COVID-19 Updates & Alerts for Providers

Is there provider support for questions about COVID-19 testing and treatment?

All California health care providers can get confidential consultation support through the COVID-19 Therapeutics Warmline (PDF) managed by the University of California, San Francisco (USCF) National Clinical Consultation Center (NCCC). Providers of any experience level can speak with a clinician or pharmacist:

• Call 866-268-4233 (866-COVID-CA). Monday–Friday, 6:00 a.m.–5:00 p.m. After-hours voice mail messages are returned the next business day.
• This support is in real-time and at no cost.
• No protected health information (PHI) is collected.

What resources are available about COVID-19 outpatient therapeutics?

Videos and resources are available from the Department of Health and Human Services' Administration for Strategic Preparedness & Response (ASPR). The website covers the following topics and more :

• Compare COVID-19 Therapeutics and Patient Requirements
• Find, Order and Report COVID-19 Therapeutics
• Learn About COVID-19 Therapeutics
• Share Resources with Patients and Other Health Care Providers

The following videos are available through ASPR and cover:

• ASPR and the COVID Response
• Overview: COVID-19 Therapeutics
• COVID-19 Therapeutics Distribution
• Separate videos about therapeutics for: Paxlovid, Lagevrio, and Veklury

Note: The U.S. Food and Drug Administration (FDA) announced on January 26, 2023, that Evusheld is no longer authorized for emergency use in the United States against developing variants of the COVID-19 virus.

Additional resources

The Office of Communications for the California Department of Public Health (CDPH) has different material to download and print – from graphics and hand-outs to social messaging in English and Spanish. The goal is to educate patients and encourage use of COVID-19 therapeutics to treat symptoms before they become severe.

How to dispel misinformation about treatments

See the CDPH COVID-19 Therapeutics Myths and Facts sheet (PDF). It covers questions, such as:

• I don't need treatment for mild-to-moderate illness.
• I'm not high risk.
• Treatments have serious side effects.
• Rebound caused by treatments is common and can be dangerous.

Where can I get information for my patients about the COVID-19 Test to Treat Program?

More information about the Test to Treat Program can be found on the CDPH website. Patients who have COVID-19 symptoms can be seen by a health care provider and get treatment at a Test to Treat site during the same visit, if needed.

• This is available to adults and children over age 12.
• Uninsured individuals can access testing and treatment services at no cost at OptumServe locations.

Is coping assistance offered to members impacted by COVID-19?

Members impacted by COVID-19 may contact MHN, our behavioral health administrator, for referrals to mental health counselors, local resources or telephonic consultations to help them cope with stress, grief, loss, or other trauma resulting from COVID-19. Members may contact MHN 24 hours a day, seven days a week at 800-227-1060, or the telephone number listed on the member's identification (ID) card.

Additional resources on how to mitigate the stress-related health outcomes anticipated with the COVID-19 emergency can be found at ACEs Aware.

Adverse Childhood Experiences (ACEs) resources and information for Medi-Cal can be found at California Department of Health Care Services Trauma Screenings and Trauma-Informed Care Provider Trainings.

What additional support does Health Net provide to enhance access to care for my patients?

Health Net offers many solutions to enhance access to care for your patients. These solutions supplement, but do not replace, the personal care you provide to your patients. Examples include:

• The Nurse Advice Line – Available to members 24 hours a day at 800-893-5597 (TTY 711).
• myStrength (tailored wellness resources to help members with mental health challenges) – If a member needs emergent or routine treatment services, call MHN at 888-327-0010 or myStrength.
• Health Net Community Connect (findhelp) – A free online search service, allows members to find free and low cost social services.

As a health care provider, you play an integral role with COVID-19 vaccinations. For regular and frequent updates on the vaccine information and distribution in California, visit Vaccinate ALL 58.

Important! Enroll to get your California Immunization Information System (IIS) ID

The California Department of Public Health (CDPH) is overseeing the registration for the COVID-19 vaccination program in California. Program enrollment is currently focused on small physician practices who routinely vaccinate their patients as well as providers that are prioritized for vaccine allocation by local health departments.

Step 1: Get your IIS ID

Enroll in your local registry to receive your Immunization Information System (IIS) ID for enrollment in CalVax. County specific information is below.

