Provider Alert! COVID-19 Disaster Declaration – COVID-19 Testing expanded to include Out-of- Network (OON) Laboratories

Date: January 7, 2021
Attention: All Provider Notice
Effective Date: NEW update for dates of service on or after October 6, 2020

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.

The content in this message will remain in effect throughout the COVID-19 Disaster Declaration period as announced by the office of the Texas Governor, Greg Abbott.
TCHP COVID-19 Utilization Management Procedure and provider alerts can be found here: http://www.thecheckup.org/provider-alerts/

 

Call to action:
Quest Diagnostics (Quest) is TCHP’s exclusive lab provider.  Quest is continuously working to expand their capacity for COVID-19 testing and ensure timely turnaround of results.  As a result of the COVID-19 disaster declaration, TCHP has instituted the following through the disaster declaration period.. At that time, TCHP will reassess the need for an extension.

In order to increase access to COVID-19 testing services TCHP will temporarily accept claims from Out of Network (OON)  Laboratory providers for COVID19 diagnostic testing only.  TCHP will consider claims under the following circumstances only:

Update effective for dates of service on or after October 6, 2020:
COVID-19 testing procedure codes 87636, 87637, and 87811 became benefits for the following programs: Medicaid, Healthy Texas Women, and the Family Planning Program.
Procedure codes 87636, 87637 and 87811 are benefits for the following providers and places of service:

 

Place of Service	Provider Type
Office	Family Planning Clinics  Physician, Physician Groups, Physician Assistant, Nurse Practitioner, Clinical Nurse Specialist, Certified Nurse Midwife
Outpatient Hospital	Family Planning Clinics
	Hospital Providers
Independent Laboratory	Independent Laboratory/Privately Owned Laboratory Providers

 

• 87636 and 87637-two laboratory tests that simultaneously detect the COVID-19 virus, and Influenza A/B and respiratory syncytial virus.
• 87811-Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19])

Reference: https://www.tmhp.com/news/2020-10-26-covid-19-testing-procedure-codes-87636-87637-and-87811-are-now-benefits

Update effective for dates of service on or after September 8, 2020:
COVID-19 testing procedure code 86413 will be added in the following programs: Medicaid, the Children with Special Health Care Needs (CSHCN) Services Program, Healthy Texas Women (HTW), and Family Planning Program.

Procedure code 86413 is a benefit for the following providers and places of service:

 

Place of Service	Provider Type
Office	County Indigent Health Care Program, Physician, Physician Groups, Physician Assistant, Nurse Practitioner, Clinical Nurse Specialist, Certified Nurse Midwife, Registered Nurse
Outpatient Hospital	Hospital Providers
Independent Laboratory	Independent Laboratory/Privately Owned Laboratory Providers

 

• Procedure code 86413 will not be reimbursed until expenditures are approved Texas Medicaid adopts the rates. Providers will be notified of any benefit changes in a future article.
• Services provided before the expenditures are approved will receive the following explanation of benefits (EOB) 02008 notification, “This procedure code has been approved as a benefit pending the approval of expenditures. Providers will be notified of the effective dates of service in a future notification if expenditures are approved.”
• Once expenditures are approved, TMHP will automatically reprocess the affected claims. Providers are not required to appeal the claims unless they are denied for other reasons after the claims reprocessing is complete.

Reference: http://www.tmhp.com/news/2020-10-13-addition-procedure-code-86413-covid-19-testing

Update effective for dates of service on or after August 10, 2020:
COVID-19 testing procedure codes 86408 and 86409 became benefits in the following programs: Medicaid, the Children with Special Health Care Needs (CSHCN) Services Program, Healthy Texas Women (HTW), and Family Planning Program.
Procedure codes 86408 and 86409 are benefits for the following providers and places of service:

Place of Service	Provider Type
Office	County Indigent Health Care Program, Physician, Physician Groups, Physician Assistant, Nurse Practitioner, Clinical Nurse Specialist, Certified Nurse Midwife, Registered Nurse
Outpatient Hospital	Hospital Providers
Independent Laboratory	Independent Laboratory/Privately Owned Laboratory Providers

• The new procedure codes will not be reimbursed until expenditures are approved and Texas Medicaid adopts the rates. Providers will be notified of any benefit changes in a future article.
• Services provided before the expenditures are approved will receive the following explanation of benefits (EOB) 02008 notification, “This procedure code has been approved as a benefit pending the approval of expenditures. Providers will be notified of the effective dates of service in a future notification if expenditures are approved.”
• Once expenditures are approved, TMHP will automatically reprocess the affected claims. Providers are not required to appeal the claims unless they are denied for other reasons after the claims reprocessing is complete.

