the following COVID-19-related services.

Commercial, Self-Funded, & State Products

  • Cost of vaccine doses: The cost of the vaccine doses currently being dispensed under federal and state vaccination plans is being funded by the federal government so the health plan will not reimburse for the doses. Independent Health will deny claims submitted for the dose for invoice in preparation for when they are no longer obtained at no cost.
  • Administration components: In most circumstances Independent Health will reimburse for the administration components of the vaccination until otherwise directed by the federal government or New York State.

Medicare Advantage

  • Medicare Fee-for-Service is paying for the vaccine and administration components for all Medicare beneficiaries, including those enrolled in Medicare Advantage plans, through calendar year 2021.
  • Providers must submit claims to their applicable Medicare Administrative Contractor (MAC) (National Government Services in Western New York) for reimbursement.

Reimbursement Rates

The below reimbursement rates are effective for vaccines which have obtained FDA Emergency Use Authorization (EUA). Visit the CMS site for a comprehensive list of vaccine products, codes and effective dates as the FDA approves them.

Dates of Service January 1, 2021 – March 14, 2021

Description Service Code Vaccine Effective Date Commercial & Self-Funded State Products
Pfizer Admin 1 0001A 12/11/2020 $15.50 $13.23
Pfizer Admin 2 0002A 12/11/2020 $25.50 $13.23
Moderna Admin 1 0011A 12/18/2020 $15.50 $13.23
Moderna Admin 2 0012A 12/18/2020 $25.50 $13.23
Janssen Admin 1 0031A 02/27/2021 $25.50 $13.23


Dates of Service March 15, 2021 – Current

Description Service Code Vaccine Effective Date Commercial & Self-Funded State Products
Pfizer Admin 1 0001A 12/11/2020 $40.00 $13.23
Pfizer Admin 2 0002A 12/11/2020 $40.00 $13.23
Moderna Admin 1 0011A 12/18/2020 $40.00 $13.23
Moderna Admin 2 0012A 12/18/2020 $40.00 $13.23
Janssen Admin 1 0031A 02/27/2021 $40.00 $13.23

Coverage Grid

This grid indicates instances when Covid-19 vaccine administration services are separately payable.

Place of Service Commercial & Self-Funded Medicare Advantage State Products
Inpatient Hospital Global Bill Medicare Payable*
ER/Observation Global Bill Medicare Global
Part A Skilled Nursing Payable* Bill Medicare Payable*
Dialysis Global Bill Medicare Global
Home Health Payable Bill Medicare Payable

*Hospitals and skilled nursing facilities should include the coding for the vaccine administration directly on the inpatient claim.

Additional Notes

  • Independent Health will be editing claims to ensure providers are not billing for more than one initial or subsequent administration.
  • The administration for the vaccine doses does not need to be completed by the same provider. In the event that a member receives a second vaccine administration from a different provider than their first dose the claim will pay.

Commercial, Self-Funded, & State Products

  • Cost of monoclonal antibody products: The cost of the monoclonal antibody products currently being dispensed are being funded by the federal government so the health plan will not reimburse for the product. Any claims submitted for these monoclonal antibody products will be denied for invoice in preparation for when they are no longer obtained at no cost.
  • Administration components: In most circumstances Independent Health will reimburse for the administration components until otherwise directed by the federal government or New York State.

Medicare Advantage

  • Medicare Fee-for-Service is paying for the monoclonal antibodies and infusion services for all Medicare beneficiaries, including those enrolled in Medicare Advantage plans, through calendar year 2021.
  • Providers must submit claims to their applicable Medicare Administrative Contractor (MAC) (National Government Services in Western New York) for reimbursement.

Reimbursement Rates

The below reimbursement rates are effective for monoclonal antibody infusions when furnished in a manner consistent with the FDA Emergency Use Authorization (EUA). Visit the CMS site for a comprehensive list of monoclonal antibody products, codes and effective dates as the FDA approves them.

