Updated: Feb. 10, 2022; revised March 4, 2022
Open each tab below to see the New York State Department of Health’s policies, as well as guidance from our pharmacy vendor Express Scripts, that EmblemHealth has adopted for our own Medicaid members:
Updated: Feb. 10, 2022; revised March 4, 2022
Open each tab below to see the New York State Department of Health’s policies, as well as guidance from our pharmacy vendor Express Scripts, that EmblemHealth has adopted for our own Medicaid members:
New York State (NYS) Medicaid Policy for Coverage:
Code | Labeler Name | Procedure Name | Effective Date |
---|---|---|---|
Q0247 | GSK | Injection, sotrovimab, 500 mg | 5/26/2021 |
M0247 | GSK | Intravenous infusion, sotrovimab, includes infusion and post administration monitoring | 5/26/2021 |
Q0220 | AstraZeneca | Injection, tixagevimab and cilgavimab, for the pre-exposure prophylaxis only, 300 mg | 12/8/2021 |
M0220 | AstraZeneca | Injection, tixagevimab and cilgavimab, for the pre-exposure prophylaxis only, includes injection and post administration monitoring | 12/8/2021 |
J0248 | Gilead | Injection, remdesivir, 1 mg | 1/21/2022 FDA-approved for outpatient use |
96365 | N/A | Infusion into a vein for therapy, prevention, or diagnosis, 1 hour or less | N/A |
Q0222 | Eli Lilly | injection, bebtelovimab, 175 mg | 2/11/2022 |
M0222 | Eli Lilly | Infusion into a vein for therapy, prevention, or diagnosis, 1 hour or less | 2/11/2022 |
The above infusion codes are reimbursable when provided in a hospital outpatient department or physician´s office. Providers should bill the codes outlined in this guidance via the ordered ambulatory and/or physician fee schedule. Note: Providers should bill CPT code "96365" to be reimbursed for the infusion/injection when administering J2048 (remdesivir).
Claims will only be reimbursed for injections or infusions provided on dates of service within the effective dates noted in the table above.
Effective Dec. 1, 2021, New York State (NYS) Medicaid provides reimbursement for Coronavirus Disease 2019 (COVID-19) vaccination counseling to unvaccinated Medicaid members/enrollees to encourage the administration of the COVID-19 vaccine.
The provider types listed below may bill for COVID-19 vaccine counseling:
Reimbursement for COVID-19 vaccination counseling is limited to unvaccinated individuals who have not received an initial/first dose of the COVID-19 vaccine and do not have an appointment to receive an initial/first dose of the COVID-19 vaccine, but who are eligible to receive the COVID-19 vaccination. If providing counseling to parents, guardians, or caregivers regarding vaccination of children, providers must bill NYS Medicaid under the Medicaid Client Identification Number (CIN) of the enrolled children. The counseling must be delivered in the presence of the children and their parents, guardians, or caregivers.
The COVID-19 vaccine counseling session must be documented in the medical or pharmacy record and must include the following:
* If there is a pharmacy software limitation, a pharmacist can provide an attestation that the above actions have been met: "Meets NYS Department of Health (DOH) Counseling Criteria for COVID Vaccination".
A provider may only request reimbursement once per unvaccinated member. Counseling on second and subsequent doses is not billable.
A provider submitting a professional claim should bill Current Procedural Terminology (CPT) code "99429", Unlisted Preventative Medicine Service, for reimbursement of COVID-19 vaccination counseling.
A provider may bill CPT code "99429":
A provider may not bill CPT code "99429":
When providing a minimum of eight minutes of COVID-19 vaccination counseling to a patient, the pharmacist may bill for counseling.
In order to appropriately submit claims for COVID-19 vaccines, in which counseling and administration of the vaccine has occurred, please include the following:
Note: COVID-19 vaccine billing guidance can be found on the NYS DOH "COVID-19 Guidance for Medicaid Providers" web page.