• Alpine, Amador, Calaveras, Mariposa, Tuolumne Counties
• Other Counties

Step 2: Enroll in myCAvax

Make sure you meet all the requirements (PDF) before enrolling. Use the Provider Enrollment Worksheet (PDF) to gather information needed ahead of time to complete enrollment in myCAvax.

Refer to the Readiness Checklist: Quick Start Guide (PDF) for additional steps to help providers onboard to the COVID-19 Vaccination Program.

More information that can help you share clear and accurate information about the COVID-19 vaccines and address common questions from patients can be found in the Communication Resources for Healthcare Providers and Staff from the Centers for Disease Control and Prevention (CDC).

Is there a current COVID-19 vaccination schedule?

The CDC develops age specific immunization schedules that give guidance based on age and medical conditions including dosage for different vaccines and interval periods between doses. Age and condition specific up-to date COVID-19 guidance is also available for:

• Children
• Adults
• Maternal

Where can I find the latest guidance for the COVID-19 vaccine?

For commercial providers:

• Centers for Medicare & Medicaid Services (CMS)

For Medi-Cal providers:

• Centers for Medicare & Medicaid Services (CMS) (PDF)
• California Department of Healthcare Services (DHCS) COVID-19 Vaccine Administration FAQs (PDF)
• Centers for Disease Control and Prevention (CDC) COVID-19 Vaccine FAQs

For Medicare Advantage providers:

• Centers for Medicare & Medicaid Services (CMS)

What are the codes to report and bill the COVID-19 vaccines?

The American Medical Association (AMA) has published updates to the Current Procedural Terminology (CPT^®) code set that includes new vaccine-specific codes to report immunizations for the novel coronavirus (SARS-CoV-2). The code set will continue to be updated as additional vaccines receive EUA approval by the U.S. Food & Drug Administration (FDA).

The following codes have been published; however, they will not be billable or payable until the specific vaccine receives official EUA approval or after the EUA is revoked.

What are the reporting requirements for the COVID-19 vaccine?

Providers must record details of the vaccination into their system of record within 24 hours, and into the applicable public health system within 72 hours.

How will the COVID-19 vaccine be covered for members?

Similar to other preventive immunizations, the COVID-19 vaccines are offered at no cost to members. In addition:

For commercial members

• CA state law will continue benefit coverage requirements as is for six months after the federal Public Health Emergency expires on May 11, 2023. In accordance with state requirements, member liability will be $0 and non-participating provider prior authorization requirements will be waived.
• Health Net will assume payment responsibility for the COVID-19 vaccine's administration fee for all of our commercial group and individual members, including those enrolled with capitated delegated groups unless negotiated otherwise. The vaccine itself is still available from the federal government free of charge until the current surplus is used, then HHS has indicated future vaccine supply will have to be purchased by providers and billed to insurance carriers like normal.
  
  Applicable claims need to include the AMA issued vaccine administration code for the applicable FDA approved vaccination. You do not need to bill the vaccine code with the vaccine administration code until such time vaccine supplies are no longer provided free by the federal government. Reimbursement will follow normal claims submission policies.

For Medi-Cal members

• CA state law will continue benefit coverage requirements as is for six months after the federal Public Health Emergency expires on May 11, 2023. The Department of Health Care Services (DHCS) intends to pay the vaccine administration fee, pending CMS waiver approvals. More information can be found at DHCS COVID-19 Vaccine Administration Provider FAQs (PDF).The vaccine itself is available from the federal government free of charge.
• Health Net will not be able to process these claims.
• Providers must submit claims for administering the COVID-19 vaccine to DHCS. Refer to these DHCS resources for more information.
  • COVID-19 Vaccine Administration: Real-Time NCPDP D.0 Pharmacy Claims Can Be Submitted
  • COVID-19 Vaccine Administration: Medical and Outpatient Claims Can Be Submitted
  • COVID-19 Vaccine Administration: Real-Time NCPDP D.0 Pharmacy Claims Submission Reminders
  • COVID-19 Vaccine Administration: Real-Time RTIP Pharmacy Claims Can Be Submitted
  • Medi-Cal List of Contract Drugs: COVID-19 Vaccines Pfizer-BioNTech and Moderna Added

For Medicare Advantage members

• For CY 2022 forward, CMS no longer directly reimburses providers for COVID-19 vaccines including their administration. Vaccine related claims should be billed like other Medicare covered vaccines. Send claims to:
  • HMO – Delegated at-risk provider groups of Health Net.
  • PPO – Health Net.
• Claims prior to January 1, 2022 should still be sent to Medicare fee-for-service.