Dates of Service January 1, 2021 – April 16, 2021

Description Service Code Vaccine Effective Date Commercial & Self-Funded State Products
Bamlanivimab M0239 11/10/2020 $310.75 $309.60
Casirivimab and imdevimab M0243 11/21/2020 $310.75 $309.60
Bamlanivimab and etesevima M0245 2/09/2021 $310.75 $309.60

Dates of Service April 17, 2021 – Current

On April 16, the FDA revoked the Emergency Use Authorization (EUA) for bamlanivimab, when administered alone, due to a sustained increase in COVID-19 viral variants in the U.S. that are resistant to this antibody therapy. The FDA determined that the known and potential benefits of bamlanivimab, when administered alone, no longer outweigh the known and potential risks. Therefore, for dates of service on or after April 17, 2021, Independent Health will no longer reimburse service code M0239.

Description Service Code Vaccine Effective Date Commercial & Self-Funded State Products
Casirivimab and imdevimab M0243 11/21/2020 $310.75 $309.60
Bamlanivimab and etesevima M0245 02/09/2021 $310.75 $309.60

Coverage Grid

This grid indicates instances when Covid-19 monoclonal antibody infusion services are separately payable.

Place of Service Commercial & Self-Funded Medicare Advantage State Products
ER/Observation Global Bill Medicare Global
Part A Skilled Nursing Global Bill Medicare Global
Home Health Payable Bill Medicare Payable

Reimbursement Rates

Independent Health’s reimbursement rates for Covid-19 laboratory testing services are as follows.

Dates of Service January 1, 2021 – April 22, 2021

Description Service Code Commercial & Self-Funded Medicare Advantage State Products
Ia nfct ab sarscov2 covid19 86328 $45.23 $43.23 $45.33
Neutrlzg antb sarscov2 scr 86408 $42.13 $42.13 $42.13
Neutrlzg antb sarscov2 titer 86409 $105.33 $105.33 $105.33
Sars-cov-2 antb quantitative 86413 $51.43 $51.43 $51.43
Sars-cov-2 covid-19 antibody 86769 $42.13 $42.13 $42.13
Sarscov coronavirus ag ia 87426 $35.33 $35.33 $45.23
Sarscov & inf vir a&b ag ia 84728 $63.59 $63.59 $73.49
Sars-cov-2 covid-19 amp prb 87635 $51.31 $51.31 $51.31
Sarscov2 & inf a&b amp prb 84636 $142.63 $142.63 $142.63
Sarscov2&inf a&b&rsv amp prb 87637 $142.63 $142.63 $142.63
Sars-cov-2 covid19 w/optic 87811 $41.38 $41.38 $41.38
Nfct ds 22 trgt sars-cov-2 0202U $416.78 $416.78 $416.78
Nfct ds 22 trgt sars-cov-2 0223U $298.60 $298.60 $298.60
Antibody sars-cov-2 titer(s) 0224U $42.13 $42.13 $42.13
Nfct ds dna&rna 21 sarscov2 0225U $416.78 $416.78 $416.78
Svnt sarscov2 elisa plsm srm 0226U $42.28 $42.28 $42.28
Nfct ds vir resp rna 3 trgt 0240U $142.63 $142.63 $142.63
Nfct ds vir resp rna 4 trgt 0241U $142.63 $142.63 $142.63
Hopd covid-19 spec collect C9803 $24.67 $24.67 Not Covered
Specimen collect covid-19 G2023 Not Covered Not Covered $23.46
N2019-ncov diagnostic p U0001 $35.91 $35.91 Not Covered
Covid-19 lab test non-cdc U0002 $51.31 $51.31 $51.31
Cov-19 amp prb hgh thruput U0003 $75.00 $75.00 $75.00
Cov-19 test non-cdc hgh thru U0004 $75.00 $75.00 $75.00
Infec agen detec ampli probe U0005 $25.00 $25.00 $25.00

Dates of Service May 1, 2021 – Current

Based on an update from NYS Medicaid dated April 23, 2021, any codes not outlined in their most recent guidance are not covered. To ensure Independent Health remains aligned with NYS Medicaid for these services we updated our fee schedule as noted below for dates of service on or after May 1, 2021.

