New York State (NYS) Medicaid Fee-for-Service (FFS) Policy and Billing Guidance for COVID-19 Point-of-Service Testing at Pharmacies

Guidance Expires 9/30/2024, see New York State Medicaid Pharmacy Policy for Coronavirus Disease 2019 Testing

As of May 1, 2024
Updates are highlighted

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

The following guidance shall continue to remain in effect in accordance with state and federal regulations for licensed pharmacists to:

  • order COVID-19 tests, approved by the Food and Drug Administration (FDA), to detect SARS-CoV-2; or its antibodies;
  • administer COVID-19 tests, subject to CLIA Certificate of Waiver requirements pursuant to the Federal Clinical Laboratory Improvement Act of nineteen hundred eighty-eight.

NYRx, will cover CLIA waived COVID-19 testing at pharmacies with no member cost sharing, in accordance with the American Rescue Plan Act. Pharmacies will only be able to bill for Medicaid non-dual eligible members for FDA approved or cleared tests, or tests that have been authorized by the FDA under Emergency Use Authorization (EUA) and in agreement with the level of complexity assigned by Wadsworth Lab. Information regarding tests that have been granted FDA Emergency Use Authorization can be found here. Test complexity levels are availablehere.See billing instructions below. Dual eligible members will continue to access testing services throughMedicare.

Since December 13th, 2021, NYS Medicaid FFS covers self-administered COVID-19 diagnostic tests for pharmacy reimbursement with no member cost sharing. Policy and billing guidance can be found here: New York State (NYS) Medicaid Pharmacy Policy and Billing Guidance for At Home COVID-19 Testing Coverage

Since May 12, 2023, the reimbursement for point-of-service testing is as reflected in Table 2 below.

NYRx Pharmacy Billing Instructions for COVID-19 Point-of-Service Testing:

IMPORTANT INFORMATION:

  • Services must be provided and documented in accordance with the guidance issued by NYSDOH.
  • Specimen collection is no longer payable by NYS Medicaid.

Table 1 - Billing Instructions for CLIA waived COVID-19 Testing:

NCPDP D.0. Claim Segment Field Value
436-E1 (Product/Service ID Qualifier) Enter the applicable value, which qualifies the code as a procedure code
407-D7 (Product/Service ID) Enter one applicable procedure code from Table 2
444-E9 (Pharmacist ID) Enter Pharmacist's National Provider Identifier (NPI) number
411-DB (Prescriber ID) Enter the Pharmacy's NPI number*
461-EU (Prior Authorization Type Code) Enter 04= Exempt Copay **

*If the test is being ordered by a prescriber and not the pharmacist, enter the prescriber's NPI number.
**NCPDP D.0 Companion guide can be foundhere.

Please see the NYS Medicaid Pharmacy Manual Policy Guidelines document for further guidance on origin code and serial number values that must be submitted on the claim for "pharmacy dispensing" when applicable for non-patient-specific orders. Enter a value of "5" in field 419-DJ (Prescription Origin Code) and a value of "99999999" in field 454-EK (Scheduled Prescription ID Number).

Table 2 - Code List and Reimbursement for CLIA waived COVID-19 testing

Code Description Reimbursement
U0002 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCov (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC $30.79
87635 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. $30.79
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]). $27.14
87811 (effective 01/01/2021) Infectious agent antigen detection by immunoassay with direct optical (i.e., visual) observation; severe acute respiratory coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]). $24.83

Resources:

For NYRx billing questions, please contact the eMedNY Call Center at (800) 343-9000.

For NYRx Pharmacy Policy questions, please contact NYRx@health.ny.gov.