COVID 19 Antibody Testing

Effective Date: August 1, 2020

Purpose:
To provide guidelines for the reimbursement of COVID 19 antibody (serological) testing (CPT Codes 86328 and 86769).

Scope:
Products included:

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

Definitions:

  • Antibody Testing: According to the CDC, an antibody test checks an individual’s blood by looking for antibodies, which indicate a past infection with the virus that causes COVID-19. Antibodies are proteins that help fight off infections and may provide protection against getting that disease again (immunity). Antibodies are disease specific. The CDC has advised that it is currently not clear whether a positive serologic test indicates immunity against COVID-19, and serologic tests should not be used at this time to determine if an individual is immune.

Policy:
New guidance was issued on June 23, 2020 jointly by the Department of Labor (DOL), the Department of Health and Human Services (HHS), and the Department of the Treasury (collectively, the Departments). Guidance was also issued by the New Jersey Department of Health (DOH) on July 31, 2020 in the form of an infograph. Those guiding documents are the basis for this reimbursement policy.

In the federal guidance, the Departments clarified that coverage for antibody testing must be provided consistent with the requirements of section 6001 of the Families First Coronavirus Response Act (FFCRA) as amended by the Coronavirus Aid, Relief, and Economic Security Act (CARES Act) when medically appropriate for the individual, as determined by the individual’s attending health care provider in accordance with accepted standards of current medical practice. Clinical decisions about testing are made by the individual’s attending health care provider and may include testing of individuals with signs or symptoms compatible with COVID-19, as well as asymptomatic individuals with known or suspected recent exposure to SARS-CoV-2 (the virus that causes COVID-19), that is determined to be medically appropriate by the individual’s health care provider, consulting Centers for Disease Control and Prevention (CDC) guidelines as appropriate. The CDC does not currently recommend using antibody testing as the sole basis for diagnosis of acute infection, and antibody tests are not authorized by the FDA for such diagnostic purposes. In certain situations, serologic assays may be used to support clinical assessment of persons who present late in their illnesses when used in conjunction with viral detection tests. In addition, if a person is suspected of having post-infectious syndrome (e.g., Multisystem Inflammatory Syndrome in Children) caused by SARS-CoV-2 infection, serologic assays may be appropriate.

Based on the combined guidance from the Departments, CDC, and DOH described above, claims received on or after August 1, 2020 and through the end of the Emergency Period (as defined under Section 1135 of the Social Security Act), Horizon NJ Health shall:

  1. consider for reimbursement, claims submitted for COVID 19 antibody testing (CPT Codes 86328 and 86769) for covered members aged 20 years and under, with no cost share, regardless of whether rendered by an in-network or out-of-network laboratory.
  2. consider for reimbursement, claims submitted for COVID 19 antibody testing (CPT Codes 86328 and 86769), for members aged 21 years and older, only upon receipt of evidence that an individualized health assessment, in the form of a clinician’s record, will substantiate the appropriateness of serological testing as part of the claims submission process. If it can be determined that the antibody test was ordered by a physician based upon an individualized health assessment (meaning that testing was being used as part of a diagnostic evaluation intending to inform medical care and the member did not self-direct for an antibody test), Horizon NJ Health shall consider the claim for reimbursement with no cost share. This methodology would apply to claims billed for both in-network and out-of-network laboratories. If it is determined that the member self-directed for the antibody testing or that it was not ordered for diagnostic purposes pursuant to an individualized health assessment, the services shall not be considered eligible for reimbursement.

This policy is subject to change as guidance from relevant authorities, including the Departments, evolves, and as regulatory or legislative requirements change.

Procedure:
Horizon NJ Health will consider for reimbursement, COVID 19 anti-body testing (CPT Codes 86328 and 86769) for covered members ages 20 years and under. Member cost-share shall not be applied to in-network or out-of-network laboratories.

Horizon NJ Health will deny claims for COVID 19 anti-body testing (CPT Codes 86328 and 86769) received on or after the effective date of this policy for covered members ages 21 years and over. If post claim processing determines that services were ordered by a physician for diagnostic purposes based on an individualized health assessment, claims may be adjusted and considered for reimbursement.

Resources:
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.