Reference: http://www.tmhp.com/news/2020-10-13-covid-19-testing-procedure-codes-86408-and-86409-are-now-benefits

Update effective for dates of service on or after June 25, 2020:

Procedure code 87426 may be reimbursed as follows:

Place of Service	Provider Type
Office	County Indigent Health Care Program, Physician, Physician Groups, Physician Assistant, Nurse Practitioner, Clinical Nurse Specialist, Certified Nurse Midwife, Registered Nurse
Outpatient Hospital	Hospital Providers
Independent Laboratory	Independent Laboratory/Privately Owned Laboratory Providers

Reference: Additional Procedure Code for COVID-19 (Coronavirus) Testing for Texas Medicaid

 

• Procedure code U0002 must be submitted with modifier QW. The provider must bill using the appropriate COVID-19 procedural coding.
• The Centers for Medicare & Medicaid services (CMS) has issued two new procedure codes for COVID-19 testing.
  • U0002 (A laboratory test that is not the CDC-developed test kit-any technique)
  • U0001 (for CDC-developed test kit). The codes are effective April 1, 2020 for dates of service on or after February 4, 2020.
  • New CPT code for use on or after March 13, 2020, 87635 (a laboratory test that is not the CDC-developed test kit- amplified probe technique).
    Reference: Update to “Coronavirus Testing Procedure Codes to Become a Benefit”
• CMS has issued two new HCPCS codes for lab tests that use high-throughput technologies to test for COVID-19. Providers can submit these codes for dates of service on or after April 14, 2020. Codes U0003 and U0004 are accepted as the codes for rapid testing:
  • U0003 – A laboratory test performed using high-throughput technologies that is not the CDC-developed test kit (amplified probe technique)
  • U0004 – A laboratory test performed using high-throughput technologies that is not the CDC-developed test kit (any technique)
• The American Medical Association (AMA) announced one revised CPT code and two new CPT codes that providers can submit for antibody testing for dates of service on or after April 10, 2020:
  • 86318 – Multiple infectious agents antibody testing performed using a single-step method immunoassay (Revised)
  • 86328 – COVID-19 Antibody testing performed using a single step method immunoassay
  • 86769 – COVID-19 Antibody testing performed using a multiple step method
• CMS has issued two new HCPCS codes for COVID-19 specimen collection. Laboratories can submit these codes for dates of service on or after March 1, 2020:
  • G2023 – Specimen collection, any specimen source (for use by laboratories only)
  • G2024 – Specimen collection from an individual in a skilled nursing facility or by a laboratory on behalf of a home health agency, any specimen source (for use by laboratories only)
• All other providers may continue to bill for the COVID-19 specimen collection using one of these existing codes:
  • 99001 – Handling and/or conveyance of specimen
  • 99211 – Established office visit not requiring the presence of a physician
• The provider must have a valid NPI number that has been attested to with Texas Medicaid;
• The provider must be a CLIA certified laboratory for high complexity lab testing.
• The provider must include their CLIA certificate number on the submitted claim for the billing laboratory;
• For Electronic Claims Submission for the billing laboratory include the CLIA certificate number in X12N 837 (HIPAA version) loop 2300, for REF02 and X4 ƒ ANSI for REF01.
  For the laboratory, include in X12N 837 (HIPAA version) loop 2400 for REF02 and F4 for REF01.
  • For Paper claims – include the CLIA certificate number in item 23 on the CMS-1500 billing form.

The provider must be FDA certified for COVID-19 testing.

NOTE: Claims must be submitted based on all established Texas Medicaid and national claim coding standards.

How this impacts providers:

• Clean claims accepted for adjudication will be reimbursed at 100% of the Texas Medicaid allowable rate established for COVID-19 testing. Please note that acceptance of a claim is not a guarantee of payment. The claim will be adjudicated at the time of submission, at which time the service will be evaluated based on the member’s eligibility and benefits status for the submitted date of service. All applicable rules and standards set forth for Texas Medicaid and TCHP claim adjudication will apply.

• Provider claims are subject to information validation upon post-payment review and are subject to recovery efforts should the above-defined criteria for claim submission not be verifiable.

Testing for medically fragile members receiving care at home:

TCHP aligns with HHSC guidance regarding specimen collection in the home as long as a trained professional is performing the collection and proper storage instructions are followed it is permitted.
Providers with a Certificate of Waiver are allowed to perform and bill procedure codes 87635 and U0002 with the QW modifier.

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.