COVID-19 Guidance for Medicaid Providers

New York State (NYS) Medicaid Fee-for-Service (FFS) Policy and Billing Guidance for COVID-19 influenza, and respiratory syncytial virus (RSV) Testing and Specimen Collection at Pharmacies

As of 2/18/2021
Updates are highlighted

  • Guidance is also available in Portable Document Format (PDF)

Per the Governor´s Executive Order #202.24 and #202.82, during the declared disaster emergency, Section 6801 of the NYS Education Law and Subdivision (6) of section 571 of the NYS Public Health Law have been temporarily modified to the extent necessary to authorize licensed pharmacists to:

  • ⮚ order COVID-19 tests, approved by the Food and Drug Administration (FDA), to detect SARS-CoV-2 or its antibodies;
  • ⮚ order influenza or RSV tests, approved by the Food and Drug Administration (FDA), to detect influenza A or B virus or RSV RNA in specimens collected from individuals ONLY if they are suspected of suffering from a COVID-19 or influenza infection;
  • ⮚ administer COVID-19, influenza, or RSV, tests subject to CLIA Certificate of Waiver requirements pursuant to the federal clinical laboratory improvement act of nineteen hundred eighty-eight, in patients suspected of a COVID-19 infection, or suspected of having recovered from COVID-19 infection, subject to completion of appropriate training developed by the Department of Health; and,
  • ⮚ be designated as a qualified healthcare professional for the purpose of directing a limited service laboratory, pursuant to subdivision 579(3) of the Public Health Law, to test patients suspected of a COVID-19 infection or its antibodies provided that such test is FDA-approved and waived for use in a limited service laboratory.

This guidance is effective May 22,2020 and shall remain in effect for the remainder of the disaster emergency declared by Executive Order No. 202.24, or until the issuance of subsequent guidance by the NYSDOH prior to the expiration of such state disaster emergency declaration. The guidance for influenza and RSV testing is effective December 13th, 2020 and shall remain in effect for the remainder of the disaster emergency declared by Executive Order No. 202.82, or until the issuance of subsequent guidance by the NYSDOH prior to the expiration of such state disaster emergency declaration.

NYS Medicaid FFS will cover COVID-19 specimen collection or CLIA waived COVID-19 testing at pharmacies in accordance with this Executive Orders.

NYS Medicaid FFS will not cover tests that are over-the counter or purchased for at home use. Refer to the NYS Medicaid Billing Guidance for COIVD-19 testing and Specimen collection for information on COVID-19 diagnostic tests with "at home" sample collection. Pharmacies will only be able to bill for Medicaid non-dual eligible members for FDA approved or cleared tests or tests that have been authorized by the FDA under Emergency Use Authorization (EUA) (see billing instructions below). Dual eligible members will continue to access testing services through Medicare.


FFS Pharmacy Billing Instructions:

IMPORTANT INFORMATION:

  • COVID-19 TESTING CLAIMS CAN ONLY BE SUBMITTED STARTING MAY 29, 2020 FOR SERVICE DATES FROM MAY 22, 2020.
  • INFLUENZA AND RSV TESTING CLAIMS CAN BE SUBMITTED STARTING FEBRUARY 18, 2021 FOR SERVICE DATES FROM JANUARY 1, 2021 FOR CODES IN TABLE 3.
  • Services must be provided and documented in accordance with the guidance issued by NYSDOH.
Table 1 - Billing Instructions for Lab Specimen Collection or CLIA waived COVID-19 influenza, or RSV testing
NCPDP D.0. Claim Segment Field Value
436-E1 (Product/Service ID Qualifier) Enter a value of "09" (HCPCS), which qualifies the code
407-D7 (Product/Service ID) Enter one applicable procedure code from Table 2
444-E9 (Pharmacist ID) Enter Pharmacist National Provider Identifier (NPI) number
411-DB (Prescriber ID) Please leave field blank*

* Effective August 6, 2020, claims should be submitted with blanks in the Prescriber ID field (411-DB).

Please see the July 2016 Medicaid Update for further guidance on origin code and serial number valuesvalues that must be submitted on the claim. In the origin code field use "5" and the corresponding serial number of "99999999" for "Pharmacy dispensing" when applicable for non-patient specific orders.

Table 2 - Code List and Reimbursement for Lab Specimen Collection or CLIA waived COVID-19 testing
Code Description Reimbursement
G2023 Specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) $23.46
U0002* 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCov (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC $51.31
87635* Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique. $51.31
87426*
(effective 06/25/2020)
Infectious agent antigen detection by immunoassay technique, (e.g., enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative, multiple-step method; severe acute respiratory syndrome coronavirus (e.g., SARS-CoV-2, SARS-CoV-2 [COVID-19]). $45.28
87811*
(effective 01/01/2021)
Infectious agent antigen detection by immunoassay with direct optical (i.e., visual) observation; severe acute respiratory coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]). $41.38

*Pharmacies that are performing and billing for COVID-19 testing should not bill for specimen collection. Reimbursement for the test includes specimen collection and generating the lab report. Furthermore, pharmacies who are already being provided payment, from another source, for either lab specimen collection or for COVID-19 testing should not bill Medicaid in addition. Information regarding tests that have been granted FDA Emergency Use Authorization can be found here.

Table 3 - Code List and Reimbursement for CLIA waived COVID-19, influenza, and/or RSV testing
Code Description Reimbursement
87634 Infectious agent detection by nucleic acid (DNA or RNA); severe respiratory syncytial virus, amplified probe technique $21.43
87807 Infectious agent detection by antigen detection by immunoassay with direct optical observation; severe respiratory syncytial virus $13.10
87502 Infectious agent detection by nucleic acid (DNA or RNA); influenza virus, for multiple types or sub-types, includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, first 2 types or sub-types. $53.45
87804 Infectious agent detection by antigen detection by immunoassay with direct optical observation; influenza a/b. $14.50
87428* Infectious agent antigen detection by immunoassay technique, (e.g., enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; severe acute respiratory syndrome coronavirus (e.g., SARS-CoV-2, SARS-CoV-2 [COVID-19]) and influenza virus types a and b. $73.49
87636* Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) and influenza virus types a and b, multiplex amplified probe technique. $142.63

*Multiplex Tests: the multiplex codes may be billed for dates of service on or after January 1, 2021. Multiplex codes not outlined in this guidance are not covered. Information regarding tests that are FDA approved and subject to CLIA Certificate of Waiver requirements can be found here.

Medicaid Managed Care (MMC) Billing

Individual MMC plan billing guidance for COVID-19 laboratory testing and specimen collection for pharmacies, is posted on the Medicaid Managed Care Pharmacy Benefit Information Center. Providers can select the MMC plan in question and then select the COVID Testing-Pharmacy Billing Guidance hyperlink to get to the plan specific guidance page on their website. Providers can also access this information on the individual MMC plan websites.

For Medicaid FFS billing questions, please contact the eMedNY Call Center at (800) 343-9000.

For Medicaid FFS Pharmacy Policy questions, please contact ppno@health.ny.gov