Effective Date: January 1, 2021

Last Revised: May 1, 2023

Purpose:

To provide guidelines for the reimbursement of COVID-19 diagnostic testing run on high throughput technology.

Scope:

Products included:

• NJ FamilyCare/Medicaid
• Fully Integrated Dual Eligible Special Needs Program (FIDE-SNP)

Policy:

IMPORTANT NOTE: The guidelines of this policy are retired beginning May 12, 2023. These policy guidelines are not applicable for services rendered May 12, 2023 and after.

Effective January 1, 2021 and throughout the period of public health emergency, Horizon NJ Health shall consider for reimbursement an additional add-on payment (Procedure code U0005) for COVID-19 diagnostic testing run on high throughput technology, when billed with procedure code U0003 or U0004, and when the following conditions are met:

• U0003 or U0004 COVID-19 testing is completed in two (2) calendar days or less for the specific test billed, and
• The laboratory can certify that 51% of the previous months U0003 and U0004 COVID-19 diagnostic testing was completed within two (2) calendar days or less.

It is the responsibility of the laboratory to maintain self-certification of the above conditions. Failure to adhere to the above conditions while continuing to bill U0005 shall be considered inappropriate billing inconsistent with this policy, and Horizon NJ Health may not consider add-on payments eligible for reimbursement.

Horizon NJ Health reserves the right to perform post service audit to ensure the above requirements are being met. If audit results determine that the billed test turnaround time or the 51% criteria in the previous month was not met, all claims reimbursed within the audit period for procedure code U0005 shall be adjusted with payment recaptured and no future payments made for U0005 until such time as Horizon NJ Health is satisfied the conditions for reimbursement are being met.

Procedure:

Horizon NJ Health will consider for reimbursement add-on procedure code U0005 when the criteria of this policy has been met.

References:

American Medical Association, Current Procedural Terminology (CPT®) and associated publications and services

Limitations and Exclusions:

Notwithstanding the foregoing, all payment determinations are subject to all other, applicable limitations, including but not limited to, the following:

• Benefit Limitations;
• The terms of any applicable provider participation agreement;
• Routine claim editing logic, including but not limited to incidental or mutually exclusive logic;
• Medical necessity; and
• Applicable law, regulatory guidance, government mandates, and the terms of the Managed Care Contract between Horizon NJ Health and the New Jersey Department of Human Services, Division of Medical Assistance and Health Services.

CPT Copyright 2017 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. The CPT codes and nomenclature used in this Policy are subject to revision and/or change by the American Medical Association. In the event of such changes, the Policy will continue to be in force, albeit applied to the new or amended coding so issued until such time as the Policy is reviewed and updated to reflect the new or amended coding.

History:

02/28/2021: Policy updated- General formatting changes and scope updated.
07/03/2022: General formatting changes.
05/12/2023: This policy is retired effective May 12, 2023 as codes U0003, U0004 and U0005 are terminated effective May 12, 2023.