(See also Billing Guidance for the Administration of COVID-19 Vaccines)
Article 28 clinics, including hospital outpatient departments (HOPDs) and Diagnostic and Treatment Centers (D&TCs), should bill an ordered ambulatory claim for COVID-19 vaccine counseling using the CPT code "99429".
HCPCS Code | Code Description | Fee |
---|---|---|
99429 | Unlisted Preventive Medicine | $25.00 |
FQHCs should bill their prospective payment system (PPS) rate when providing COVID-19 vaccination counseling, but FQHCs are encouraged to perform other evaluation and management, or clinical services included within the PPS rate in connection with the counseling session.
The rate-based provider types listed below may bill for COVID-19 vaccination counseling using rate code "5521" with Category of Service (COS) code "0268" when provided to unvaccinated Medicaid members:
Rate Code | Rate Code Description | Fee |
---|---|---|
5521 | COVID-19 VACCINE COUNSEL TO UNVAC INDV - EIGHT MINUTE MINIMUM | $25.00 |
Physicians, NPs, and licensed midwives should bill the CPT code "99429" appended with the GQ modifier to indicate the service was provided via audio-only (telephonic) telehealth. Article 28 clinics (including HOPDs and D&TCs) should bill an ordered ambulatory claim using the CPT code "99429" appended with the GQ modifier to indicate the service was provided via audio-only (telephonic) telehealth. Pharmacists may provide audio-only (telephonic) telehealth counseling and must document the counseling in the pharmacy record with the claim that is submitted for CPT code "99429".
The other rate-based providers listed above should bill using rate code "5521" with CPT code "99429" appended with the GQ modifier to indicate the service was provided via audio-only (telephonic) telehealth. FQHCs should bill the off-site rate code "4012" with CPT code "99429" appended with the GQ modifier to indicate the service was provided via audio-only (telephonic) telehealth.
A. NYS Medicaid Will Not Reimburse for the Cost of COVID-19 Vaccine
B. Claims Submission
In order to appropriately submit claims for COVID-19 vaccines, in which counseling and administration of the vaccine has occurred, please include the following:
COVID-19 vaccine claims administered to patients where counseling services were not conducted will continue to submit claims with:
C. Reimbursement for Administration of Authorized COVID-19 Vaccines
Medicaid Pharmacy Policy and Billing Guidance for At-Home COVID-19 Testing Coverage
Update Effective: Dec. 13, 2021; revised Feb. 10, 2022
Effective Dec. 13, 2021, EmblemHealth will cover COVID-19 diagnostic and screening tests with “at-home” sample collection for Medicaid members only with no member cost-sharing. Effective Jan. 10, 2022, a fiscal order is not required for the first eight (8) tests per month. Additional tests may be covered with a fiscal order, when medically necessary. Coverage will be provided for COVID-19 test kits used in accordance with the Centers for Disease Control and Prevention (CDC) recommendations for antigen detection. This aligns with New York State’s coverage policy, which provides for coverage when the:
Pharmacy Billing for COVID- 19 Test Kits
Pharmacies may bill using the National Drug Codes (NDCs) provided, which have been derived by using the Universal Product Code (UPC). For a list of tests that are covered, providers can perform a search using the eMedNY formulary search page. Select “Description” in the drop-down field and type in “COVID” to return all tests on the formulary.
Table 1
Billing Instructions for COVID-19 Tests
NCPDP D.0. Claim Segment Field* | Value |
---|---|
436-E1 (Product/Service ID Qualifier) | Enter a value of “03” (NDC) |
407-D7 (Product/Service ID) | Enter one applicable NDC from New York State’s COVID-19 Guidance for Medicaid Providers |
444-E9 (Pharmacist ID) | Enter Prescriber National Provider Identifier (NPI) number |
411-DB (Prescriber ID) | Please leave field blank * |
* The NCPDP D.0 Companion Guide can be found on eMedNY 5010/D.0 Transaction Instructions .
