COVID-19 Information Center

Yes. QualChoice is making COVID-19 tests available at no cost if you go to an in-network pharmacy. Also, the Biden Administration is making free tests available by the United States Postal Service.  Every home in the U.S. is eligible to order 4 free at-⁠home COVID-⁠19 tests. Orders will usually ship in 7-12 days. Please visit https://www.covidtests.gov/ for more information.

QualChoice is currently working with our pharmacy partners to ensure the COVID-19 tests are available at no cost if you go to an in-network pharmacy.  If you purchased the at-home COVID-19 test at the pharmacy we will reimburse you for the cost of the test after you complete the medical claim form (PDF).

The reimbursement will be limited up to the amount set in the federal guidance ($12, or the cost of the test if less than $12, per test per covered individual) released on January 10, 2022.

If you purchased a kit prior to January 15, 2022, QualChoice will reimburse when accompanied by a physician prescription.

Yes, if you purchased the at-home COVID-19 test at any location outside of our pharmacies (e.g., Amazon, grocery store, etc.), we will reimburse you for the cost of the test after you complete the medical claim form (PDF).

The reimbursement will be limited up to the amount set in the federal guidance ($12, or the cost of the test if less than $12, per test per covered individual) released on January 10, 2022.

If you purchased a kit prior to January 15, 2022, QualChoice will reimburse when accompanied by a physician prescription.

Please print an image of the digital receipt along with the member reimbursement form.  If you are unable to produce a digital receipt, please put the order or invoice number for the purchase on the reimbursement form for tracking and validation.

Yes, QualChoice will only cover 8 at-home COVID-19 tests or 4 at-home COVID-19 test kits (each kit contains 2 tests) obtained over-the-counter per covered individual in a 30 day period, consistent with the federal guidance released on January 10, 2022.

Effective 06/01/2021 some services may require pre-authorization. Please refer to Services Requiring Pre-authorization.

Medically necessary COVID-19 diagnostic testing, medical screening services and/or treatment and the associated physician’s visit will be covered when ordered, referred and/or performed in the following In-Network locations:

• Physician’s/Practitioner’s Office
• Independent Laboratory/Diagnostic Facility
• Urgent Care Facility
• Emergency Department Facility

Are you unsure if you have been exposed to or at-risk of being infected with COVID-19? Schedule a virtual care visit with a provider. It is a good option for non-urgent care to limit potential exposure in a physician’s office or other healthcare facility.

No. We will cover medically necessary COVID-19 diagnostic testing and medical screening services at no charge to you, when such services are ordered and/or referred by a licensed health care provider. If applicable, your plan’s copayment, coinsurance and/or deductible cost-sharing will be waived for medically necessary COVID-19 diagnostic testing and medical screening services.**

*Members of self-funded plans should refer to their Plan Administrator for questions regarding COVID-19 coverage.

**Out-of-network providers may bill the member for the difference between the maximum allowable charge and the bill amount (balance bill).

Any medically necessary treatment related to COVID-19 would be considered a covered benefit. We are committed to ensuring access to COVID-19 treatment services in accordance with federal and state law. Member cost sharing will apply. Please refer to plan documents.

There are now vaccinations available that will give you the best chance of protecting yourself and your loved ones from getting COVID-19 in the future. Some COVID-19 vaccines will have two doses a few weeks in between each shot. You will get a COVID-19 Vaccination Reminder Card that will help you keep track of which vaccine you receive and when to get a second dose, if needed. If you receive a vaccine that requires two doses, it is important to get both doses.

The vaccine is being administered to different populations in a tiered approach. When you are able to get the vaccine, call your doctor with any questions and ask when you can make an appointment with them or at your local pharmacy. Or, find out where to get your vaccine at cdc.gov/coronavirus/2019-ncov/vaccines or vaccinefinder.org.

While it is not a requirement, getting your COVID-19 vaccine will give you the best chance of protecting yourself and your loved ones from getting COVID-19 in the future.

Even if you have already had COVID-19, you should still get the vaccine. It may be possible to be infected more than once so getting the vaccine is a safe choice.

Currently, the Pfizer-BioNTech vaccine is recommended for people ages 12 and older. The Moderna and Johnson & Johnson vaccines are recommended for those ages 18 and older.

According to the CDC, people who are pregnant and part of a group to receive the COVID-19 vaccine may choose to be vaccinated. If you have questions about getting the vaccine, it is recommended to discuss with your doctor to make an informed decision.

The CDC announced on March 8 that fully vaccinated Americans can discontinue masking and social distancing with other fully vaccinated people indoors in small groups. Or, visiting with unvaccinated people from a single household who are at low risk for severe COVID-19 disease indoors.

Fully vaccinated is considered two weeks past final dose, meaning the second dose of the Moderna or Pfizer mRNA vaccine, or, two weeks past the single dose Johnson & Johnson vaccine.

Fully vaccinated people can resume activities without wearing a mask or physically distancing, except where required by federal, state, local, tribal, or territorial laws, rules, and regulations, including local business and workplace guidance.