Effective February 11, 2023, Health and Human Services (HHS) Secretary Xavier Becerra renewed the COVID-19 Public Health Emergency for a final time with a 90-day notice. This extends flexibilities and funding tied to the public health emergency (PHE) to continue through May 11, 2023, at which time the PHE will expire. California state law adds six months to the federal PHE requirements on health plans to continue covering COVID-19 tests, vaccines and therapeutics from any licensed provider (in- or out-of-network) with no prior authorization or enrollee cost sharing.

Does Health Net allow access to telehealth services to increase access to care? And what is the reimbursement rate?

To limit members' risk of COVID-19 infection, Health Net encourages use of telehealth to deliver care when medically appropriate and capable through telehealth modalities for covered services.

Commercial and Medi-Cal members – Health Net's coverage for telehealth services is in accordance with regulatory requirements, and will be reimbursed whether the telehealth service is delivered via audio/video technology or via audio-only technology (when deemed medically appropriate for the patient's medical condition).

• Federally Qualified Health Centers (FQHCs), Regional Health Centers (RHCs), and Indian Health Service (IHS) Clinics – Health Net's Medi-Cal coverage for telehealth services will follow guidelines released by the Department of Health Care Services (DHCS), which includes virtual/telephonic visits consistent with in person visits.
• Health Net will reimburse fee-for-service providers the same contracted rate for the procedure code billed, whether service is provided in person or through telehealth technology. Billing must be in accordance with Health Net requirements in order to receive payment parity.
• Services that cannot be appropriately delivered remotely are not eligible for telehealth coverage and reimbursement.
• Capitated physician groups or independent practice associations (IPAs) are required to support, cover and enable telehealth services and to abide by regulatory requirements for coverage and payment of telehealth services as outlined above. Claims processing risk will follow the in-person location place of service where the service would have been delivered in lieu of telehealth.

Medicare Advantage members – Health Net's coverage for telehealth services will follow guidance released by CMS, which includes telecommunications involving audio and video technology and audio only technology. More information can be found here.

In addition to telehealth services offered through our network of providers, Health Net has expanded access to telehealth services through third parties.

What are the guidelines for telehealth services specific to risk adjustment?

For Medicare, providers should follow the guidance in the communication from the Centers for Medicare and Medicaid Services (CMS) dated April 10, 2020, regarding the Applicability of diagnoses from telehealth services for risk adjustment (PDF).

How do I bill for telehealth services?

For commercial and Medi-Cal

Use appropriate American Medical Association (AMA) CPT and HCPCS codes most descriptive for the service delivered:

• For Medi-Cal:
  • Provider should bill for telehealth services in accordance with the DHCS Provider Manual Telehealth requirements (PDF).
• For Commercial:
  • Use the normal Place of Service code (11, 23, etc.) – excluding FQHC/RHCs
  • Use appropriate modifiers – excluding FQHC/RHCs
    • Modifier 95 (Synchronous, interactive audio and telecommunications systems), OR
    • Modifier GQ (Asynchronous store and forward telecommunications systems)
  • Use of Place of Service codes "2" or "10" will not result in payment parity. Claims for such CPT codes billed with POS 02 or POS 10 must be re-billed as corrected claims in order to receive rate parity.

For Medicare

• Providers should bill in accordance with CMS requirements found at Telehealth.HHS.GOV

Examples of benefits or services not appropriate for telehealth delivery:

Below are some examples (not exhaustive) of benefits or services that would not be appropriate for delivery via a telehealth modality:

• Performed in an operating room or while the patient is under anesthesia.
• Require direct visualization or instrumentation of bodily structures.
• Involve sampling of tissue or insertion/removal of medical device.
• Require the in-person presence of the patient for any reason.

