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CMS Issues Guidance to Reduce Commercial Payer Denials for COVID-19 Testing

CMS maze of rules and regulations

New CMS guidance reinforces that commercial payers should cover asymptomatic COVID-19 testing

The US Centers for Medicare and Medicaid Services (CMS) provided new guidance for payers in late February 2021, to reduce potential loopholes that some commercial payers may be using to deny COVID-19 testing claims. Three issues addressed by this new guidance include COVID-19 test claim denials, cost-sharing imposed for individuals that are asymptomatic, and vaccination coverage.

Eight Key Points of the CMS Guidance to Commercial Payers

  1. Payers cannot use medical screening criteria to deny (or impose cost-sharing on) a claim for COVID-19 testing for an asymptomatic individual who has no known or suspected exposure to COVID-19.
  2. Payers can distinguish between testing asymptomatic individuals for medical purposes and screening for workplace health, public surveillance, and other similar types of screening tests.
  3. Payers should cover COVID-19 diagnostic tests “provided through state- or locality-administered testing sites”.
  4. Point-of-care tests should be covered like any other COVID-19 test.
  5. Payers typically have to cover COVID-19 vaccines without cost-sharing.
  6. Payers do have to “cover the vaccine administration fee when the plan or issuer is not billed for the vaccine”.
  7. Payers cannot deny coverage for a vaccine if the person getting the vaccine was not in a category that was recommended for early vaccination.
  8. Payers may not have to cover certain vaccinations that are provided by an employer.

The guidance also clarifies what items and services that plans and issuers are required to cover, that are associated with COVID-19 diagnostic testing (and in various settings), as well as reported areas of noncompliance with CARES Act requirements.

Clinical laboratory leaders wishing to view the guidance in its entirety can do so here.

Related Resource:

CMS: FAQs About Families First Coronavirus Response Act and Coronavirus Aid, Relief, And Economic Security Act Implementation Part 44