Description Service Code Commercial & Self-Funded Medicare Advantage State Products
Ia nfct ab sarscov2 covid19 86328 $45.23 $43.23 $45.33
Neutrlzg antb sarscov2 scr 86408 $42.13 $42.13 Not Covered
Neutrlzg antb sarscov2 titer 86409 $105.33 $105.33 Not Covered
Sars-cov-2 antb quantitative 86413 $51.43 $51.43 Not Covered
Sars-cov-2 covid-19 antibody 86769 $42.13 $42.13 $42.13
Sarscov coronavirus ag ia 87426 $35.33 $35.33 $45.23
Sarscov & inf vir a&b ag ia 84728 $63.59 $63.59 $73.49
Sars-cov-2 covid-19 amp prb 87635 $51.31 $51.31 $51.31
Sarscov2 & inf a&b amp prb 84636 $142.63 $142.63 $142.63
Sarscov2&inf a&b&rsv amp prb 87637 $142.63 $142.63 Not Covered
Sars-cov-2 covid19 w/optic 87811 $41.38 $41.38 $41.38
Nfct ds 22 trgt sars-cov-2 0202U $416.78 $416.78 Not Covered
Nfct ds 22 trgt sars-cov-2 0223U $298.60 $298.60 Not Covered
Antibody sars-cov-2 titer(s) 0224U $42.13 $42.13 Not Covered
Nfct ds dna&rna 21 sarscov2 0225U $416.78 $416.78 Not Covered
Svnt sarscov2 elisa plsm srm 0226U $42.28 $42.28 Not Covered
Nfct ds vir resp rna 3 trgt 0240U $142.63 $142.63 Not Covered
Nfct ds vir resp rna 4 trgt 0241U $142.63 $142.63 Not Covered
Hopd covid-19 spec collect C9803 $24.67 $24.67 Not Covered
Specimen collect covid-19 G2023 $0.00 $0.00 $23.46
N2019-ncov diagnostic p U0001 $35.91 $35.91 Not Covered
Covid-19 lab test non-cdc U0002 $51.31 $51.31 $51.31
Cov-19 amp prb hgh thruput U0003 $75.00 $75.00 $75.00
Cov-19 test non-cdc hgh thru U0004 $75.00 $75.00 $75.00
Infec agen detec ampli probe U0005 $25.00 $25.00 $25.00

Specimen Collection Billing & Reimbursement

Commercial, Medicare Advantage and Self-Funded

  • Service Code: C9803
  • Hospital outpatient departments may bill for clinic visits dedicated to specimen collections. This service is conditionally packaged and only receives separate payment when it is billed without another primary covered hospital outpatient service or with a clinical diagnostic laboratory test that is assigned status indicator “A” in Addendum B of the OPPS.

State Products

  • Service Code: G2023
  • During the period of emergency separate reimbursement is available for specimen collection when this is the only service being performed, including the laboratory test itself.

Additional Notes

  • When specimen collection is done via a blood draw, the appropriate specimen collection code would be 36415 (collection of venous blood by venipuncture).
  • Independent Health is following CMS and NYS Medicaid default fee schedule methodology for high-throughput testing. Effective for dates of service January 1, 2021 and after, HCPCS U0003 and U0004 have a rate of $75 for all lines of business. Participating Hospitals may submit, and Independent Health will reimburse, the HCPCS U0005 add-on fee of $25 provided claims meet the following criteria:
    • Participating Hospital completed the test in two calendar days or less; and
    • Participating Hospital completes the majority (> 50%) of COVID-19 diagnostic tests that use high throughput technology in two calendar days or less for all patients in the previous month.
  • In alignment with current Independent Health methodology, payment for Covid-19 laboratory testing within an emergency room, observation, or inpatient stay is packaged to our reimbursement for the hospital stay.
  • When testing is performed by an outside laboratory, claims should be submitted with Modifier 90 (Reference Laboratory).