Origin Codes and Serial Codes
In the origin code field, use “5” and the corresponding serial number of “99999999” for “Pharmacy dispensing” when applicable for non-patient-specific orders. For quantities greater than eight (8) tests per month that require a fiscal order, the NPI of the Medicaid-enrolled practitioner is required.
Please see the July 2020 Medicaid Update for further guidance on origin code and serial number values that you must submit on the claim.
Table 2
OTC COVID-19 Tests – Maximum Reimbursement
Reimbursement* | Tests per kit |
---|---|
Up to $24 | 2 |
Up to $12 | 1 |
*Actual reimbursement for each test will be the lower of the maximum reimbursement amount shown in Table 2 above, or the usual and customary U&C price charged to the general public. In accordance with 42 C.F.R. § 447.512(b), pharmacies must provide a U&C price when submitting pharmacy claims for prescription and OTC (nonprescription) items. U&C is defined as the lowest price charged to the general public after all applicable discounts, including promotional discounts and discounted prices associated with loyalty programs.
Reminder: The Medicaid program is the payer of last resort and providers should take reasonable measures necessary to ensure that all available options for coverage, including free at-home COVID tests from COVIDtests.gov and third-party insurance, are utilized prior to submitting claims to the Medicaid program.
For further information regarding COVID-19 tests, see: FDA Emergency Use Authorizations for Medical Devices.
NEW YORK MEDICAID
COVID-19 Sample Collection and Testing Claims Submission
Effective: August 21, 2020
In response to the current novel Coronavirus (COVID-19) emergency situation, and pursuant to the New York State Medicaid Fee-for- Service Policy and Billing Guidance for COVID-19 Testing and Specimen Collection at Pharmacies, New York Medicaid plans will reimburse Providers for COVID-19 specimen collection or CLIA waived COVID-19 testing for Medicaid Members, when such collection or testing is in compliance with the Governor’s Executive Order #202.24.
The terms and rates herein are subject to change pursuant to any changes or updated to the New York State Medicaid Fee-for- Service Policy and Billing Guidance for COVID-19 Testing and Specimen Collection.
NCPDP D.0. Claim Segment Field | Value |
---|---|
436-E1 (Product/Service ID Qualifier) | Enter a value of 03. |
407-D7 (Product/Service ID) | Enter the 11-digit NDC for test kit, if there is no test kit enter valid NDC for specimen collection |
440-E5 (Professional Service Code) | Enter a value of MA |
411-DB (Prescriber ID) |
Enter the Pharmacist National Provider Identifier (NPI) number. |
Reimbursement for Lab Specimen Collection or CLIA waived COVID-19 Testing*
Description | Reimbursement |
---|---|
Specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) (NDC 99999-0992-11 only) | $23.46 |
*2019-nCoV Coronavirus, SARS-CoV-2/2019-nCov (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC | $51.31 |
*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 |
*Pharmacies 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.
Only test kits with an FDA approved Emergency Use Authorization (EUA) are covered. Specimen collection without a test kit is also covered. To identify FDA approved tests,see the Test Kit Manufacturers and Commercial Laboratories Table https://www.fda.gov/medical-devices/emergency-situations-medical-devices/emergency-use-authorizations#covid19ivd
Subject to change, the following are sample NDCs covered under this program:
NDC 11877-0011-26 ID NOW COVID-19 TEST KIT
NDC 22066-0005-11 RAPID RESPONSE COVID-19 TEST
NDC 60004-0417-80 COVID-19 Test Administration
NDC 99999-0992-11 SPECIMEN COLLECTION
NDC 00042-0222-24 COVID-19 TEST SPECIMEN COLLECT
NDC 14613-0339-08 SOFIA SARS ANTIGEN FIA TEST
Please be aware that the Medicaid program prohibits providers from billing members for charges for COVID-19 protective measures including personal protective equipment (PPE). Please ensure that only the copay returned in the NCPDP response field is collected from a Medicaid member, and no additional charges are added for PPE.
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