If you are fully vaccinated and have a known exposure to someone with COVID-19, the CDC says that you may refrain from quarantine and testing if you are asymptomatic. It is recommended to continue to monitor for symptoms for 14 days.

The safety of the COVID-19 vaccine is a top priority! The Food and Drug Administration (FDA) carefully reviews all safety data from clinical trials and authorizes emergency vaccine use only when the expected benefits outweigh potential risks. COVID-19 vaccines were tested in large clinical trials to make sure they meet safety standards.

You may run a fever after you get the vaccine. This is normal as your body builds immunity and fights off future COVID-19 exposures. You may feel sick after getting vaccinated. You could develop a fever, headache or body aches. This is your body reacting to the vaccine, which is a normal response. It is important to know that it is impossible to get COVID-19 from the vaccine. The vaccines currently in use and others being developed do not contain a live virus.

No. The COVID-19 vaccine will be at no cost to you. You do not need to get a pre-authorization for your vaccine.

Please call the administering facility/provider you received your first dose from to ask about your vaccine information and verify your second appointment/location.

The provider should have scheduled a second appointment with you at the same facility when you received the first dose. However, you can receive your second dose from another provider/facility and you should present your COVID-19 Vaccination Record Card.

Worry and anxiety can rise about the spread of COVID-19. Concern for friends and family who live in places where COVID-19 is spreading or the progression of the disease is natural.

• Take care of your body. Take deep breaths, stretch or meditate.
• Connect with others. Share your concerns and how you are feeling with a friend or family member. Maintain healthy relationships and a sense of hope and positive thinking.
• Share the facts about COVID-19 and the actual risk to others. People who have returned from areas of ongoing spread more than 14 days ago and do not have symptoms of COVID-19 do not put others at risk.
• For more information, see the CDC’s suggestions for mental health and coping during COVID-19

• Be alert for patients who meet the criteria for persons under investigation and know how to coordinate laboratory testing.
• Review your infection prevention and control policies and CDC's recommendations for healthcare facilities for COVID-19.
• Know how to report a potential COVID-19 case or exposure to facility infection control leads and public health officials. Contact your local and/or state health department to notify necessary health officials in the event of a person under investigation for COVID-19.
• Refer to the CDC and the World Health Organization for the most up-to-date recommendations about COVID-19, including signs and symptoms, diagnostic testing and treatment information.

In an effort to help facilities accept patients during the COVID-19 pandemic, QualChoice has implemented the following changes to allow more flexibility for inpatient stays and post-acute transfers.

These changes will be effective until March 31, 2022, but the end date may be changed. Please be sure to sign up for our provider emails so that you can receive important notifications from us.

The changes apply to inpatient admissions, skilled nursing facilities, long-term acute care, and acute rehabilitation facilities for all lines of business. Acute transfers from psychiatric stays at behavioral health facilities are excluded.

Inpatient Admissions:

QualChoice will allow notification of admission up to five days after the initial admission date and will complete medical necessity reviews once the notification is received.

Post-Acute Accommodations for Rehab Hospitals and Long-Term Acute Care Hospitals (LTACH):

QualChoice is relaxing the following requirements related to facility transfers:

• QualChoice will not require discharging acute care facilities to obtain prior authorization for patient transfers to participating post-acute facilities.
• We will not require sending facilities to provide notification of transfer to participating providers.
• However, we will require receiving facilities to notify the health plan of patient admission. We will accept notification up to five days post-transfer.
• QualChoice will continue to conduct medical necessity review.

As we will not have visibility prior to transfer, we request that hospitals utilize our in-network post-acute facilities.

Skilled Nursing Facilities:

QualChoice will allow a post-admission notification and authorize up to a seven-day stay before an additional continued stay review is required.

If you have questions about this notification or would like to speak to one of our provider relations representatives, please call us at 1-800-235-7111 (TTY: 711). Thank you for your continued partnership in helping our members live better.

We are working to quickly address and support screening, testing and treatment for COVID-19, and are closely following guidance from the Centers for Medicare and Medicaid Services (CMS). As of April 1, 2020, the following guidance can be used to bill for services related to the screening and treatment of COVID-19.

Testing and Treatment Services

For fully insured group plans, QualChoice will cover medically necessary COVID-19 diagnostic testing and/or medical screening services at no charge to members, when services are ordered and/or referred by a licensed healthcare provider. Members’ copayment, coinsurance and/or deductible cost-sharing requirements will be waived for testing. Members of self-funded plans should refer to their Plan Administrator for questions regarding COVID-19 coverage.

Acute Transfers

Please provide notification of admission by submitting an authorization request review within the first five days of a patient’s admission. We will continue to provide concurrent review after the initial seven-day approval. This waiver is in effect from December 2, 2020 to March 15, 2021.

Skilled nursing facilities, long-term acute care and acute rehab for QualChoice will include respite as well.

Vaccines – Physician Offices

The Centers for Medicare and Medicaid Services (CMS) has begun to publish guidance for providers regarding vaccine administration. Similar to other COVID-19 services, vaccines will be offered at no cost to your patients. In addition:

• QualChoice will configure its systems to properly adjudicate COVID-19 vaccine-related claims, both for the vaccine and its administration.
• Member liability will be $0.
• Three COVID-19 vaccines have received approval by the FDA of their emergency use authorizations (EUA). The Pfizer, Moderna and Janssen (Johnson & Johnson) products have been approved and have been/are being distributed. 