Are there member cost shares for commercial and Medicare network provider telehealth services?

Member cost shares for covered services delivered via telehealth will be subject to the cost sharing provisions of a member's benefit plan for particular covered service delivered.

Capitated Physician Groups/IPAs:

Capitated physician groups or IPAs are required to support, cover and enable telehealth services and to abide by regulatory requirements for coverage and payment of telehealth services as outlined above.

What is Health Net's strategy to support telehealth services for providers and members?

Health Net is committed to supporting your relationship with your patients. We continuously encourage members to first take advantage of the telehealth services provided by their primary care provider before considering Health Net's contracted vendors.

What additional telehealth options are available to my patients?

Health Net offers additional telehealth services to enhance access to care for your patients. These services supplement, but do not replace, the personal care you provide to your patients. Health Net is contracted with Babylon Health (excludes Medicare) and Teladoc^® (excludes commercial and Medi-Cal).

Providers can also refer to Telehealth Platforms for Providers for a variety of telehealth platforms that optimize the availability of telehealth capabilities to our providers. These platforms accommodate most medical conditions, including COVID-19, and allow for a compliant way to administer health care services to your patients.

What support will Babylon Health provide to me if my patients use them?

Babylon Health supports the primary care physician (PCP) and their relationship with their patient. Babylon services include:

• Visit summaries sent to the PCP for close communication and continuity of care.
• Referring patients back to the assigned PCP for follow up appointments.
• Prescribing of non-scheduled, non-lifestyle medications.
• Ordering of and follow up on basic ancillary testing for immediate treatment of the medical condition.
• Direct communication back to the member's PCP about clinical assessments that include a recommendation for a referral for advanced imaging, such as CT, MRI or referral to a specialist.
  • The PCP, who best knows the member and their clinical needs, then decides whether such referral is required and, if so, directs the patient to the most appropriate resource.
• Availability of the member's medical records through the Babylon Health app.

What support will Teladoc provide to me if my patients use them?

Teladoc supports the PCP and their relationship with their patient. Teladoc services include:

• Visit summaries sent to the PCP for close communication and continuity of care, at the member's request.
• Referring patients back to the assigned PCP for follow-up appointments.
• Prescribing of non-scheduled, non-lifestyle medications.
• Availability of the member’s medical records through the Teladoc app.

On November 8, 2021, Governor Newsom signed California Senate Bill 510 ("SB 510") impacting Commercial and Medi-Cal lines of business. This bill became law effective January 1, 2022 and addresses, among other things, reimbursement for COVID-19 diagnostic and screening testing.

Health Net has analyzed SB 510 and has taken appropriate steps to comply; however, please be advised that the California Association of Health Plans and the Association of California Life and Health Insurance Companies are challenging the constitutionality of the retroactive application of Health & Safety Code 1342.2 and Insurance Code 10110.7, respectively.

On July 5, 2022, the Superior Court of California in Los Angeles County granted a preliminary injunction enjoining the California Department of Managed Health Care from enforcing the retroactive application of SB 510during the pendency of the lawsuit. Prior to January 1, 2022, Health Net continues to assert that its capitated delegated providers are financially responsible for reimbursing COVID-19 testing under the parties' contractual Division of Financial Responsibility. Until the pending lawsuit is resolved, and unless the Superior Court of California determines that Health & Safety Code 1342.2 is constitutionally sound, Health Net will not pay COVID-19 testing claims retroactively as Health Net risk unless negotiated otherwise.

Health Net has taken the necessary actions to implement SB 510 on a prospective basis only and is reimbursing for Commercial and Medi-Cal COVID-19 testing claims for dates of service on or after January 1, 2022. There will be no change for Medicare Advantage. Unless the parties’ contract explicitly directs otherwise, for dates of service January 1, 2022, and forward Health Net has not and will not cap-deduct any Commercial or Medi-Cal costs of COVID-19 testing from capitation payments and Health Net ceased the redirection of testing providers for their reimbursement.

As a reminder, Health Net is currently reimbursing providers for the vaccination administration fee for Commercial members. Vaccination administration costs for Medi-Cal will continue to be reimbursed by DHCS. For more information, see "How will the COVID-19 vaccine be covered for members?" under the COVID-19 Vaccines section.

