New York State Medicaid Billing Guidance for Coronavirus (COVID-19) Testing in School Based Health Centers

Updates as of 5/3/2023 are highlighted in yellow

  • Guidance is also available in Portable Document Format (PDF)

New York State Medicaid covers COVID-19 testing in school-based health centers in accordance with the guidelines outlined in this article. COVID-19 tests must be Food and Drug Administration (FDA)-approved or granted Emergency Use Authorization (EUA) through the FDA and in agreement with the level of complexity assigned by Wadsworth Laboratory to be eligible for reimbursement. COVID-19 test coverage for diagnostic and screening, including administration, must be consistent with the recommendations of the Centers for Disease Control and Prevention (CDC).
*The fees and effective dates below are current as of February 2022. Providers should periodically check their respective fee schedules in eMedNY for updates through the eMedNY "Provider Manuals" web page. Complexity levels are available on the CDC Clinical Laboratory Improvement Amendments (CLIA) "Test Complexities" web page. Tests with EUA can be found on the FDA "Emergency Use Authorizations for Medical Devices".

Please note: COVID-19 test codes not outlined in this guidance are not covered.

Individuals with signs or symptoms of COVID-19 should have diagnostic testing. The CDC also recommends testing for the following individuals listed on the CDC "Overview of Testing for SARS-CoV-2, the virus that causes COVID-19" web page. Providers are reminded that, "all persons being tested, regardless of results, should receive counseling on the continuation of risk reduction behaviors that help prevent the transmission of SARS-CoV-2 (e.g., wearing masks, physical distancing, and avoiding crowds and poorly ventilated spaces)" per CDC guidance. Additional information regarding risk reduction behaviors is available on the CDC COVID-19 "Protect Yourself" web page.

Covered Tests - Effective 5/12/2023 Lab Fees for COVID-19 related tests have been reduced

Molecular/Polymerase Chain Reaction (PCR) Tests
  • "87635" (effective 3/13/2020) - Infectious agent detection by nucleic acid [deoxyribonucleic acid (DNA) or ribonucleic acid (RNA)]; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (COVID-19), amplified probe technique.
    FFS fee = $ 51.31 (effective for dates of service from 3/13/2020 to 5/11/2023) Post PHE FFS fee = $30.79 (effective 5/12/2023)
  • "U0002" (effective 3/13/2020) - 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCov (COVID-19), any technique, multiple types, or subtypes (includes all targets), non-CDC.
    FFS fee = $ 51.31 (effective for dates of service from 3/13/2020 to 5/11/2023) Post PHE FFS fee = $30.79 (effective 5/12/2023)
Antigen Tests
  • "87426" (effective 06/25/2020) - Infectious agent antigen detection by immunoassay technique, (e.g., enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative, multiple-step method; severe acute respiratory syndrome coronavirus (e.g., SARS-CoV-2, SARS-CoV-2 [COVID-19]).
    FFS fee = $45.23 (effective for dates of service from 6/25/2020 to 5/11/2023) Post PHE FFS fee = $27.14 (effective 5/12/2023)
  • "87811" (effective 10/06/2020) - Infectious agent antigen detection by immunoassay with direct optical (i.e., visual) observation; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (COVID-19).
    FFS fee = $41.38 (effective for dates of service from 10/6/2020 to 5/11/2023) Post PHE FFS fee = $24.83 (effective 5/12/2023)
Multiplex Tests
  • "87428" (effective 11/10/2020) - Infectious agent antigen detection by immunoassay technique, (e.g., enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; severe acute respiratory syndrome coronavirus (e.g., SARS-CoV-2, SARS-CoV-2 [COVID-19]) and influenza virus types a and b.
    FFS fee = $ 73.49 (effective for dates of service from 11/10/2020 to 5/11/2023) Post PHE FFS fee = $18.65 (effective 5/12/2023)
  • "87636" (effective 10/06/2020) - Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (COVID-19) and influenza virus types a and b, multiplex amplified probe technique.
    FFS fee = $ 142.63 (effective for dates of service from 10/6/2020 to 5/11/2023) Post PHE FFS fee = $85.59 (effective 5/12/2023)
  • "87637" (effective 12/01/2021) - 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.
    FFS fee = $ 142.63 (effective for dates of service from 12/1/2021 to 5/11/2023) Post PHE FFS fee = $85.59 (effective 5/12/2023)

Specimen Collection (effective 05/22/2020 through 5/11/2023) - specimen collection will no longer be covered effective 5/12/2023):

During the period of the emergency separate Medicaid reimbursement is available for specimen collection when this is the only service being performed. Providers billing for reimbursement of one of the above tests should not bill separately for specimen collection or report. These specimen collection components are included in reimbursement for the test. Providers/Clinics billing for other primary procedures for the same patient on the same day should not bill for specimen collection.

  • "G2023" (effective 5/22/2020 through 5/11/2023 ) - Specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19])
    FFS fee = 23.46 (effective for dates of service from 5/22/2020 to 3/31/2022)
    FFS fee = 23.69 (effective for dates of service from 4/1/2022 to 5/11/2023)

Reporting

Providers are required to report SARS-CoV-2 diagnostic or serology testing results, including those using SARS-CoV-2 point-of-care tests, to the Commissioner of Health through the Electronic Clinical Laboratory Reporting System (ECLRS) within 24 hours. Required reporting includes all positive, negative, and indeterminate results, as well as test type, specimen source, and several demographic details of the individual tested. Results must be reported to ECLRS through HL7 or manual entry. Contact the ECLRS Help Desk at (866) 325-7743 or via eclrs@health.ny.gov with any technical questions. For additional testing guidance from the CDC and Wadsworth Center please see the following links:

Billing

School Based Health Centers who are already receiving payment from another source for COVID-19 testing or specimen collection are not eligible for reimbursement from Medicaid for those services.

School Based Health Centers not receiving payment or free tests from another source should bill the codes outlined in this guidance via the ordered ambulatory fee schedule and append the "HA" modifier to the appropriate test or specimen collection code above. The COVID-19 test, and specimen collection codes are not payable under ambulatory patient groups (APGs).

Claims previously denied through APGs or claims unable to be processed may be resubmitted with the "HA" modifier, if less than two years old. For claims over 90 days a delay reason code of 03 can be used for submission. SBHCs can resubmit claims less than two years old until April 15, 2022. Denied claims will be reprocessed as a special input during the week of April 18, 2022.

Reminders

In accordance with federal guidelines, providers are prohibited from charging a co-payment or cost sharing responsibility to Medicaid members for COVID-19 related services. Providers should enter a "Y" in the emergency indicator field to identify COVID-19 related services. SBHC providers are also reminded that Medicaid members under 21 are exempt from all co-payments or cost sharing responsibilities for COVID and non-COVID related services.

Questions

  • NYS Medicaid Fee-for-Service claim questions should be directed to the eMedNY Call Center at (800) 343-9000.
  • NYS Medicaid Fee-for-Service coverage and policy questions should be directed to the Office of Health Insurance Programs (OHIP) Division of Program Development and Management (DPDM) by phone at (518) 473-2160 or by email at FFSMedicaidPolicy@health.ny.gov.