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Tuesday, June 2, 2020

FAQ: COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing and Treatment of the Uninsured Program


A unique challenge for health care providers and facilities is the ability to get reimbursed for providing services and care to those patients who are uninsured. This challenge is exacerbated when operating in our current environment of the COVID-19 pandemic. With unemployment at a level not seen since the Great Depression of the 1930s, the population of uninsured patients has increased sharply. The severity and community-wide impact of COVID-19 is undeniable. The financial impact on health care providers and facilities treating uninsured patients has the potential to be devasting.

Fortunately, the COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing and Treatment of the Uninsured Program is available to provide reimbursements to eligible providers for claims that are attributable to the testing and treatment of COVID-19 for uninsured patients.


What is the source of funding? How much funding is available? Who administers the program?

Funding for this program is provided by the Families First Coronavirus Response Act (FFCRA) Relief Fund. FFCRA includes funds received from the Public Health and Social Services Emergency Fund and the Paycheck Protection Program and Health Care Enhancement Act (PPPHCEA), specifically to reimburse providers for conducting COVID-19 testing for uninsured individuals. Funding is also provided by the Provider Relief Fund, which includes funds received from the Public Health and Social Services Emergency Fund (appropriated in the CARES Act and the PPHCEA) to reimburse providers for treating uninsured individuals with a COVID-19 diagnosis.

Funding for the program includes $2 billion, of which $1 billion is provided by FFCRA and another $1 billion is provided by PPPHCEA. The Provider Relief Fund, established by the CARES Act, contributes $100 billion. PPHCEA appropriated another $75 billion in funds to the program.

The U.S. Department of Health and Human Services’ Health Resources and Services Administration (HRSA) has contracted with UnitedHealth Group to administer the program.


What must I do as a health care provider to participate in the program?

The program provides claims reimbursement to health care providers that have conducted COVID-19 testing for or provided treatment to uninsured patients with a COVID-19 diagnosis on or after February 4, 2020. Claims reimbursements can be submitted electronically and will generally be reimbursed at Medicare rates, subject to available funding. Health care providers must do the following:

  • Enroll as a provider participant
    • Validate Tax Identification Number (can take up to 2 business days to process)
    • Set-up Optum Pay Automated Clearing House (can take 7-10 business days to process; ACH via Optum Pay is required)
    • Add provider roster (available after Tax Identification Number validation is complete; can take up to 3 business days to process)
  • Check patient eligibility
    • Patient roster will include demographic information, date of service, etc.
  • Submit patient information
  • Submit claims (individually or in batch)
  • Receive payment via direct deposit

To participate, health care providers must attest to the following as part of the registration process:

  • They have checked for health care coverage eligibility and confirmed that the patient is uninsured, verifying that the patient does not have coverage such as individual, employer-sponsored, Medicare or Medicaid coverage, and that no other payer will reimburse them for COVID-19 testing and/or care for that patient
  • They will accept defined program reimbursement as payment in full
  • They will not balance bill the patient
  • They will agree to the program terms and conditions and may be subject to post-reimbursement audit review

Under the program, all claims that are submitted for reimbursement must be complete and final. No interim bills or corrected claims will be permitted. There will be no adjustments to the payment once the claims reimbursements are made.


What services are reimbursable under the program?

The following services are reimbursable under the program:

  • Specimen collection, diagnostic and antibody testing
  • Testing-related visits in the following settings: office, urgent care, emergency room or telehealth
  • Treatment provided, including the following: office visit (including telehealth), emergency room, inpatient, outpatient/observation, skilled nursing facility, long-term acute care, acute inpatient rehab, home health, DME (i.e. oxygen, ventilator), emergency ambulance transportation, non-emergent patient transfers via ambulance, FDA approved drugs as they become available for COVID-19 treatment and administered as part of an inpatient stay
  • An FDA-approved vaccine, when available

What diagnostic codes should be used when submitting claims for reimbursement?

  • For dates of service or discharges on or after April 1, 2020, providers will use the primary diagnosis U07.1 to indicate that COVID-19 is the primary reason for treatment except for pregnancy for which providers will use O98.5- as the primary diagnosis and U07.1 as the secondary diagnosis
  • For dates of service or discharges prior to April 1, 2020, there is no equivalent diagnosis to indicate COVID-19 is the primary reason for treatment. HRSA has established guidance for this program to use B97.29 as the primary reason for treatment except for pregnancy, which would necessitate using O98.5- and B97.29 as the primary and secondary diagnosis, respectively
  • also released recent guidance indicating pricing can occur when B97.29 is included in any position on the claim, including primary, for dates of service before April 1, 2020
  • The COVID-19 diagnosis code must be the primary diagnosis code submitted. The only exception is for pregnancy (O985-), when the COVID-19 code may be listed as secondary
  • For diagnostic testing and testing-related services to be eligible for reimbursement, claims submitted for testing-related visits rendered in an office, urgent care or emergency room or via telehealth setting must include one of the following diagnosis codes:
    • Z03.818 - Encounter for observation for suspected exposure to other biological agents ruled out (possible exposure to COVID-19)
    • Z20.828 - Contact with and (suspected) exposure to other viral communicable (confirmed exposure to COVID-19)
    • Z11.59 - Encounter for screening for other viral diseases (asymptomatic)
  • For antibody testing and testing-related services to be eligible for reimbursement, claims submitted for testing-related visits rendered in an office, urgent care or emergency room or via telehealth setting must include one of the following procedure codes:
    • 86318 - Immunoassay for infectious agent antibody, qualitative or semi-quantitative, single step method (e.g., reagent strip)
    • 86328 - Immunoassay for infectious agent antibody(ies), qualitative or semi-quantitative, single step method (e.g., reagent strip); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19])
    • 86769 - Antibody; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19])
  • In addition, single line item claims for the following procedure codes with any diagnosis will also be eligible for reimbursement:
    • COVID-19 tests: U0001, U0002, U0003, U0004, 87635
    • Antibody tests: 86318, 86328, 86769
    • Specimen collection: G2023, G2024

See program FAQs for more information.

For the latest regulatory changes and other information on keeping your organization running through disruption, visit our COVID-19 Resource Center.

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