Is Health Net requiring prior authorization, precertification, prior notification, or step therapy protocols for COVID-19 screening and testing? Will cost shares be applied?

Commercial & Medi-Cal – CA state law will continue benefit coverage requirements as is for six months after the federal Public Health Emergency expires on May 11, 2023. Health Net will continue applying member cost shares or requiring prior authorization, precertification, prior notification, or step therapy protocols for COVID-19 screening and testing services at this time for both network and out of network providers. The primary purpose of the visit must be for screening for COVID-19 testing for the waivers to apply, as identified by the primary diagnosis being for COVID-19 screening.

Medicare – After the PHE expires on May 11, 2023, the application of member cost share, prior authorization and out of network coverage rules will apply per the member's posted benefit plan design.

What billing codes should be used to bill for COVID-19 testing?

CMS updated the list of valid HCPCS codes used for COVID-19 related testing and billing effective May 12, 2023. Claims after that date must reflect a valid HCPCS code for reimbursement.

Specimen Collection – Valid codes:

• HCPCS C9803 - Hospital outpatient clinic visit specimen collection for severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]).
• CPTs 99000, 99001, or 99211 when billed with a COVID-19 related diagnosis code.

Invalid specimen collection codes for billing dates of service on or after May 12, 2023:

• HCPCS G2023
• HCPCS G2024

Active Virus Testing – Valid codes:

• HCPCS U0001 - For CDC developed tests only: 2019-nCoV Real-Time RT-PCR Diagnostic Panel.
• HCPCS U0002 - For all other commercially available tests: 2019-nCoV Real-Time RT-PCR Diagnostic Panel.
• CPT 87635 – (effective March 13, 2020): 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. The industry standard for reporting of novel coronavirus tests across the nation's health care system.
• CPT 0202U - (effective May 20, 2020): Infectious disease (bacterial or viral respiratory tract infection), pathogen specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected.
• CPT 0223U (effective June 25, 2020) Infectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected.
• CPT 87426 (effective June 25, 2020) Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]) qualitative or semi-quantitative, multiple-step method; severe acute respiratory syndrome coronavirus (e.g., SARS-CoV, SARS-CoV-2 [COVID-19]).
• CPT 0225U (effective September 8, 2020) Infectious disease (bacterial or viral respiratory tract infection) pathogen-specific DNA and RNA, 21 targets, including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), amplified probe technique, including multiplex reverse transcription for RNA targets, each analyte reported as detected or not detected.
• CPT 0226U (effective September 8, 2020) Surrogate viral neutralization test (sVNT), severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID-19]), ELISA, plasma, serum.
• CPT 0240U (effective October 6, 2020) Infectious disease (viral respiratory tract infection), pathogen-specific RNA, 3 targets (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2], influenza A, influenza B), upper respiratory specimen, each pathogen reported as detected or not detected.
• CPT 0241U (effective October 6, 2020) Infectious disease (viral respiratory tract infection), pathogen-specific RNA, 4 targets (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2], influenza A, influenza B, respiratory syncytial virus [RSV]), upper respiratory specimen, each pathogen reported as detected or not detected.
• CPT 87636 (effective October 6, 2020) 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.
• CPT 87637 (effective October 6, 2020) Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), influenza virus types A and B, and respiratory syncytial virus, multiplex amplified probe technique.
• CPT 87811 (effective October 6, 2020) Infectious agent antigen detection by immunoassay with direct optical (i.e., visual) observation; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]).
• CPT 87913 (effective February 21, 2022) Infectious agent genotype analysis by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]), mutation identification in targeted region(s).

