Medicaid Pharmacy Policy and Billing Guidance for At Home COVID-19 Testing Coverage

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New York State (NYS) Medicaid Pharmacy Policy and Billing Guidance for At Home COVID-19 Testing Coverage

Updated November 29, 2023
Updates are highlighted

In response to the ending of the COVID-19 public health emergency on May 11, 2023, the NYS Medicaid program has made changes to the coverage policy of COVID-19 at-home test kits.

Effective November 29, 2023, a fiscal order is not required for the first four tests per month. Furthermore, pharmacy reimbursement and covered products available on the pharmacy formulary will be modified. Additional tests may be covered with a fiscal order, when medically necessary. Coverage will be provided for OTC FDA-authorized COVID-19 test kits that are used in accordance with the Centers for Disease Control and Prevention (CDC) recommendations for antigen detection. This policy for coverage of at-home test kits via NYRx, the NYS Medicaid Pharmacy Program, will remain in effect until further notice.

NYS Medicaid Policy for Coverage:
  • Covered OTC test kits must be authorized by the FDA for use in both symptomatic and asymptomatic patients and allow for self-collection without medical observation.
  • Two (2) OTC tests per claim, with no refills (a test kit may contain two tests and is considered two OTC tests).
  • Up to four (4) OTC tests per month can be requested by a member at the pharmacy, without a fiscal order. Pharmacies dispensing OTC tests must retain documentation that includes:
    • Member consent, and
    • Modality of request (in pharmacy or by phone), and
    • Date and time of the request
  • If medically necessary, additional OTC tests will be covered with a fiscal order by a Medicaid-enrolled practitioner (which includes all the same information contained on a prescription). Refills will not be allowed.
  • Quantities greater than four tests per month will require a fiscal order. Pharmacies will receive edit 00715 "Procedure Conflicts with Prior Service". This will occur when a pharmacy has already billed 4 OTC tests in a month. Questions regarding the edit may be routed to eMedNY Call Center at 1-800-343-9000.
  • If a member needs more than 4 tests per month, and all other resources were utilized, and the member has a fiscal order the pharmacy may call the Pharmacy Policy unit at 518-486-3209 for a review of medical necessity.
NYRx FFS Pharmacy Billing for COVID-19 Test Kits:

Pharmacies may bill using the National Drug Codes (NDCs), 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 dropdown field and type in "COVID" to return all tests on the formulary.

Table 1 - Billing Instructions for COVID 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 for the test
444-E9 (Pharmacist ID) Enter Prescriber National Provider Identifier (NPI) number
411-DB (Prescriber ID) Enter the Pharmacy's NPI, or Prescriber's NPI for fiscal orders

* The NCPDP D.0 Companion Guide can be found on the eMedNY 5010/D.0 Transaction Instructions web page.
Please see the Serial Number and Origin Code Requirement section in the NYRx Pharmacy Manual Policy Guidelines document for further guidance on origin code and serial number values that must be submitted on the claim. 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 8 test per month which require a fiscal order, the NPI of the Medicaid-enrolled practitioner is required

Reminder:
  • It is inappropriate practice to engage new or existing patients for the sole purpose of dispensing COVID-19 OTC tests without cause.
  • 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 any other entity or third-party insurance, are utilized prior to submitting claims to the Medicaid program. Members and providers are encouraged to check the free distribution program from the federal government, which continues to be available at this time.
  • All unsubstantiated claims are subject to audit and recovery.
Additional Information