Participating Hospital Covid-19 Reimbursement

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 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

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.

Coverage Grid

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

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.

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).