Invalid active virus testing codes for billing dates of service on or after May 12, 2023:

• HCPCS U0003
• HCPCS U0004
• HCPCS U0005

Antibody (serologic) Testing –

• CPT 86318 (Medi-Cal only) Immunoassay for infectious agent antibody(ies), qualitative or semi quantitative, single step method (eg, reagent strip); (EXISTING PARENT CODE NOT SPECIFIC TO COVID 19).
• CPT 86328 Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), (Coronavirus disease [COVID-19]), (For severe acute respiratory syndrome, coronavirus 2 [SARS-CoV-2] [Coronavirus, disease {COVID-19}] antibody testing using multiple-step method, use 86769).
• CPT 86769 Antibody; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) (For severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] [Coronavirus disease {COVID-19}] antibody testing using single step method, use 86328).
• CPT 0224U (effective June 25, 2020) Antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), includes titer(s), when performed.
• CPT 86408 (effective August 10, 2020) Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]); screen.
• CPT 86409 (effective August 10, 2020) Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]); titer.
• CPT 86413 (effective September 8, 2020) Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) antibody, quantitative.

CDC Antibody Testing Guidance: View the Interim Guidelines for COVID-19 Antibody Testing

What diagnosis codes should be used to bill for services related to COVID-19 screening and testing?

For complete and up-to-date diagnosis coding for COVID-19, visit the CDC National Center for Health Statistics website.

The following diagnosis codes can be used to bill for screening and testing services related to COVID-19.

• Z11.52 – Encounter for screening for COVID-19.
• Z20.822 – Contact with and (suspected) exposure to COVID-19.

Can providers balance bill members for fees related to screening and testing for COVID-19?

Balance billing is strictly prohibited by state and federal law and Health Net's PPA. Providers may not bill members for any fees related to screening and testing for COVID-19.

Are there changes to the appeal process for Medi-Cal members during the public health emergency (PHE)?

Through the duration of the PHE, whenever a member's appeal involves the termination, suspension or reduction of previously authorized services, Health Net must provide Aid Paid Pending (APP) when an appeal and state fair hearing is filed timely. Health Net is not allowed to seek reimbursement or payment for the additional days of services furnished during this period.

Is Health Net waiving cost-share requirements for COVID-19 related therapeutics?

As of September 25, 2022, therapeutics approved or granted emergency use authorization by the federal Food and Drug Administration (FDA) for the treatment of COVID-19 when prescribed or furnished by a licensed health care provider acting within their scope of practice and the standard of care will be provided with no member costshare for all commercial and Medi-Cal members.

CA state law will continue benefit coverage requirements as is for six months after the federal Public Health Emergency expires on May 11, 2023.

What COVID-19 ICD-10 diagnoses codes are approved for use in treatment?

• U07.1: 2019-nCoV - Confirmed by lab testing (effective April 1, 2020)
• M35.81: Multisystem Inflammatory Syndrome (MIS) (effective January 1, 2021)

Does Health Net cover monoclonal antibody infusion treatment for COVID-19?

For dates of service prior to June 1, 2021, COVID-19 monoclonal antibody treatments available under an FDA Emergency Use Authorization (EUA) are covered benefits with no cost share or prior authorization required. The medications are available from the federal government at no cost to providers.

• From June 1, 2021 to September 24, 2022, normal cost shares and prior authorization guidelines, if any, applied.
• As of September 25, 2022, there is no prior authorization or cost shares for commercial and Medi-Cal members.
• CA state law will continue benefit coverage requirements as is for six months after the federal Public Health Emergency expires on May 11, 2023.

The following codes have been published. However, they are not billable or payable until after the specific treatment received official EUA approval.

* medication code not payable

Commercial: The medication and infusion's administration fee is billable to the appropriate payor based on Health Net's existing division of financial responsibility with the capitated physician group/IPA. Medication that is available free from the federal government is not reimbursable.

Medi-Cal: Per DHCS clarification, the infusion administration is not carved out of the managed Medi-Cal program. The medication and infusion's administration fee is billable to the appropriate payor based on Health Net's existing division of financial responsibility with the capitated physician group/IPA. Medication that is available free from the federal government is not reimbursable. See a list of infusion sites that offer monoclonal antibody infusion treatments:

• Health Net infusion sites (XLSX)
• CalViva Health infusion sites (XLSX)

Medicare: Effective January 1, 2022, the medication and infusion's administration fee is billable to the appropriate payor based on Health Net's existing division of financial responsibility with the capitated physician group/IPA. Medication that is available free from the federal government is not reimbursable. Prior to 2022, the medication and infusion's administration fee is billable to CMS directly for both Original Medicare and Medicare Advantage members.