Provider Alert! Update to COVID-19 Testing Billing, Modifier QW

Date: March 21, 2022

Attention: Primary Care Providers

Effective Date: January 3, 2022

Providers should monitor the Texas Children’s Health Plan (TCHP) Provider Portal regularly for alerts and updates associated to the COVID-19 event.  TCHP reserves the right to update and/or change this information without prior notice due to the evolving nature of the COVID-19 event.

Regarding system configuration updates, TCHP will apply updates and reprocess impacted claims as soon as possible. However, due to volume, please allow up to sixty (60) business days to complete. Providers are not required to appeal the claims unless they are denied for other reasons after the claims reprocessing is complete.

Providers should direct questions to their assigned Provider Relations Liaison or send an email inquiry to the Provider Relations Department at providerrelations@texaschildrens.org.

Call to action: In addition to the Clinical Laboratory Improvement Amendments (CLIA) regulations, The Centers for Medicaid and Medicare Services (CMS) released updated guidance for COVID-19 testing billing.

How this impacts providers: Beginning January 3, 2022, the Health and Human Services Commission (HHSC) is requiring providers to include modifier QW when billing for the COVID-19 procedure code 86328 for dates of service on or after September 23, 2020.

The QW modifier is a CLIA guidelines requirement for specific procedure codes based on their complexity and must be included on claims that have CLIA-waived procedure codes. Providers must have the required CLIA certification on file, and must use the QW modifier when it is required. Claims will be denied if the QW modifier is not present on applicable CLIA-waived tests.

Resource: CMS CLIA website

TCHP will reprocess affected claims submitted with the 86328 procedure code and date of service on or after September 23, 2020. Providers may receive an additional payment but are not required to appeal the claims unless they are denied for other reasons after the claims reprocessing is complete.

Next steps for providers: Providers should share this communication with their billing staff.

If you have any questions, please email Provider Network Management at: providerrelations@texaschildrens.org.

For access to all provider alerts, log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.