FAQs 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 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 866-268-4322 (866-COVID-CA). Monday–Friday, 6:00 a.m. – 5:00 p.m. After-hours voice mail messages are returned the next business day or fill out an online case submission form.
• 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 for providers and staff to use internally and to educate patients are available at:

• Office of Communications for the California Department of Public Health (CDPH)
• DHCS Administration for Strategic Preparedness & Response (ASPR) – COVID-19 Therapeutics: Resources for Health Care Professionals and Public Health Officials
• Centers for Disease Control and Prevention – COVID-19 Treatment and Preventive Medication
• FDA – Coronavirus (COVID-19) Drugs

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.

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

Members impacted by COVID-19 may contact Behavioral Health Member Services at the number on their member ID card 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.

Additional resources on how to mitigate stress-related health due to COVID-19 can be found at ACEs Aware, under ACE Fundamentals for COVID-19 & Stress. Other topics under ACE Fundamentals include:

• The Science of ACEs and Toxic Stress
• Trauma-Informed Care
• Clinical Assessment and Treatment
• Health Equity

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, they can call Behavioral Health Member Services at the number on their member ID card, or visit 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 all vaccinations including COVID-19. For regular and frequent updates on the vaccine information and distribution in California, visit Vaccinate ALL 58.

Enroll in CAIR and myCAvax

The California Department of Public Health (CDPH) oversees the registration for the COVID-19 vaccination program in California under the California Immunization Registry (CAIR). CAIR is accessed online and is a secure, confidential, statewide immunization information system.

Step 1: Get your IIS ID

Enroll in your local registry to receive your Immunization Information System (IIS) ID for enrollment in CalVax.

Step 2: Enroll in myCAvax

Next, complete enrollment in myCAvax at no cost.

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

Is there a current COVID-19 vaccination schedule?

The CDC has specific immunization schedules that give guidance based on age and medical conditions including dosage for different vaccines and interval periods between doses.

Other resources that include updated COVID-19 Provider FAQs and the latest vaccine fact sheets for the 2023-2024 Formula are listed below:

• COVID-19 Vaccine and Therapeutics FAQs (PDF)
• COVID-19 Vaccine Infant/Toddler (6M–4Y), 2023–2024 Formula, Vaccine Fact Sheet (PDF)
• COVID-19 Vaccine Adolescent/Adult (12+Y), 2023–2024 Formula, Vaccine Fact Sheet (PDF)

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

For Commercial providers:

• COVID-19 Vaccine Policies & Guidance

For Medi-Cal providers:

• Centers for Medicare & Medicaid Services (CMS): Coverage and Reimbursement of COVID-19 Vaccines, Vaccine Administration and Cost-Sharing under Medicaid, the Children’s Health Insurance Program and Basic Health Program (PDF)
• California Department of Healthcare Services (DHCS): COVID-19 Vaccine Administration Provider FAQs (PDF)
• Centers for Disease Control and Prevention (CDC): COVID-19 Vaccine Product Information

For Medicare Advantage providers:

• Medicare Billing for COVID-19 Vaccine Shot Administration
  

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, COVID-19 vaccines are offered at no cost to members. In addition:

For Commercial members

• Starting November 12, 2023, cost shares may be applicable for Commercial out-of-network vaccines, depending on the benefit design.
• As of September 11, 2023, Health Net will assume payment responsibility for the COVID-19 vaccine and the administration fee for all of our Commercial group and individual members, including those enrolled with capitated delegated groups unless negotiated otherwise. Previously, only the vaccine administration fee was payable by Health Net while the vaccine itself was available from the federal government free of charge.
• Applicable claims need to include the AMA issued vaccine related codes for the applicable FDA approved vaccination. Reimbursement will follow normal claims submission policies.

For Medi-Cal members

• Department of Health Care Services: COVID-19 Information for Beneficiaries & Members

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 May 11, 2023, the PHE expired. Review the Fact Sheet: COVID-19 Public Emergency Transition roadmap for more information. California state law added 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. Starting November 12, 2023, cost shares may be applicable for Commercial out-of-network testing, vaccines, and/or therapeutics, depending on the benefit design.

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 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 about telehealth policy.

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 are 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. Effective August 10, 2023, Health Net is contracted with Teladoc^® for all lines of business.

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, litigation brought by the California Association of Health Plans and the Association of California Life and Health Insurance Companies challenged the constitutionality of the retroactive application of Health & Safety Code 1342.2 and Insurance Code 10110.7, respectively, and 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.

We are aware of the Court's final judgment in the litigation on June 27, 2023, which reversed the injunction and held that SB 510 will apply to COVID-19 testing with dates of service prior to January 1, 2022. An appeal of the Court's decision is pending. In the interim, Health Net is working to address affected 2020-2021 claims previously denied to the at-risk delegates. Delegated at-risk entities can submit to their Health Net contracting representative their detailed requests for reimbursement for delegate paid COVID testing claims for dates of service prior to 2022. Requests, including claim level detail, must be received by Health Net prior to September 1, 2023, to be considered for reimbursement.

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: Per CA state law, benefit coverage requirements continued as is for six months after the federal Public Health Emergency expired on May 11, 2023. Health Net will continue not 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. Starting November 12, 2023, cost shares may be applicable for Commercial out-of-network testing, depending on the benefit design.

Medicare: After the PHE expired 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 (Note: This code was not covered by Medi-Cal prior to May 12, 2023, as well)

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?

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?

Starting November 12, 2023, cost shares may be applicable for Commercial out-of-network therapeutics, depending on the benefit design.

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.

Refer to the FDA – Coronavirus (COVID-19) Drugs for current information about COVID-19 treatment.

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.

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.