We strongly encourage Members to receive services from in-network providers to avoid the risk of balance billing.

Vaccines – Pharmacies

Vaccines are being administered by some pharmacies and will be covered, with no member cost share, for fully insured members and members of self-funded plans using OptumRx through QualChoice. Pharmacies may bill OptumRx through the pharmacy benefit per the instructions provided. Review OptumRx claim submission requirements.

We strongly encourage Members to receive services from in-network providers to avoid the risk of balance billing.

Claims
Claims with COVID-19 testing will be processed with no member liability, beginning April 1, 2020 with a retroactively effective date of February 4, 2020.

• In-network: COVID-19 testing codes will be processed with no member cost share.
• Out-of-network: COVID-19 testing codes will be processed at the maximum allowed charge (the rate that QualChoice would normally reimburse a provider).
  
  QualChoice will not require pre-authorization for out-of-network COVID-19 care but we do expect to be notified within 48 hours of any hospital admission. NOTE: Out-of-network providers may balance bill. Out-of-network claims will be processed at the maximum allowed charge. 

Screening Codes
If no testing is performed, providers may still bill for COVID-19 screening visits for suspected contact using the following Z codes:

• Z20.828 – Contact with a (suspected) exposure to other viral communicable diseases
• Z03.818 – Exposure to COVID-19 and the virus is ruled out after evaluation

Testing Codes
For dates of service from February 4, 2020, through March 31, 2020 providers should use the ICD-10 diagnosis code:

• B97.29 – Confirmed Cases – other coronavirus as the cause of diseases classified elsewhere

For dates of service of April 1, 2020 and later, providers should use the ICD-10 diagnosis code:

• U07.1 – 2019-nCov Confirmed by Lab Testing

Vaccine Codes

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 approval by the U.S. Food & Drug Administration (FDA).

The following codes are billable for the specific vaccines below.

Code	CPT Short Descriptor	Labeler Name	Vaccine/Procedure Name
91300	SARSCOV2 VAC 30MCG/0.3ML IM	Pfizer	Pfizer-BioNTech COVID-19 Vaccine
0001A	ADM SARSCOV2 VAC 30MCG/0.3ML 1ST	Pfizer	Pfizer-BioNTech COVID-19 Vaccine Administration – First Dose
0002A	ADM SARSCOV2 VAC 30MCG/0.3ML 2ND	Pfizer	Pfizer-BioNTech COVID-19 Vaccine Administration – Second Dose
91301	SARSCOV2 VAC 100MCG/0.5ML IM	Moderna	Moderna COVID-19 Vaccine
0011A	ADM SARSCOV2 VAC 100MCG/0.5ML 1ST	Moderna	Moderna COVID-19 Vaccine Administration – First Dose
0012A	ADM SARSCOV2 VAC 100MCG/0.5ML 2ND	Moderna	Moderna COVID-19 Vaccine Administration – Second Dose
91303	SARS-CoV-2 VAC 5/1010 VIRAL PARTICLES/.5 ML	Janssen	Janssen COVID-19 Vaccine
0031A	SARS-CoV-2 VAC 5/1010 VIRAL PARTICLES/.5 ML	Janssen	Janssen COVID-19 Vaccine Administration

 

CMS has also published a set of toolkits to help providers prepare to swiftly administer the vaccine once it is available. For questions about upcoming vaccines or the COVID-19 services QualChoice covers, please contact Provider Services at 501.228.7111, ext. 7004.

Guidance will be updated as more information becomes available.

To ensure that all of our members have needed access to care, we are increasing the scope and scale of our use of telehealth services for all products for the duration of the COVID-19 emergency. These coverage expansions will benefit not only members who have contracted or been exposed to the novel coronavirus, but also those members who need to seek care unrelated to COVID-19 and wish to avoid clinical settings and other public spaces.

Effective immediately, the policies we are implementing include:

• Any services that can be delivered virtually will be eligible for telehealth coverage.
• Telehealth services may be delivered by providers with any connection technology to ensure patient access to care.**

Medical Coding

• Audio-visual telehealth services should be billed using Modifier 95 or Modifier GT and Place of Service code 02. Any services that can be delivered virtually will be eligible for telehealth coverage. For questions regarding audio-visual telehealth coverage, please contact your QualChoice Provider Relations Representative.
• Telephone-only services will be covered for the duration of the Public Health Emergency. Any services that can be delivered via telephone will be eligible for coverage. For questions regarding telephone based service coverage, please contact your QualChoice Provider Relations Representative.

QualChoice Provider Relations

• 800.235.7111 or 501.228.7111, ext. 7004
• pr@qualchoice.com
• Provider Relations Representatives

*For Health Savings Account (HSA)-Qualified plans, IRS guidance is pending as to deductible application requirements for telehealth/telemedicine related services.

**Providers should follow state and federal guidelines regarding performance of telehealth services including permitted modalities.