COVID-19: COVID Testing and Specimen Collection Codes – Updated
The MO HealthNet Division (MHD) continues to monitor Centers for Medicare & Medicaid Services (CMS) guidance related to COVID-19 testing and specimen collection. The tables below lists the COVID-19 testing and specimen collection procedure codes MHD currently covers as well as who can bill each code, effective dates, max units, and rates.
Effective November 1, 2021, MO HealthNet will cover at-home COVID-19 tests through the Fee-for-Service pharmacy benefit when prescribed and dispensed by MO HealthNet enrolled providers. At-home COVID-19 tests will be covered for participants who are dually eligible for Medicaid and Medicare when the test is excluded from Medicare Part D coverage.
Effective for dates of service on or after 7/1/2021, MO HealthNet will allow Hospital & Clinic providers to bill for an inhaler if the participant is diagnosed with COVID or the participant has been exposed to COVID-19, and the facility is awaiting test results.
On December 22, 2021, the FDA issued an emergency use authorization (EUA) for Pfizer’s COVID-19 treatment, Paxlovid. Paxlovid is indicated for the treatment of mild-to-moderate coronavirus disease (COVID-19) in adults and pediatric patients (12 years of age and older weighing at least 40 kilograms) with positive results of direct SARS-CoV-2 testing and who are at high risk for progression to severe COVID-19, including hospitalization or death.
Effective November 1, 2021, MO HealthNet will cover at-home COVID-19 tests through the Fee-for-Service Pharmacy Benefit. MO HealthNet will reimburse the lesser of the MAC rate plus a dispensing fee or the Usual & Customary submitted by the provider. At-home tests must be prescribed by a MO HealthNet provider. MO HealthNet will monitor the use of at-home tests to prevent potential waste. Below are the covered at-home tests, including the MAC price per unit.
Effective October 21, 2021, MO HealthNet will implement a new Extended Supply Fiscal Edit. This new edit requires participants to receive a 90 day supply on select medication. The fiscal edit, including a complete list of medications included in the 90 day supply requirement, can be found on our website at https://dss.mo.gov/mhd/cs/pharmacy/pages/clinedit.htm.
The MO HealthNet Division (MHD) is aware of the sustained increased positivity of RSV virology in the State of Missouri outside of the regular RSV season. MHD has considered RSV prophylaxis requests starting in July 2021. Effective September 28th: participants who meet the clinical edit requirements, including age restrictions, may receive approval for up to 6 doses. This includes 1 dose for October and up to 5 doses during the regular Missouri RSV season (November thru April). Previously approved doses given from July through September are not considered to be part of the 6 doses.
The MO HealthNet Division (MHD) is aware of the sustained increased positivity of RSV virology in the State of Missouri. MHD will consider RSV prophylaxis prior authorization requests during July, August & September. For participants who meet the clinical edit requirements, approval will include up to three doses.
The MO HealthNet Division (MHD) is aware of the increased positivity of RSV virology in the State of Missouri. MHD will consider RSV prophylaxis prior authorization requests during July & August. For participants who meet the clinical edit requirements, approval will include two doses. For participants who were approved in July the doses will be for July and August, for participants approved in August the doses will be for August and September. MHD will evaluate the need for additional doses on a month-to-month basis, dependent on RSV virology.
The MO HealthNet Division (MHD) is aware of the increased positivity of RSV virology in the State of Missouri. MHD will consider RSV prophylaxis prior authorizations requests during July. For participants who meet the clinical edit requirements, approval will include two doses. MHD will evaluate the need for additional doses on a month-to-month basis, dependent on RSV virology. Providers with questions may call MO HealthNet at 800-392-8030.
